NDT Advance Access originally published online on October 13, 2006
Nephrology Dialysis Transplantation 2006 21(12):3602; doi:10.1093/ndt/gfl579
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Reply
Email: haubitz.marion{at}mh-hannover.deSir,
Dr Magee wonders why patients with a myeloma-associated kidney disease should have a kidney biopsy [1] as he doubts that biopsy results will alter management in these patients justifying the increased risk of bleeding.
In patients with myeloma, renal lesions are heterogeneous and combined pathological lesions may be found. In autopsy series, cast nephropathy is the most common lesion but AL-amyloidosis (not diagnosed pre-mortem) and light chain deposition disease were also found [2]. Forty-five percent of the patients had more than one finding. Besides the diagnosis, renal histology gives information about fibrosis, tubular atrophy, and may help to assess the chance of recovery. In a long-term outcome study, Montseny et al. [3] underlined the value of initial renal biopsy. They found that histology predicts prognosis. In their report, only 41% of the patients were identified as myeloma kidney, whereas AL amyloidosis or light chain disease was found in nearly half of the remaining cases. Patients with light-chain deposition disease (underestimated when biopsy is not performed) had the best prognosis. Renal diagnosis will alter treatment decisions in some patients. Taking into account the poor prognosis of AL amyloidosis, the use of high-dose chemotherapy and autologous stem-cell support will be restricted to very few patients. As Dr Magee stated, plasmapheresis has not shown any benefit in a recently published randomized trial [4]. However, the authors themselves discussed the limitations of their study, one of them, the missing renal biopsy, as an inclusion criterion.
Dr Magee has stressed an important point: the increased risk of bleeding in patients with myeloma. This has been found in patients with amyloidosis [5], and may be due to amyloid-associated factor X deficiency or the deposition of amyloid either in the vessel wall or in the perivascular region. However, biopsy studies of Hergesell et al. [6] and Manno et al. [7] did not report an increased incidence of major complications nor did Magee et al. in 21 patients with myeloma [8]. Nevertheless, there must be a clear awareness of the bleeding tendency in those patients (history of bleeding, haematomas at examination, abnormal coagulation tests) not to further increase the risk by performing a kidney biopsy.
Conflict of interest statement. None declared.
1Department of Nephrology
2Department of Haematology
Haemostaseology and Oncology
Hannover Medical School
Hannover
Germany
References
- Haubitz M and Peest D. (2006) Myeloma—new approaches to combined nephrological-haematological management. Nephrol Dial Transplant 21:582–590.
[Free Full Text] - Herrera GA, Joseph L, Gux Hough A, Barlogie B. (2004) Renal pathologic spectrum in an autopsy series of patients with plasma cell dyscrasia. Arch Pathol Lab Med 128:875–879.[Web of Science][Medline]
- Montseny JJ, Kleinknecht D, Meyrier A, et al. (1998) Long-term outcome according to renal histological lesions in 118 patients with monocloncal gammopathies. Nephrol Dial Transplant 13:1438–1445.
[Abstract/Free Full Text] - Clark WF, Stewart AK, Rock GA, et al. (2005) Plasma exchange when myeloma presents as acute renal fialure. Annals Int Med 143:777–784.
[Abstract/Free Full Text] - Eiro M, Katoh T, Watanabe T. (2005) Risk factors for bleeding complictions in percutaneous renal biopsy. Clin Exp Nephrol 9:40–45.[CrossRef][Medline]
- Hergesell O, Felten H, Andrassy K, Kuhn K, Ritz E. (1998) Safety of ultrasound-guided percutaneous renal biopsy-retrospective analysis of 1090 consecutive cases. Nephrol Dial Trnasplant 13:975–977.
[Abstract/Free Full Text] - Manno C, Strippoli GF, Arnesano L, et al. (2004) Predictors for bleeding complications in percutaneous ultrasound-guided renal biopsy. Kidney Int 66:1570–1577.[CrossRef][Web of Science][Medline]
- Magee C, Vella JP, tormex WP, Walshe JJ. (1998) Multiple myeloma and renal failure: one center's experience. Renal Failure 20:597–606.[Web of Science][Medline]
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