What is the treatment for Multiple Myeloma (MM) induced renal failure, also known as Impaired renal function?

From the Guidelines

Treatment of myeloma-induced renal failure should prioritize a multi-faceted approach, including aggressive hydration, correction of hypercalcemia, discontinuation of nephrotoxic medications, and rapid initiation of chemotherapy with bortezomib-based regimens, as these interventions can improve renal recovery and overall outcomes. The approach to treating myeloma-induced renal failure involves several key components:

• Aggressive hydration with intravenous fluids to maintain urine output and dilute nephrotoxic light chains, as recommended by 1
• Correction of hypercalcemia with IV fluids and bisphosphonates like zoledronic acid or pamidronate, as suggested by 1
• Discontinuation of nephrotoxic medications, including NSAIDs, ACE inhibitors, ARBs, and iodinated contrast, to prevent further renal injury
• Rapid initiation of chemotherapy, typically with bortezomib-based regimens such as VCD or VRD, which can be used in renal failure without dose adjustment, as noted in 1 Some key points to consider in the management of myeloma-induced renal failure include:
• The importance of reducing circulating serum free light chains (FLCs) as quickly as possible, which can be achieved with regimens like daratumumab combined with VCD or VD, as recommended by 1
• The potential role of extracorporeal light chain removal with plasmapheresis (PLEX) or high-cutoff hemodialysis in severe cases with cast nephropathy, as discussed in 1
• The need for careful assessment of fluid status to avoid hypervolemia, especially in patients with oliguria renal failure, as cautioned by 1
• The importance of considering the individual patient's disease features, age, comorbidities, and personal preferences when selecting a treatment approach, as emphasized by 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Myeloma Induced Renal Failure

• The primary cause of renal failure in myeloma is damage to the kidney by excessive amounts of light chain produced by the myeloma tumor, giving rise to cast nephropathy (myeloma kidney) 2.
• Early and adequate chemotherapy in association with symptomatic treatment can lead to rapid reduction of serum light chain concentration, which is necessary to prevent development of renal failure 3.
• Bortezomib-based regimens are the cornerstone of the management of patients with multiple myeloma and renal impairment at diagnosis 4.
• New quadruplet and triplet combinations, including proteasome inhibitors, immunomodulatory drugs, and anti-CD38 monoclonal antibodies, improve renal and survival outcomes in both newly diagnosed patients and those with relapsed or refractory disease 4.

Role of Dialysis in Renal Failure Treatment

• Renal function repair can be accelerated by removing light chains from serum by dialysis with high-cutoff membrane (HCO-HD) 3.
• High cut-off haemodialysis should be restricted to MM patients on chemotherapy with histological diagnosis of MCN and haemodialysis requirements 5.
• Data from previously published studies on HCO-HD have not yielded as optimistic results as originally expected, however, HCO-HD could be beneficial for some subgroup of patients with renal failure in myeloma kidney 3.

Importance of Early Intervention

• Moderate and severe renal impairment increases the risk of early death; thus rapid intervention and initiation of anti-myeloma treatment is essential and improves renal outcomes in patients with renal impairment 6.
• Determining whether the renal impairment is due to cast nephropathy should be the first priority, and once the diagnosis is confirmed, appropriate treatment should be initiated without delay 2.
• Supportive care and high-dose dexamethasone are required for all patients with myeloma-induced renal impairment 4.