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SPM- Renal > The Kidneys and Myeloma > Flashcards

The Kidneys and Myeloma Flashcards

1
Q

What is multiple myeloma?

A

Multiple myeloma is a cancer formed from plasma cells that hyper-secrete a single Ig (Monoclonal Ig). There are multiple plasma cells tumours found within the bone marrow

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2
Q

What are plasma cells?

A

Plasma cells are mature B cells that secrete Ig

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3
Q

What is the monoclonal Ig that is hyper-secreted called in multiple myeloma?

A

M- Protein- This can either be in-tact Ig or just light chains

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4
Q

What is the useful acronym for remembering the features of myeloma?

A 
C- Calcium raised
R- Renal Impairment
A- Anaemia
B- Bone Pain
I- Infection/Immunosuppressed
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5
Q

What kind of lesions of the bone are seen in myeloma?

A

Lytic lesions where there is a clear almost punched out margin to the bone. X-rays of the skull have a pepper pot appearance.

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6
Q

What causes the hypercalcaemia in myeloma?

A

There is breakdown of the bone matrix which produces lytic lesions- this occurs due to stimulation of osteoclasts

This causes calcium to increase and also causes increases in ALP

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7
Q

What are the diagnostic criteria for multiple myeloma?

A

M-Protein >30 g/L
Bone marrow plasma cells greater than 10%
Related end-organ damage

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8
Q

Describe the process that causes casts to form in myeloma

A

Process is called cast nephropathy

Light chains enter the filtrate and are normally re-absorbed in the PCT. In myeloma there is an excess of light chains and the re-absorption capability is overwhelmed.

This causes there to be an abnormal level of light chains in the filtrate which precipitate further in the nephron to form casts, particularly in the loop of Henle. Casts form when light chains bind to THP.

The rate of cast formation if directly proportional to the amount of light chain produced by the myeloma

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9
Q

What do light chains bind to to form casts?

A

THP

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10
Q

Why do casts formed in myeloma cause renal damage?

A

They deposit to cause inflammation and sclerosis which leads to long term renal damage.

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11
Q

What other features increase the amount of cast formation to cause greater renal damage?

A

Dehydration- (If suspected give IV fluids aggressively)
Furosemide
Acidosis
Hypercalcaemia (this is bad as myeloma causes this itself)

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12
Q

What is the tumour marker used in myeloma?

A

M-Protein is the tumour marker- this is the mono-clonal Ig produced by the plasma cells

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13
Q

What kind of symptoms might someone with myeloma present with?

A 
Fatigue
Lethargy
Bone pain
Weight loss
Easy fractures
Recurrent infections (suppressed other Ig)
High calcium on results in past

Features are not very specific so have a low threshold for doing a myeloma screen- consider for anyone with an AKI as the associated nephropathy can occur very quickly.

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14
Q

What is included in a myeloma screen?

Urine, Blood, Imaging

A

Urine
Urine bence jones proteins (light chains in the urine)

Blood
Serum Protein Electrophoresis- Showing a mono-clonal rise in a single Ig
Serum Free Light Chains
Calcium/ ALP- Marker of bone breakdown
FBC- Normocytic anaemia

Imaging of any symptomatic areas- (investigate for lytic lesions

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15
Q

What further investigations would be done after an initial myeloma screen?

A

Imaging of bone to investigate for lytic lesions
Bone marrow biopsy (Plasma cells >10% for diagnosis)
Kidney biopsy- if suspecting renal impairment could be due to myeloma, but if light chains are very high can generally assume

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16
Q

What is the management for hypercalcaemia in myeloma?

A 
IV Bisphosphonates (Pamidronate, Zolidronate)
- Bisphosphonates reduce osteoclast activity and so reduce bone breakdown
IV Fluids
17
Q

Why is it important to correct any metabolic acidosis in myeloma kidney? How is this done?

A

Acidosis precipitates cast formation and so worsens the condition

Treated with sodium bicarb (care must be taken in CKD and AKI as can increase the sodium load leading to fluid retention)

18
Q

What medication should be stopped in patients developing myeloma kidney?

A

Furosemide as it increases the rate of cast formation

19
Q

What is the standard treatment for myeloma?

A

Dexamethasone, Cyclophosphamide and Thalidomide

Other variations available e.g Bortezomib and lenolidomide

20
Q

What can be done after standard treatment and it improves survival but it is not curative?

A

Autologous stem cell transplant-

G-CSF given and stem cells are harvested. Patient is then given very strong chemotherapy to deplete their marrow. Replaced with the stem cells and this rescues the patient (would die from chemo otherwise)

SPM- Renal (9 decks)

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