Kihara M, Ikeda Y, Shibata K, Masumori S, Ebira H
Second Department of Internal Medicine, Yokohama Minami-Kyousai Hospital, Japan.
Nihon Jinzo Gakkai Shi. 1994 Feb;36(2):177-81.
A 52-year-old man was admitted to our hospital because of oliguric renal failure. The patient was well until four weeks earlier, when he developed nausea and anorexia. The urea nitrogen was 179 mg/dl, creatinine 29.2 mg/dl, uric acid 19.0 mg/dl and potassium 8.6 mEq/1. Hemodialysis was started immediately after admission. Bone marrow aspiration showed atypical plasma cell infiltration consistent with multiple myeloma. The immunoelectrophoresis revealed urinary lambda -type Bence Jones protein and serum IgD- lambda -type M protein. The findings of renal biopsy study were consistent with myeloma kidney. On the fourth hospital day, administration of prednisolone 40 mg and melphalan 2 mg was started. The patient also underwent double filtration plasma-pheresis (DFPP). Serum IgD level was decreased from 950 to 113 mg/dl. After a course of chemotherapy, however, he developed severe leukopenia and was complicated with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. This complication was successfully treated with imipenem/cilastation and vancomycin combined with granulocyte colony stimulating factor (G-CSF). The patient was discharged and returned to work on maintenance hemodialysis. Fifteen months after the presentation, he manifested progressive peripheral nerve disturbances. Three months later, the patient died--not from renal failure, but from ventricular arrhythmia. The application of maintenance dialysis therapy to myelomatosis has until now been questioned. The present case, however, suggests that aggressive treatment consisting of chronic dialysis therapy as well as chemotherapy and plasma exchange should be administered even in patients with established renal failure.
一名52岁男性因少尿性肾衰竭入院。该患者此前身体状况良好，直到四周前出现恶心和厌食症状。尿素氮为179mg/dl，肌酐29.2mg/dl，尿酸19.0mg/dl，血钾8.6mEq/1。入院后立即开始血液透析。骨髓穿刺显示非典型浆细胞浸润，符合多发性骨髓瘤。免疫电泳显示尿λ型本周氏蛋白和血清IgD-λ型M蛋白。肾活检结果与骨髓瘤肾病相符。入院第四天，开始给予泼尼松龙40mg和马法兰2mg。患者还接受了双重滤过血浆置换（DFPP）。血清IgD水平从950mg/dl降至113mg/dl。然而，经过一个疗程的化疗后，他出现了严重的白细胞减少症，并并发耐甲氧西林金黄色葡萄球菌（MRSA）肺炎。通过亚胺培南/西司他丁和万古霉素联合粒细胞集落刺激因子（G-CSF）成功治疗了该并发症。患者出院，继续进行维持性血液透析并恢复工作。发病15个月后，他出现了进行性周围神经功能障碍。三个月后，患者死亡——并非死于肾衰竭，而是死于室性心律失常。迄今为止，维持性透析治疗在骨髓瘤病中的应用一直受到质疑。然而，本病例表明，即使是已确诊肾衰竭的患者，也应给予包括慢性透析治疗、化疗和血浆置换在内的积极治疗。
