Detection of renal impairment as one specific comorbidity factor in multiple myeloma: Multicenter study in 198 consecutive patients

Department of Hematology and Oncology, Medical Center, University of Freiburg Medical Center, Germany.
European Journal Of Haematology (Impact Factor: 2.07). 07/2009; 83(6):519-27. DOI: 10.1111/j.1600-0609.2009.01318.x
Source: PubMed

ABSTRACT Comorbidity factors have been reported in cancer patients to predict progression free survival (PFS) and overall survival (OS). Renal impairment (RI) is postulated as one negative prognostic factor in multiple myeloma (MM). The study aim was to detect the best way to define RI and the impact of different RI stages on MM outcome.
In this multicenter analysis, we determined RI [serum creatinine, estimated glomerular filtration rate (eGFR) by modification of diet in renal disease (MDRD) and Cockcroft-Gault] and other prognostic factors in 198 MM patients to ascertain their value on PFS and OS.
Median serum creatinine was 0.9 mg/dL in all patients, whereas the eGFR - being decreased with a median of 80 mL/min/1.73 m(2)- allowed to detect early stages of RI. Via univariate analysis, we observed increasing hazard ratios (HRs) for impaired OS with deteriorating eGFR: with eGFR(MDRD)<90 and <30, HRs were 1.3 and 2.9, respectively. Multivariate analysis determined RI with eGFR<30 and <50 as well as age >59 yr as most important variables for OS. By incorporating eGFR<30 as the most relevant factor determined via multivariate analysis and beta(2)-microglobulin (beta(2)-MG) in a novel MM-risk score, we identified patients with significantly differing OS: median survival with 0, 1 or 2 risk factors were 71, 48, and 24 months, respectively.
These findings demonstrate that RI is frequent in MM, best detected via eGFR determination and an important prognostic factor. eGFR in combination with beta(2)-MG allows definitive risk stratification with largely differing survival in MM.

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    • "In the 1980s, serum beta-2 microglobulin levels were identified as a strong prognostic factor in MM [15]. Recently, a risk score has been proposed that identified eGFR and beta-2 microglobulin levels as the capital predicting prognosis but did not include serum albumin levels because the unavailability of results for all patients [16]. The accumulation of the evidence suggests that kidney function is closely correlated with myeloma cell mass; that is, patients with a large tumor burden are more likely to have CKD. "
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    ABSTRACT: Multiple myeloma (MM) has a high incidence rate in the elderly. Responsiveness to treatments differs considerably among patients because of high heterogeneity of MM. Chronic kidney disease (CKD) is a common clinical feature in MM patients, and treatment-related mortality and morbidity are higher in MM patients with CKD than in patients with normal renal function. Recent advances in diagnostic tests, chemotherapy agents, and dialysis techniques are providing clinicians with novel approaches for the management of MM patients with CKD. Once reversible factors, such as hypercalcemia, have been corrected, the most common cause of severe acute kidney injury (AKI) in MM patients is tubulointerstitial nephropathy, which results from very high circulating concentrations of monoclonal immunoglobulin free light chains (FLC). In the setting of AKI, an early reduction of serum FLC concentration is related to kidney function recovery. The combination of extended high cutoff hemodialysis and chemotherapy results in sustained reductions in serum FLC concentration in the majority of patients and a high rate of independence from dialysis.
    The Scientific World Journal 10/2013; 2013:487285. DOI:10.1155/2013/487285 · 1.73 Impact Factor
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    • "Either the Cockcroft-Gault or the MDRD (modification of diet in renal disease) formula may be used to calculate creatinine clearance. Caution is urged in calculating the renal function based solely on serum creatinine level in older patients with MM [36]. Lenalidomide treatment should be used with caution in patients with thrombocytopenia (i.e., platelet counts <50 × 10 9 /L or <30 × 10 9 /L in those with heavy marrow infiltration with myeloma) and absolute neutrophil counts <1.0 × 10 9 /L; if lenalidomide is used in this setting, measures for aggressive growth factor supplementation and/or platelet transfusion support must be in place. "
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    ABSTRACT: Major improvement milestones in the treatment of patients with multiple myeloma (MM) include the introduction of the melphalan/prednisone combination in the 1960s; high-dose chemotherapy supported by autologous stem cell transplant in the 1980s; and the more recent introduction of the novel agents, thalidomide, lenalidomide, bortezomib, and pegylated liposomal doxorubicin. While, historically, age and eligibility for autologous stem cell transplantation were the primary basis for treatment selection, cytogenetics and other risk stratification methods are increasingly being used to guide treatment, especially with the newer agents. This trend reflects our improved understanding of the numerous genetic and biological abnormalities that mark this complex disease. In the absence of prospective, randomised studies assessing the value of risk stratification in guiding treatment decisions, and the use of the newest therapies, results of a number of studies provide a rationale for this approach. Currently available data indicate that the use of novel therapies in both the induction and maintenance settings, accompanied by risk stratification, may improve prognosis for patients with MM. Large, prospective randomised studies are needed to confirm these early pilot studies.
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