From the Research
Managing renal failure in patients with myelofibrosis requires a multifaceted approach addressing both the underlying hematologic disease and kidney dysfunction, with the most recent evidence suggesting that JAK inhibitors like ruxolitinib may need dose reduction in renal impairment 1.
Key Considerations
- Treatment should begin with optimizing fluid balance through careful monitoring of intake and output, with a target of euvolemia to prevent further kidney injury.
- Nephrotoxic medications should be immediately discontinued or dose-adjusted based on creatinine clearance, particularly chemotherapeutic agents used for myelofibrosis.
- Anemia management is crucial, with erythropoiesis-stimulating agents often needed, targeting hemoglobin levels of 9-10 g/dL to reduce transfusion requirements while avoiding hyperviscosity.
- Blood pressure control should aim for targets of <140/90 mmHg, preferably using ACE inhibitors or ARBs if proteinuria is present.
Advanced Renal Failure Management
- For advanced renal failure, renal replacement therapy may be necessary, with peritoneal dialysis sometimes preferred in patients with severe thrombocytopenia to minimize bleeding risks.
- Allogeneic stem cell transplantation should be considered in eligible patients as it remains the only potentially curative option for myelofibrosis and may improve renal outcomes, as suggested by the most recent study on JAK inhibitor failure in myelofibrosis 1.
Individualized Approach
- The management approach must be individualized, considering the complex interplay between myelofibrosis-related factors (cytokine storm, extramedullary hematopoiesis affecting kidneys) and traditional causes of renal failure.
- The use of non-JAKi agents, such as pelabresib, navitoclax, parsaclisib, navtemadlin, and imetelstat, is being explored in clinical trials for patients with JAKi failure, offering potential new treatment options 1.