(1336) A Chain Reaction: Presentation of Sudden Renal Failure After Multiple Myeloma Diagnosis

Introduction: Kidney disease is an anticipated complication in half of all patients diagnosed with multiple myeloma (MM), and fulminant renal failure with dialysis dependence occurs in only 1-3% of cases. When the initial diagnosis of MM includes acute kidney injury to any extent, approximately 80% can expect improvement with induction chemotherapy followed by hematopoietic stem cell transplantation. The need for dialysis and time between onset of renal failure and initiation of MM treatment predict kidney recovery. Close outpatient monitoring of renal function is recommended. Prompt hematology consult by the critical care team to start chemotherapy may prevent dialysis dependence.

Description: A 61-year-old male with history of monoclonal gammopathy diagnosed six months prior was admitted to the ICU at a small community hospital for hyperkalemia and oliguric renal failure requiring urgent dialysis.  Initial complaints were fatigue, nausea, and vomiting for 3 days, as well as associated back pain and reduction in urine output for the past day. Prior to this, patient was asymptomatic in his usual state of health. Vitals were stable. Exam was remarkable for ill-appearance and 1+ non-pitting edema of the lower extremities. Notably, patient was not altered. Workup revealed potassium 8.4 mMol/L, BUN 137 mg/dL, creatinine 19.9 mg/dL, bicarbonate < 5 mMol/L, and anion gap >21 mMol/L, and unremarkable ECG. Patient received continuous venovenous hemodiafiltration on ICU day 1 and 2. Although electrolyte derangements generally improved, azotemia persisted and he remained oliguric and dialysis dependent. Bone marrow biopsy revealed MM and patient was initiated on bortezomib, cyclophosphamide, and dexamethosone three days after admission. Due to continued oliguria and dialysis dependence, renal biopsy was performed, demonstrating light chain cast nephropathy. Patient was eventually discharged with scheduled outpatient dialysis.

Discussion: Dialysis dependence can be a severe consequence of MM. By detecting renal dysfunction early and initiating induction chemotherapy promptly, a patient’s chance at recovering kidney function is maximized. If a patient with known monoclonal gammopathy is admitted to the ICU for acute renal failure, consideration for urgent initiation of induction treatment of MM is recommended.