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    Proposed evaluation of multiple myeloma patient and kidney failure and follow-up

  • 1.

    Heybeli C, et al. Kidney transplantation in patients with monoclonal gammopathy of renal significance (MGRS)-associated lesions: A case series. Am J Kidney Dis 2022; 79:202216. doi: 10.1053/j.ajkd.2021.04.015

    • Search Google Scholar
    • Export Citation
  • 2.

    Kormann R, et al. Kidney transplantation for active multiple myeloma or smoldering myeloma: A case-control study. Clin Kidney J 2021; 14:156166. doi: 10.1093/ckj/sfz128

    • Search Google Scholar
    • Export Citation
  • 3.

    Chitty DW, et al. Kidney transplantation in patients with multiple myeloma: Narrative analysis and review of the last two decades. Nephrol Dial Transplant [published online ahead of print December 9, 2020]. doi: 10.1093/ndt/gfaa361; https://academic.oup.com/ndt/advance-article/doi/10.1093/ndt/gfaa361/6028994?login=false

    • Search Google Scholar
    • Export Citation
  • 4.

    Owoyemi I, El Ters M. Pro-kidney transplantation should be considered in patients with multiple myeloma. J Onco-Nephrol 2020; 4:1821. https://journals.sagepub.com/doi/full/10.1177/2399369320902773

    • Search Google Scholar
    • Export Citation
  • 5.

    Nair V. Kidney transplantation in patients with multiple myeloma: A word of caution. J Onco-Nephrol 2020; 4:2225. https://journals.sagepub.com/doi/full/10.1177/2399369320903135

    • Search Google Scholar
    • Export Citation
  • 6.

    Dinh AR, et al. Outcomes of kidney transplant recipients with ESKD due to plasma cell dyscrasia: A case series. Clin Transplant 2022; 36:e14541. doi: 10.1111/ctr.14541

    • Search Google Scholar
    • Export Citation
  • 7.

    Le TX, et al. Kidney transplantation for kidney failure due to multiple myeloma: Case reports. Am J Kidney Dis 2017; 69:858862. doi: 10.1053/j.ajkd.2016.12.023

    • Search Google Scholar
    • Export Citation
  • 8.

    Lum EL, et al. Kidney transplantation in patients with active multiple myeloma: Case reports. Transplant Direct 2017; 3:e200. doi: 10.1097/TXD.0000000000000716

    • Search Google Scholar
    • Export Citation
  • 9.

    Shah S, et al. Risk of relapse of multiple myeloma following kidney transplantation. Clin Kidney J 2019; 12:216223. doi: 10.1093/ckj/sfy137

  • 10.

    Huskey JL, et al. Kidney transplant in the era of modern therapy for multiple myeloma. Transplantation 2018; 102:19942001. doi: 10.1097/TP.0000000000002449

    • Search Google Scholar
    • Export Citation
  • 11.

    Hedvat J, et al. Outcomes of renal transplantation in patients with previous hematologic malignancies. J Onco-Nephrol 2019; 3:124130. https://journals.sagepub.com/doi/10.1177/2399369319865539

    • Search Google Scholar
    • Export Citation
  • 12.

    Leung N, et al. Long-term outcome of renal transplantation in light-chain deposition disease. Am J Kidney Dis 2004; 43:147153. doi: 10.1053/j.ajkd.2003.09.020

    • Search Google Scholar
    • Export Citation
  • 13.

    Sánchez Quintana A, et al. Renal transplant in plasma cell dyscrasias with lenalidomide treatment after autologous stem cell transplantation. Nephrology (Carlton) 2013; 18:641643. doi: 10.1111/nep.12116

    • Search Google Scholar
    • Export Citation
  • 14.

    Domínguez-Pimentel V, et al. Kidney transplantation after hematopoietic cell transplantation in plasma cell dyscrasias: Case reports. Transplant Proc 2019; 51:383385. 10.1016/j.transproceed.2018.10.005

    • Search Google Scholar
    • Export Citation
  • 15.

    Beitinjaneh A, et al. Solid organ transplantation in survivors of hematopoietic cell transplantation: A single institution case series and literature review. Clin Transplant 2010; 24:E94E102. doi: 10.1111/j.1399-0012.2009.01155.x

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Should a Kidney Transplant Be Performed in a Patient with Multiple Myeloma?

