Renal Complications in Hematologic Malignancies<br />Julie M. Vose, M.D.<br />University of Nebraska Medical Center<br />j...
Renal Complications in Hematologic Malignancies<br />Causes of Renal Insufficiency <br />Direct infiltration (NHL, AML, MM...
Ultrasound of the right (A) and left (B) kidney showing hypoechogenic massively enlarged kidneys.<br />Sellin L et al. Nep...
Kidney biopsy.<br />NHL<br />CD 20+<br />Sellin L et al. Nephrol. Dial. Transplant. 2004;19:2657-2660<br />Nephrol Dial Tr...
Treatment of NHL with Renal Failure<br />Nephrostomy if necessary<br />IV Hydration<br />Alkalinization<br />Treat Hyperur...
The graph shows the rapid increase of the serum creatinine during the development of ARF.<br />Sellin L et al. Nephrol. Di...
Pathogenesis<br /><ul><li>MM is characterized by
Excessive numbers        of abnormal plasma          cells in the bone marrow
Overproduction of intact monoclonal immunoglobulins (IgG, IgA, IgD, or IgE) or Bence-Jones protein (free antibody light ch...
Hallmarks of MM<br />Plasma cell<br />Lytic lesions,<br />Pathologic fractures,<br />Hypercalcemia<br />Anemia<br />Bone d...
Renal Complications of Multiple Myeloma<br />Serum creatinine > 2 in 25-40% of patients<br />Causes<br />“myeloma kidney” ...
Renal Complications of Multiple Myeloma<br />Light chain production higher than ability to filter the protein<br />Heavy a...
Treatment of Renal Failure and Multiple Myeloma<br />Treatment of renal insufficiency<br />IV Hydration<br />Remove contra...
Cryoglobulinemia<br /><ul><li>Associated with:
IgG Multiple Myeloma
Waldenstrom’s Macroglobulinemia
Indolent lymphomas
Hepatitis C</li></li></ul><li>Cryoglobulinemia<br />20-40% of cases with mixed cryoglobulinemia have renal involvement (hi...
Tumor Lysis Syndrome – Diagnosis and Treatment<br />
Lysis of Tumor Cells and the Release of DNA, Phosphate, Potassium, and Cytokines.<br />Howard SC et al. N Engl J Med 2011;...
Crystals of Uric Acid, Calcium Phosphate, and Calcium Oxalate.<br />Howard SC et al. N Engl J Med 2011;364:1844-1854<br />
Upcoming SlideShare
Loading in …5
×

LLA 2011 - J.M. Vose - Renal problems in patients treated for haematological malignancy

502 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
502
On SlideShare
0
From Embeds
0
Number of Embeds
6
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

LLA 2011 - J.M. Vose - Renal problems in patients treated for haematological malignancy

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

×