• Save
LLA 2011 - J.M. Vose - Renal problems in patients treated for haematological malignancy
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
590
On Slideshare
587
From Embeds
3
Number of Embeds
1

Actions

Shares
Downloads
0
Comments
0
Likes
0

Embeds 3

http://www.eso.net 3

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Renal Complications in Hematologic Malignancies
    Julie M. Vose, M.D.
    University of Nebraska Medical Center
    jmvose@unmc.edu
  • 2. Renal Complications in Hematologic Malignancies
    Causes of Renal Insufficiency
    Direct infiltration (NHL, AML, MM)
    Hydronephrosis (NHL, HD)
    Thrombosis, HUS/TTP (rare cause)
    Hypercalcemia (MM, NHL)
    Hyperuricemia (NHL, AML, MM)
    Nephrotoxic agents
    Tumor lysis syndrome
  • 3.
  • 4.
  • 5. Ultrasound of the right (A) and left (B) kidney showing hypoechogenic massively enlarged kidneys.
    Sellin L et al. Nephrol. Dial. Transplant. 2004;19:2657-2660
    Nephrol Dial Transplant Vol. 19 No. 10 © ERA-EDTA 2004; all rights reserved
  • 6. Kidney biopsy.
    NHL
    CD 20+
    Sellin L et al. Nephrol. Dial. Transplant. 2004;19:2657-2660
    Nephrol Dial Transplant Vol. 19 No. 10 © ERA-EDTA 2004; all rights reserved
  • 7. Treatment of NHL with Renal Failure
    Nephrostomy if necessary
    IV Hydration
    Alkalinization
    Treat Hyperuricemia
    If due to direct infiltration – treatment of NHL most important
    Need reduced doses of some medications – Methotrexate, Cytarabine
  • 8. The graph shows the rapid increase of the serum creatinine during the development of ARF.
    Sellin L et al. Nephrol. Dial. Transplant. 2004;19:2657-2660
    Nephrol Dial Transplant Vol. 19 No. 10 © ERA-EDTA 2004; all rights reserved
  • 9. Pathogenesis
    • MM is characterized by
    • 10. Excessive numbers of abnormal plasma cells in the bone marrow
    • 11. Overproduction of intact monoclonal immunoglobulins (IgG, IgA, IgD, or IgE) or Bence-Jones protein (free antibody light chains)
    Reproduced with permission from the Multiple Myeloma Research Foundation Web site. Available at: http://www.multiplemyeloma.org/about_myeloma/index.html
    Ig=immunoglobulin.
    Kufe. Cancer Medicine. 6th ed. 2003:2219.
  • 12. Hallmarks of MM
    Plasma cell
    Lytic lesions,
    Pathologic fractures,
    Hypercalcemia
    Anemia
    Bone destruction
    Marrow infiltration
    MULTIPLE MYELOMA
    Reduced globulins
    Monoclonal globulins
    Urine: Renal failure
    Blood: Hyperviscosity,
    Cryoglobulins,
    Neuropathy
    Tissue: Amyloidosis
    Infection
    Carr et al, 1999.
  • 13. Renal Complications of Multiple Myeloma
    Serum creatinine > 2 in 25-40% of patients
    Causes
    “myeloma kidney” – light chain deposition
    Dehydration
    Hypercalcemia
    Hyperuricemia
    Amyloidosis (10-15% of cases)
    Medications (NSAIDs, diuretics, etc)
  • 14. Renal Complications of Multiple Myeloma
    Light chain production higher than ability to filter the protein
    Heavy and light chain deposition cause tubular damage – cast formation
    Serum free light chain assay is more helpful than urine
  • 15. Treatment of Renal Failure and Multiple Myeloma
    Treatment of renal insufficiency
    IV Hydration
    Remove contraindicated medications
    Treat hypercalcemia - Aredia (not Zometa)
    Treat hyperuricemia
    Plasmapheresis?
    Dialysis if needed – may reverse renal insufficiency in some cases
    Treat the MM – bortezomib containing combination (lenalidamide reduced dosing)
  • 16. Cryoglobulinemia
    • Associated with:
    • 17. IgG Multiple Myeloma
    • 18. Waldenstrom’s Macroglobulinemia
    • 19. Indolent lymphomas
    • 20. Hepatitis C
  • Cryoglobulinemia
    20-40% of cases with mixed cryoglobulinemia have renal involvement (highest type II)
    Progression to sclerosing nephritis and end stage renal failure is uncommon
    Treatment
    Treat underlying hematologic malignancy
    Steroids, immunosuppressive therapy, plasma exchange
  • 21. Tumor Lysis Syndrome – Diagnosis and Treatment
  • 22. Lysis of Tumor Cells and the Release of DNA, Phosphate, Potassium, and Cytokines.
    Howard SC et al. N Engl J Med 2011;364:1844-1854
  • 23. Crystals of Uric Acid, Calcium Phosphate, and Calcium Oxalate.
    Howard SC et al. N Engl J Med 2011;364:1844-1854
  • 24. Definitions of Laboratory and Clinical Tumor Lysis Syndrome.
    Howard SC et al. N Engl J Med 2011;364:1844-1854
  • 25. Assessment and Initial Management of the Tumor Lysis Syndrome.
    Howard SC et al. N Engl J Med 2011;364:1844-1854
  • 26. Increased Risk of Tumor Lysis Syndrome
    Large volume, bulky mass, high blast count or a large number of circulating cells
    High proliferative tumor – high LDH, high KI-67, etc
    Renal involvement by tumor
    Highly chemosensitive tumor
    Dehydration, Hyperuricemia
  • 27. Increased Risk of Tumor Lysis Syndrome
    Acidic urine
    Exogenous potassium or phosphates
    Delayed uric acid removal
    Exposure to nephrotoxins
    Nephropathy before diagnosis
  • 28. Renal Failure and Hematologic Malignancies
    Multiple causes – direct or indirect
    Need to check at diagnosis and as treatment starts
    Remove contributory drugs or toxins
    Continue to monitor during therapy
    Modifications of therapy as needed