TREATMENT MANAGEMENT IN MULTIPLE MYELOMA WITH RENAL DISORDER

IF 1.8 Q3 HEMATOLOGY

Hematology, Transfusion and Cell Therapy Pub Date : 2025-07-01 DOI:10.1016/j.htct.2025.103905

Meryem Sener

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Abstract

Introduction

Multiple Myeloma (MM) is a plasma cell neoplasm characterized by the accumulation of monoclonal plasma cells in the bone marrow, leading to osteolytic lesions, anemia, infections, hypercalcemia, and kidney impairment. This review focuses on managing kidney disease in MM, particularly light chain cast nephropathy.

Case

A 66-year-old male with progressive fatigue, dizziness, weight loss, and recurrent pneumonia was referred for anemia evaluation on 28.11.2024. Laboratory results showed:

• Hemoglobin: 5.4 g/dL, Hematocrit: 18.3%, Platelets: 56 × 10³/uL

• Creatinine: 1.39 mg/dL, Calcium: 9.7 mg/dL, Total Protein: 9 g/L, Albumin: 2.9 g/L

• IgA: 4295 mg/dL, IgG: 141 mg/dL, IgM: < 5 mg/dL

Peripheral smear showed rouleaux formation, and protein electrophoresis revealed a gamma peak. Immunofixation detected IgA-lambda bands, with bone marrow biopsy confirming 70% plasma cell infiltration. The patient was started on VCD chemotherapy (bortezomib, cyclophosphamide, dexamethasone). Neutropenia worsened, requiring G-CSF support. Renal function improved, and zoledronic acid was given for widespread lytic lesions. Due to Febrile Neutropenia (FEN), treatment was switched to VRD (bortezomib, lenalidomide, dexamethasone). After four cycles, symptoms improved, and cytopenia’s resolved. Although serum immunofixation remained positive, the patient achieved a Very Good Partial Response (VGPR). A follow-up bone marrow biopsy is planned after four more cycles, with Autologous Stem Cell Transplant (ASCT) scheduled if the response continues.

Conclusion

Managing MM with renal impairment requires balancing efficacy and toxicity. A four-drug regimen (Dara-CyBorD or Isa-CyBorD) is preferred in fit patients with severe AKI, while a three-drug regimen (Dara-Vd) is recommended for frail patients. If daratumumab or isatuximab is unavailable, CyBorD is an alternative. Bortezomib, daratumumab, and isatuximab can be safely used in kidney dysfunction without dose adjustments. Lenalidomide is avoided in AKI unless refractory. In this case, VCD was chosen initially, and after renal improvement, VRD was used despite FEN episodes. The patient achieved VGPR and is now planned for ASCT.

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多发性骨髓瘤合并肾脏疾病的治疗管理

多发性骨髓瘤（MM）是一种浆细胞肿瘤，其特征是骨髓中单克隆浆细胞的积累，导致溶骨性病变、贫血、感染、高钙血症和肾损害。本文综述了MM肾病的治疗，特别是轻链型肾病。病例1例66岁男性，进行性疲劳、头晕、体重减轻、复发性肺炎，于2024年11月28日行贫血评估。实验室结果显示：•血红蛋白：5.4 g/dL，红细胞压积：18.3%，血小板：56 × 10³/uL•肌酐：1.39 mg/dL，钙：9.7 mg/dL，总蛋白：9 g/L，白蛋白：2.9 g/L•IgA: 4295 mg/dL, IgG: 141 mg/dL, IgM: <；5 mg/ dl外周涂片示rouleaux形成，蛋白电泳示γ峰。免疫固定检测IgA-lambda带，骨髓活检证实70%浆细胞浸润。患者开始VCD化疗（硼替佐米、环磷酰胺、地塞米松）。中性粒细胞减少症恶化，需要G-CSF支持。肾功能改善，并给予唑来膦酸广泛溶解性病变。由于发热性中性粒细胞减少症（FEN），治疗转为VRD（硼替佐米、来那度胺、地塞米松）。四个疗程后，症状好转，细胞减少症消失。虽然血清免疫固定仍然呈阳性，但患者获得了非常好的部分反应（VGPR）。计划在四个周期后进行随访骨髓活检，如果反应持续，则计划进行自体干细胞移植（ASCT）。结论治疗肾损害MM需要平衡疗效和毒性。对于健康的严重AKI患者，首选四药方案（Dara-CyBorD或Isa-CyBorD），而对于虚弱的患者，建议采用三药方案（Dara-Vd）。如果没有daratumumab或isatuximab， CyBorD是一种选择。硼替佐米、达拉单抗和isatuximab可以安全地用于肾功能不全而无需剂量调整。来那度胺避免用于AKI，除非是难治性的。本例患者最初选择VCD，在肾脏改善后，尽管FEN发作，仍使用VRD。患者达到了VGPR，现在计划进行ASCT。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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