prevention and early management of renal damage associated with multiple myeloma
Last reviewed 12/2021
Myeloma patients presenting with renal impairment have a high early mortality rate.
Early diagnosis of myeloma (both new and relapsed) is important which will enable early intervention and prevention of renal damage which will significantly improve survival (1). The following advice should be given to patients to optimise renal function:
- patients should be instructed to have a high fluid intake (at least 3 litres/day) and to continue it throughout the course of the disease
- nephrotoxic drugs such as aminoglycosides and NSAID's should be avoided (1)
Recommendations for initial management of renal insufficiency are as follows:
- vigorously rehydrate patient with at least 3 litres of normal saline per day
- treat precipitating causes to reduce the light chain load delivered to the kidney tubule
- discontinue nephrotoxic drugs, particularly NSAIDs
- methods of removing free light chains from the blood (plasma exchange, large pore haemofiltration) could be considered
- if not contraindicated, high dose dexamethasone should be used pending initiation of definitive treatment which should be started without delay
- monitor serum free light chain levels
- identify and treat infection vigorously
- patients with renal failure require dose modification of bisphosphonates and the risk of renal adverse events may be greater in patients with impaired renal function (1)
NICE state (2):
- consider immediately starting a bortezomib- and dexamethasone-based combination regimen for people with untreated, newly diagnosed, myeloma-induced acute renal disease.
- if a bortezomib-based combination regimen is unsuitable for people with untreated, newly diagnosed, myeloma-induced acute renal disease, consider immediately starting a thalidomide- and dexamethasone-based combination regimen
- do not perform plasma exchange for myeloma-induced acute renal disease
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