Irish A B, Winearls C G, Littlewood T
Oxford Regional Renal Unit, Churchill/John Radcliffe Hospital, Oxford, UK.
QJM. 1997 Dec;90(12):773-80. doi: 10.1093/qjmed/90.12.773.
We reviewed the clinical features and outcome of 56 patients with myeloma and severe renal failure managed in a single institution over a 15-year period. Renal failure was recognized within 2 months of the diagnosis of myeloma in 75% of patients, and was the initial presentation of myeloma in 50%. Patients were staged by the Durie and Salmon classification. Light-chain and IgD myeloma accounted for 46% of cases, and Bence-Jones proteinuria was identified in > 90%. In 43%, a potential precipitant of renal failure was identified, usually hypercalcaemia or a non-steroidal anti-inflammatory agent. A preserved corrected calcium at presentation was characteristic (2.40 +/- 0.15 mmol/l, n = 42), even after excluding those with hypercalcaemia requiring specific intervention (n = 14, 2.76 +/- 0.51; p < 0.01): this finding in patients with unexplained acute renal failure should alert clinicians to the possibility of myeloma. Forty-seven patients (84%) required dialysis. Only seven (15%) ever regained renal function. Median survival (all patients) was 8 months. One-third died within 3 months of referral and one-third survived > 1 year. Hypoalbuminaemia and reduced platelet count at presentation were associated with reduced survival, but hypercalcaemia, infection, dialysis, (urgent or long-term), and dialysis modality were not. Chemotherapy was associated with increased survival, but progression of myeloma and infection were the two most frequent causes of death. Severe renal failure was associated with advanced myeloma stage and light-chain/IgD paraproteinaemia. Survival was related to severity of myeloma and not requirement for dialysis per se.
我们回顾了15年间在单一机构中接受治疗的56例骨髓瘤合并严重肾衰竭患者的临床特征及预后情况。75%的患者在骨髓瘤诊断后2个月内出现肾衰竭，50%的患者以肾衰竭为骨髓瘤的首发表现。患者根据Durie和Salmon分期系统进行分期。轻链型和IgD型骨髓瘤占病例的46%，90%以上的患者出现本周蛋白尿。43%的患者可确定肾衰竭的潜在诱因，通常为高钙血症或非甾体类抗炎药。即便排除需要特殊干预的高钙血症患者（14例，血钙2.76±0.51 mmol/L；p<0.01），初诊时校正血钙正常仍为其特征（42例，血钙2.40±0.15 mmol/L）：这一发现应提醒临床医生，对于不明原因的急性肾衰竭患者，需警惕骨髓瘤的可能。47例患者（84%）需要透析治疗。仅7例（15%）恢复了肾功能。中位生存期（所有患者）为8个月。三分之一的患者在转诊后3个月内死亡，三分之一的患者存活超过1年。初诊时低白蛋白血症和血小板计数降低与生存期缩短相关，但高钙血症、感染、透析（紧急或长期）及透析方式与生存期无关。化疗与生存期延长相关，但骨髓瘤进展和感染是最常见的两个死亡原因。严重肾衰竭与骨髓瘤晚期及轻链/IgD副蛋白血症相关。生存期与骨髓瘤严重程度有关，而非透析本身的需求。
