Abstract
Multiple myeloma (MM) is characterized by a proliferation of malignant plasma cells and a subsequent overabundance of monoclonal paraprotein. This disease commonly presents with hypercalcemia, kidney failure, anemia, and bone lesions. Acute kidney failure (AKF) as an initial presentation of MM has rarely been reported. Herein, we present a case of a 49-year-old female who was admitted to our intensive care unit (ICU) for AKF in June 2017. The patient was admitted to our emergency room (ER) with abdominal pain and biliary vomiting within six days. From the laboratory tests, we highlight a serum creatinine of 19 mg/dl and urea of 377 mg/dl. The physical examination was globally unremarkable. Once clinically stable, she was admitted to our infirmary with a creatinine of 8.00 mg/dl. The patient underwent an extensive study: markers for hepatitis B and C, human immunodeficiency syndrome (HIV), and autoimmune markers were all negative; renal ultrasound, abdominal and pelvic CT had no relevant alteration; and the skeletal survey had no significant change. Peripheral blood smear showed no abnormalities. Serum immunoglobulin analysis revealed an elevated immunoglobulin A (IgA). Serum protein electrophoresis showed a monoclonal spike and urine protein electrophoresis showed an increased amount of protein consistent with Kappa light chains. The Kappa:Lambda chain ratio was increased. In order to understand the etiology of this AKF, we ended up performing a kidney biopsy, which was compatible with a myeloma kidney. The patient was transferred to the Portuguese Oncology Institute in Porto and initiated chemotherapy. Two months after the hospital discharge, creatinine levels were stable around 1.5 g/dL. This case illustrates AKF as the initial and sole presentation of MM. This presentation, even though previously reported, is very uncommon, especially considering that it occurred in a young woman and it was associated with light chain precipitation of IgA. MM is an important differential diagnosis in AKF, particularly when excluded pre and post-renal etiologies. Although being an invasive procedure with inherent possible complications, a kidney biopsy is still a very important procedure that was essential in this case to achieve a final diagnosis and, therefore, the patients' treatment.
Highlights
Multiple myeloma (MM) is a debilitating malignancy that is part of a spectrum of diseases ranging from monoclonal gammopathy of unknown significance (MGUS) to plasma cell leukemia
First described in 1848, MM is characterized by a proliferation of malignant plasma cells and a subsequent overabundance of monoclonal paraprotein (M protein)
This disease commonly presents with hypercalcemia, renal failure, anemia, and bone lesions, which are used in diagnostic evaluation for MM
Summary
Multiple myeloma (MM) is a debilitating malignancy that is part of a spectrum of diseases ranging from monoclonal gammopathy of unknown significance (MGUS) to plasma cell leukemia. It was observed that relatives of patients with MGUS as compared to normal controls had a higher relative risk of developing MGUS (2.8 fold), MM (2.9 fold), Waldenström macroglobulinemia (4.0 fold), and chronic lymphocytic leukemia [2] This disease commonly presents with hypercalcemia, renal failure, anemia, and bone lesions (the CRAB features), which are used in diagnostic evaluation for MM. The comprehensive laboratory panel included hepatitis B surface antigen (HbsAg), hepatitis C antibody (HCV Ag), HIV, anti-nuclear antibody (ANA), antineutrophil cytoplasmic antibody (ANCA), and glomerular basement membrane antibody (GBM Ab), which were all negative She did another renal ultrasound (the first one was made while she was in the ER) and showed both kidneys measuring 12 cm of bipolar diameter with no evidence of renal mass lesions, hydronephrosis, or calcifications (Figure 1). The patient was referred for nephrology and internal medicine consultation, and two months following discharge, the creatinine was stable between 1.3 and 2.3 g/dl
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