Zhonghua Nei Ke Za Zhi. 2017 Nov 1;56(11):871-875. doi: 10.3760/cma.j.issn.0578-1426.2017.11.022.
Renal impairment (RI) is a common complication of multiple myeloma (MM), which is presented as chronic kidney disease (CKD) or acute kidney injury (AKI). The typical pathological feature is cast nephropathy. Presently international system staging (ISS) is used in evaluating MM. Although the classic Durie-Salmon staging system could be still used in clinical practice, it may miss out some patients with renal impairment. For evaluations of RI in MM patients with CKD, it's recommended to assess the estimated glomerular filtration rate (eGFR) by creatinine based formula CKD-epidemiology collaboration (EPI) or modification of diet in renal disease(MDRD) and to stage the renal injuries according to 2013 Kidney Disease Improving Global Outcomes (KDIGO) CKD guidelines. For MM patients with AKI, KDIGO AKI guidelines is recommended for evaluation. Renal biopsy is not a routine procedure in all MM patients. It's necessary for patients presenting with glomerular injuries such as albuminuria > 1 g/24 h to eliminate immunoglobulin associated amyloidosis (AL) and monoclonal immunoglobulin deposition disease (MIDD). The effective treatment of MM can reduce serum light chain concentration and improve renal function. The basis of the RI treatment in MM is bortizomib-based regimen, which does not require dosage adjustment in patients with dialysis or renal insufficiency. Thalidomide and lenalidomide are two major immunomodulators in MM treatment. Thalidomide can be used effectively in RI patients without dosage adjustment while lenalidomide should be used cautiously in patients with mild or moderate RI with dosage adjustment and serum toxicity surveillance. High-dose therapy (HDT) and autologous peripheral blood stem cell transplantation (APBSCT) can be therapeutical options for RI patients younger than 65 y, and they should be considered more prudently in patients with severe renal insufficiency (GFR<30 ml/min). For patients who are not suitable for the treatment mentioned above, they can be treated with conventional chemotherapy, including VAD (vincristine, adriamycin and dexamethasone), MP (mephalan and prednisolone) and high-dose dexamethasone regimen. Adequate hydration (at least 3 litres of fluid intake a day or 2 L·m(-2)·d(-1)) and correcting reversible causes of RI are key points for the supportive care. Renal replacement therapy (more often hemodialysis) should be started in patients with severe AKI and end stage renal disease (ESRD). High flux or high cut-off membrane are recommended because routine hemodialysis could not remove the serum free light chain (sFLC) effectively. Plasmapheresis (PE) is recommended for patients with hyperviscosity syndrome or cast nephropathy presented with AKI, which may help to increase the dialysis-independency.
肾功能损害（RI）是多发性骨髓瘤（MM）的常见并发症，表现为慢性肾脏病（CKD）或急性肾损伤（AKI）。典型的病理特征是管型肾病。目前国际分期系统（ISS）用于评估MM。虽然经典的Durie-Salmon分期系统仍可用于临床实践，但它可能会遗漏一些肾功能损害患者。对于CKD的MM患者的RI评估，建议通过基于肌酐的公式CKD-流行病学协作组（EPI）或肾脏病饮食改良（MDRD）评估估算肾小球滤过率（eGFR），并根据2013年改善全球肾脏病预后组织（KDIGO）CKD指南对肾损伤进行分期。对于AKI的MM患者，建议采用KDIGO AKI指南进行评估。肾活检并非所有MM患者的常规检查。对于出现蛋白尿>1 g/24 h等肾小球损伤的患者，有必要排除免疫球蛋白相关淀粉样变性（AL）和单克隆免疫球蛋白沉积病（MIDD）。MM的有效治疗可降低血清轻链浓度并改善肾功能。MM中RI治疗的基础是以硼替佐米为基础的方案，该方案在透析或肾功能不全患者中无需调整剂量。沙利度胺和来那度胺是MM治疗中的两种主要免疫调节剂。沙利度胺可有效用于RI患者且无需调整剂量，而来那度胺在轻度或中度RI患者中应谨慎使用，并需调整剂量及监测血清毒性。大剂量治疗（HDT）和自体外周血干细胞移植（APBSCT）可作为65岁以下RI患者的治疗选择，对于严重肾功能不全（GFR<30 ml/min）的患者应更谨慎考虑。对于不适合上述治疗的患者，可采用传统化疗，包括VAD（长春新碱、阿霉素和地塞米松）、MP（美法仑和泼尼松龙）和大剂量地塞米松方案。充足的水化（每天至少摄入3升液体或2 L·m(-2)·d(-1)）以及纠正RI的可逆病因是支持治疗的关键。对于严重AKI和终末期肾病（ESRD）患者应开始肾脏替代治疗（更多情况下是血液透析）。建议使用高通量或高截留膜，因为常规血液透析无法有效清除血清游离轻链（sFLC）。对于出现AKI的高黏滞综合征或管型肾病患者，建议进行血浆置换（PE），这可能有助于提高透析的独立性。
