Approach to acute renal failure in biopsy proven myeloma cast nephropathy: Is there still a role for plasmapheresis?

Abstract

A 75-year-old Caucasian man with hypertension and severe, emphysema, presented to the Veterans Administration New York Harbor Health Care System Hospital outpatient clinic, for his bi-yearly physical in March 2003. The patient had a macrocytic anemia and a serum creatinine (Scr) level of 3.3mg per 100 ml (baseline Scr, 0.9 mg per 100 ml 1 month earlier). An outpatient nephrology consultation was initiated after a comprehensive negative gastrointestinal workup. Detailed history and physical examination were performed. He denied the following symptoms: headache, visual changes, hesitancy, frequency, oliguria, dysuria, nausea, vomiting, fever, chills, bone pain, and change in weight, appetite or bowel habits. He also denied the following: hematochezia, melena, fatigue, dyspnea, dizziness, or chest pain. His medications on presentation included lisinopril 20 mg day -1 and combination albuterol and atrovent inhaler. He denied occupational or chemical exposure, and use of herbal or over-the-counter medications. The patient quit smoking and drinking over 20 years ago. He had no history of diabetes mellitus, macroscopic hematuria, or tuberculosis. His family history was non-contributory. Physical examination revealed an alert, healthy-appearing older male with a blood pressure of 134/83 mm Hg (without orthostasis), pulse rate of 78 beats min -1 , weight of 89kg, and body mass index of 29 kg m -2 . There was no lymphadenopathy. Heart examination showed regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to percussion and auscultation. Abdomen had normal bowel sounds, was soft, non-tender, with no masses or hepatomegaly. There was dullness in Traube's space on deep inspiration. Extremities revealed no clubbing, cyanosis, rash, or edema. Neurological examination was essentially normal. Diagnostic studies were performed. Renal ultrasound showed 11.7 and 12.4 cm right and left kidney, respectively. Both kidneys demonstrated mildly increased, diffuse parenchymal echogenicity, consistent with mild medical renal disease, with no scarring or masses. There was no hydronephrosis. Renal veins were patent bilaterally. The bladder was not distended. Spleen was enlarged, measuring 12.6 cm. Results of the laboratory studies are detailed in Table 1. Urinary dipstick showed trace protein but sulfosalicyclic acid testing was not performed. Twenty-four-hour urine protein level was 3.1 g day -1 . Urine protein electrophoresis was unremarkable, but urine and serum immunofixation electrophoresis and serum protein electrophoresis showed a monoclonal band (IgAκ). His quantitative serum immunoglobulin A (IgA) level was 2330 mg per 100ml. Bone marrow biopsy revealed 90% plasma cells (Figure 1). Skeletal survey was negative. A diagnosis of multiple myeloma (MM) Durie-Salmon stage III was made.