title: Paraprotein-Related Kidney Disease: Evaluation and Treatment of Myeloma Cast Nephropathy.
abstract: Nearly 50% of patients with multiple myeloma develop renal disease, most commonly from AKI caused by cast nephropathy. Development of AKI is associated with poor 1-year survival and reduces the therapeutic options available to patients. There is a great need for more effective therapies. Cast nephropathy is caused by the interaction and aggregation of filtered free light chains and Tamm-Horsfall protein causing intratubular obstruction and damage. The key to treating cast nephropathy is rapid lowering of free light chains, because this correlates with renal recovery. Newer chemotherapy agents rapidly lower free light chains and have been referred to as renoprotective. There is additional great interest in using extracorporeal therapies to remove serum free light chains. Small trials initially showed benefit of therapeutic plasma exchange to improve renal outcomes in cast nephropathy, but a large randomized trial of therapeutic plasma exchange failed to show benefit. A newer technique is extended high-cutoff hemodialysis. This modality uses a high molecular weight cutoff filter to remove free light chains. To date, trials of high-cutoff hemodialysis use in patients with cast nephropathy have been encouraging. However, there are no randomized trials showing the benefit of high-cutoff hemodialysis when used in addition to newer chemotherapeutic regimens. Until these studies are available, high-cutoff hemodialysis cannot be recommended as standard of care.
authors.affiliation: Department of Medicine, Division of Renal Diseases and Hypertension, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas.|Department of General Internal Medicine, Nephrology Section, University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Kevin W
authors.initials: KW
authors.lastname: Finkel
authors.affiliation: Nephrology Section, Baltimore Veterans Affairs Medical Center, University of Maryland School of Medicine, Baltimore, Maryland; and.
authors.forename: Eric P
authors.initials: EP
authors.lastname: Cohen
authors.affiliation: Department of Medicine, Section of Nephrology, Yale University Medical School, New Haven, Connecticut.
authors.forename: Anushree
authors.initials: A
authors.lastname: Shirali
authors.affiliation: Department of General Internal Medicine, Nephrology Section, University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Ala
authors.initials: A
authors.lastname: Abudayyeh
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology; D000970:Antineoplastic Agents / Q000627:therapeutic use; D006801:Humans; D007147:Immunoglobulin Light Chains / Q000378:metabolism; D007674:Kidney Diseases / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy*; D009101:Multiple Myeloma / Q000150:complications* / Q000628:therapy*; D010951:Plasma Exchange; D006435:Renal Dialysis / Q000379:methods; D033581:Stem Cell Transplantation; D058949:Uromodulin / Q000378:metabolism
chemical_list: D000970:Antineoplastic Agents; D007147:Immunoglobulin Light Chains; C548612:UMOD protein, human; D058949:Uromodulin
keywords: HCO dialysis; Humans; Immunoglobulin Light Chains; Molecular Weight; Myeloma Proteins; Plasma Exchange; Randomized Controlled Trials as Topic; Standard of Care; Uromodulin; acute renal failure; cast nephropathy; free light chains; multiple myeloma; multiple myeloma M-proteins; renal dialysis