  • 1 Jaya Kala, MD, FASN, is Assistant Professor and Director of the Section of Onco-Nephrology, Division of Renal Disease and Hypertension, Department of Internal Medicine, UTHealth Science Center at Houston-McGovern Medical School, Houston, TX.
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Kidney injury and kidney failure are frequently found in patients with multiple myeloma. With the introduction of novel agents in the last two decades, the outcome of patients with multiple myeloma has tremendously improved. The median survival has reached 7.7 years for patients under the age of 65 years (1). Despite the advances in therapies, patients continue to develop end stage kidney disease (ESKD). The survival of myeloma patients on dialysis is inferior to those without myeloma. Because of poor prognosis of multiple myeloma, kidney transplantation has not been considered an option (2). However, with evolving

Kidney injury and kidney failure are frequently found in patients with multiple myeloma. With the introduction of novel agents in the last two decades, the outcome of patients with multiple myeloma has tremendously improved. The median survival has reached 7.7 years for patients under the age of 65 years (1). Despite the advances in therapies, patients continue to develop end stage kidney disease (ESKD). The survival of myeloma patients on dialysis is inferior to those without myeloma. Because of poor prognosis of multiple myeloma, kidney transplantation has not been considered an option (2). However, with evolving therapies for multiple myeloma, which have significantly improved the progression-free survival and overall survival of patients, it would be reasonable to consider patients with multiple myeloma with advanced chronic kidney disease for eligibility of kidney transplant (3). With improved understanding of risk stratification, clinical prognostic factors, and prediction of early relapse based on genetic testing, an informed decision regarding candidacy of patients with multiple myeloma for kidney transplantation is feasible (4).

Over the last 18 years, several cases have been reported describing patients with multiple myeloma undergoing kidney transplantation after chemotherapy and/or stem cell transplantation (SCT). Patients’ characteristics and outcomes that were reviewed are shown in Table 1. Due to missing data, percentages did not always add up to 100%. Of the 58 cases reviewed, over a 1- to 5-year follow-up, 43 patients underwent chemotherapy with SCT, and 13 experienced chemotherapy alone. After kidney transplant with 28 living donors and 23 deceased donors, relapse of multiple myeloma was seen in 50% (29 of 58) and graft loss in approximately 25% (15 of 58), and approximately 32% (19 of 58) died. The wait period for kidney transplant varied from 4 months before to 13 years after remission. As a result of the rapidly changing treatment landscape, the regimens used varied significantly among the patients. The cytogenetic risk and minimal residual disease status were unknown in these patients.

Table 1

Published reports of outcomes of multiple myeloma patients after kidney transplantation

Table 1

Because of the low number of patients analyzed and significant heterogenicity between studies, no clear conclusion about factors impacting recurrence, death, or graft loss can be made. With improved survival with multiple myeloma, there is a need to address the burden of ESKD, and transplant is a logical strategy. However, heavy immunosuppression for SCT before kidney transplant can increase incidence of myeloid and non-myeloid neoplasms (5, 6). Newly introduced immunomodulators for multiple myeloma can lead to organ rejection. Therefore, while considering kidney transplantation in multiple myeloma patients, several pros and cons need to be examined (Table 2). Although robust data for this unique group of patients are not available, a risk-adapted approach could be used, as proposed, based on expert opinion (Figure 1). A careful evaluation for kidney transplant after multiple myeloma remission is appropriate (6).

Table 2

Favorable and unfavorable factors for kidney transplant in the multiple myeloma patient

Table 2
Figure 1
Figure 1

Proposed evaluation of multiple myeloma patient and kidney failure and follow-up

Citation: Kidney News 14, 6

The diagnosis of multiple myeloma should not be considered as an absolute contraindication for kidney transplant. A multidisciplinary approach with the transplant team and hematology both before and after transplant are crucial to maximize the chances of success for these individuals and maximize years gained from transplanted organs. With an ever-expanding wait list, organ shortage, and prolonged wait times, careful consideration of transplant candidates must be made.

References

  • 1.

