Myeloma and Kidney Disease
Myeloma is a cancer of the bone marrow. The bone marrow is the spongy space inside bones, where blood is made. Marrow is found in all bones, but most of it is in the ribs, backbone, pelvis and the larger bones of the arms and legs.
The marrow makes several different types of cell for the blood. Cells are tiny particles, each one alive and with a special function. There are red blood cells which carry oxygen around the body, and white blood cells which help fight infection. In myeloma, one particular type of white blood cell, the plasma cell, becomes cancerous. This means that the plasma cells grow uncontrollably.
The plasma cell is an important part of the immune system, the bodys natural defence. Plasma cells produce antibodies, which are tiny molecules dissolved in the blood. Antibodies recognise germs and stick to them, making them burst or helping other parts of the immune system destroy them.
In myeloma, as the plasma cells grow uncontrollably, they can produce extremely large amounts of antibody. The antibody passes in to the blood, and can cause problems with the kidneys. Damage occurs if the antibody passes through the filters in the kidneys into tiny drainage tubes. There they can form lumps, blocking the flow of urine. Blockage to enough of the tiny tubes in the kidneys can then cause kidney failure.
This varies from person to person. Most patients with myeloma do not get kidney damage, in others kidney damage can be severe. If there is damage to the kidneys, it is often at its worst when the myeloma is first diagnosed, and then the kidneys improve with treatment.
Blood tests are used to measure kidney function. A chemical called creatinine is widely used. Creatinine builds up to higher levels in the blood if the kidneys are damaged. Creatinine has a normal level of about 100, and if the kidneys fail completely it rises to about 1000. By doing frequent blood tests, the progress of the kidneys can be monitored.
If a myeloma patient develops kidney damage, sometimes a kidney biopsy will be performed to confirm the diagnosis. A biopsy is when a needle is passed into the kidney and a fragment removed to examine under the microscope (click here for more information on kidney biopsy). In some cases, kidney damage develops before myeloma is suspected, and the kidney biopsy is the test that makes this diagnosis.
Many people with myeloma and kidney disease improve with treatment, so that dialysis (artificial kidney treatment) is not needed. However the kidneys seldom go back to normal with treatment, so long term monitoring of the kidneys is needed.
If the kidneys do fail completely, the blood and kidney specialists, will carefully assess the benefits and complications of treatment. These will be discussed with you and your family. Dialysis treatment can be successful in some myeloma patients, but dialysis only removes poisonous chemicals from the blood. It does not make the kidneys better and does not treat the underlying myeloma.
There are two important ways to try and improve the kidneys. First, the blockages in the tubes in the kidney can be washed away by giving more fluids. People with myeloma are commonly short of water, so at first fluid is given through a drip in the arm. In the long term, it is usually necessary to drink over 3 litres (5 pints) of fluid a day to keep the kidneys flushed through, so long as the kidneys are able to pass this much urine. If someone has very poor kidney function or is on dialysis, they may need to restrict their water intake. It is possible that there is some benefit in removing the myeloma protein form the blood, so that it cannot pass into the kidneys. This can be done using dialysis or plasma exchange. Because the benefit from this treatment is uncertain, clinical trials are under way, and people with myeloma and kidney involvement in the UK may be asked to take part.
Secondly, the bone marrow can be treated, reducing the activity of myeloma in the bone marrow. This is described in the section What is the Treatment for Myeloma?.
The symptoms of myeloma include tiredness, coughs and colds and a loss of appetite, sickness, and depression. There can be excessive bruising or bleeding.
Kidney disease is not by itself painful, though severe kidney failure can make you feel generally run down with sickness and itching. However, in some cases the myeloma cells in the bone marrow can cause pain (often in the ribs or in the back). Treatment for pain is very effective, using painkillers and sometimes a short course of radiotherapy (radiation treatment). Always tell the medical team if you are starting to develop new pains, so you can get treatment as soon as possible.
Myeloma is not usually curable, but treatment can keep myeloma under control. Drugs are usually used to try and kill the myeloma cells in the bone marrow. This type of treatment is called chemotherapy. Unfortunately chemotherapy also kills some normal cells in the marrow, so the drugs have to be given carefully. New approaches to myeloma treatment have improved results over the last 15 years, including the use of a bone marrow transplant and a newer type of drug called bortezomib (trade name Velcade). Your blood specialist (haematologist) will advise you on the best regime of medication
Myeloma is a very serious condition, and can cause death. The treatment of myeloma is more complicated if there is kidney trouble. However, the survival in individual cases depends on the details of the case, so that some badly affected people die in weeks or months, but others remain well on treatment for many years. You must therefore ask your hospital specialists for individual advice.
This varies from person to person. In many cases, after a course of drugs (chemotherapy), life may get almost back to normal, and a return to work and other activities such as holidays may be possible. However, it is common to feel tired during the first few months of treatment, and it may be best not to plan holidays or an early return to work. Myeloma varies a lot from person to person, so ask your medical team for advice about the activities you can perform safely.
Ask your doctors and nurses for advice on any extra help needed. This might be practical help at home, advice on how to ask for financial help, or support from counselling groups or other organisations. Further written information is produced by the International Myeloma Foundation (tel 0131 557 3332) www.myeloma.org.uk and Macmillan Cancer Support (tel 0808 808 00 00) www.macmillan.org.uk
Written by Rob Higgins and Andy Stein, Renal Consultants, Walsgrave Hospital, Coventry, 1999.
The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.