What is the treatment of renal insufficiency in multiple myeloma?
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- Answered 7 Nov 2019 Conflict of interest declaration: None What is the treatment of renal insufficiency in multiple myeloma? We found no guidelines on the topic but did find a fairly recent review (2016) “International Myeloma Working Group Recommendations for the Diagnosis and Management of Myeloma-Related Renal Impairment” , this makes the following recommendations: “All patients with myeloma at diagnosis and at disease assessment should have serum creatinine, estimated glomerular filtration rate, and electrolytes measurements as well as free light chain, if available, and urine electrophoresis of a sample from a 24-hour urine collection (grade A). The Chronic Kidney Disease Epidemiology Collaboration, preferably, or the Modification of Diet in Renal Disease formula should be used for the evaluation of estimated glomerular filtration rate in patients with stabilized serum creatinine (grade A). International Myeloma Working Group criteria for renal reversibility should be used (grade B). For the management of RI in patients with multiple myeloma, high fluid intake is indicated along with antimyeloma therapy (grade B). The use of high-cutoff hemodialysis membranes in combination with antimyeloma therapy can be considered (grade B). Bortezomib-based regimens remain the cornerstone of the management of myeloma-related RI (grade A). High-dose dexamethasone should be administered at least for the first month of therapy (grade B). Thalidomide is effective in patients with myeloma with RI, and no dose modifications are needed (grade B). Lenalidomide is effective and safe, mainly in patients with mild to moderate RI (grade B); for patients with severe RI or on dialysis, lenalidomide should be given with close monitoring for hematologic toxicity (grade B) with dose reduction as needed. High-dose therapy with autologous stem cell transplantation (with melphalan 100 mg/m(2) to 140 mg/m(2)) is feasible in patients with RI (grade C). Carfilzomib can be safely administered to patients with creatinine clearance > 15 mL/min, whereas ixazomib in combination with lenalidomide and dexamethasone can be safely administered to patients with creatinine clearance > 30 mL/min (grade A).” The document is available, full-text, via the link below. We did find one multiple myeloma guideline  from this year. It did not answer the question about how to treat renal insufficiency but does explore how to manage MM in patients with renal insufficiency, reporting: “Renal dysfunction is a common finding in patients with multiple myeloma at the time of diagnosis, with nearly 30% of the patients having some degree of renal dysfunction. As such, the Cockroft-Gault formula or similar creatinine clearance assessment tool should be routinely used to estimate clearance prior to initiating therapy. Many of the medications used to treat myeloma will need dosage modifications based on the degree of renal dysfunction. The treating physician should modify the doses of antimyeloma therapies accordingly, especially the immunomodulatory drugs such as lenalidomide and pomalidomide, and should follow the product insert guidelines. Monoclonal antibodies and most PIs do not need dose modifications in the setting of renal insufficiency, but ixazomib should be dose reduced in context of renal insufficiency as per the product insert.” We include this for interest. References 1) https://academy.myeloma.org.uk/wp-content/uploads/sites/2/2017/11/IMWG-management-of-relapse.pdf 2) https://ascopubs.org/doi/full/10.1200/JCO.18.02096