    Heybeli C, et al. Kidney transplantation in patients with monoclonal gammopathy of renal significance (MGRS)-associated lesions: A case series. Am J Kidney Dis 2022; 79:202216. doi: 10.1053/j.ajkd.2021.04.015

    • Search Google Scholar
    • Export Citation
  • 2.

    Kormann R, et al. Kidney transplantation for active multiple myeloma or smoldering myeloma: A case-control study. Clin Kidney J 2021; 14:156166. doi: 10.1093/ckj/sfz128

    • Search Google Scholar
    • Export Citation
  • 3.

    Chitty DW, et al. Kidney transplantation in patients with multiple myeloma: Narrative analysis and review of the last two decades. Nephrol Dial Transplant [published online ahead of print December 9, 2020]. doi: 10.1093/ndt/gfaa361; https://academic.oup.com/ndt/advance-article/doi/10.1093/ndt/gfaa361/6028994?login=false

    • Search Google Scholar
    • Export Citation
  • 4.

    Owoyemi I, El Ters M. Pro-kidney transplantation should be considered in patients with multiple myeloma. J Onco-Nephrol 2020; 4:1821. https://journals.sagepub.com/doi/full/10.1177/2399369320902773

    • Search Google Scholar
    • Export Citation
  • 5.

    Nair V. Kidney transplantation in patients with multiple myeloma: A word of caution. J Onco-Nephrol 2020; 4:2225. https://journals.sagepub.com/doi/full/10.1177/2399369320903135

    • Search Google Scholar
    • Export Citation
  • 6.

    Dinh AR, et al. Outcomes of kidney transplant recipients with ESKD due to plasma cell dyscrasia: A case series. Clin Transplant 2022; 36:e14541. doi: 10.1111/ctr.14541

    • Search Google Scholar
    • Export Citation
  • 7.

    Le TX, et al. Kidney transplantation for kidney failure due to multiple myeloma: Case reports. Am J Kidney Dis 2017; 69:858862. doi: 10.1053/j.ajkd.2016.12.023

    • Search Google Scholar
    • Export Citation
  • 8.

    Lum EL, et al. Kidney transplantation in patients with active multiple myeloma: Case reports. Transplant Direct 2017; 3:e200. doi: 10.1097/TXD.0000000000000716

    • Search Google Scholar
    • Export Citation
  • 9.

    Shah S, et al. Risk of relapse of multiple myeloma following kidney transplantation. Clin Kidney J 2019; 12:216223. doi: 10.1093/ckj/sfy137

  • 10.

    Huskey JL, et al. Kidney transplant in the era of modern therapy for multiple myeloma. Transplantation 2018; 102:19942001. doi: 10.1097/TP.0000000000002449

    • Search Google Scholar
    • Export Citation
  • 11.

    Hedvat J, et al. Outcomes of renal transplantation in patients with previous hematologic malignancies. J Onco-Nephrol 2019; 3:124130. https://journals.sagepub.com/doi/10.1177/2399369319865539

    • Search Google Scholar
    • Export Citation
  • 12.

    Leung N, et al. Long-term outcome of renal transplantation in light-chain deposition disease. Am J Kidney Dis 2004; 43:147153. doi: 10.1053/j.ajkd.2003.09.020

    • Search Google Scholar
    • Export Citation
  • 13.

    Sánchez Quintana A, et al. Renal transplant in plasma cell dyscrasias with lenalidomide treatment after autologous stem cell transplantation. Nephrology (Carlton) 2013; 18:641643. doi: 10.1111/nep.12116

    • Search Google Scholar
    • Export Citation
  • 14.

    Domínguez-Pimentel V, et al. Kidney transplantation after hematopoietic cell transplantation in plasma cell dyscrasias: Case reports. Transplant Proc 2019; 51:383385. 10.1016/j.transproceed.2018.10.005

    • Search Google Scholar
    • Export Citation
  • 15.

    Beitinjaneh A, et al. Solid organ transplantation in survivors of hematopoietic cell transplantation: A single institution case series and literature review. Clin Transplant 2010; 24:E94E102. doi: 10.1111/j.1399-0012.2009.01155.x

    • Search Google Scholar
    • Export Citation
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