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Song SM, Jeon J, Jang HR, Kim K, Huh W, Kim YG, Lee JE. Acute kidney injury in bortezomib-treated patients with multiple myeloma. Nephrol Dial Transplant 2023; 38:2077-2085. [PMID: 36662030 DOI: 10.1093/ndt/gfad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The nephrotoxicity of bortezomib, a proteasome inhibitor, has not yet been elucidated, although tumor lysis syndrome (TLS) associated with multiple myeloma (MM) has been reported to increase after introduction of the drug. This study compared the incidence and risk factors for acute kidney injury (AKI) and TLS in patients with MM after bortezomib-based chemotherapy to investigate drug-related nephrotoxicity. METHODS From 2006 to 2017, 276 patients who underwent a first cycle of bortezomib-based chemotherapy for MM were identified in a single tertiary hospital. Laboratory TLS was defined according to the Cairo-Bishop definition. Development of AKI was assessed by AKI Network criteria within 7 days of the first chemotherapy. RESULTS The median (interquartile range) age was 65 (56-72) years, and baseline estimated glomerular filtration rate (eGFR) was 61.3 (34.1-89.1) mL/min/1.73 m2. The incidences of AKI and laboratory TLS were 17% (n = 47) and 13% (n = 36), respectively. Ten (3.6%) subjects met both AKI and TLS criteria. Multivariate analyses showed that lower eGFR category [30-59, odds ratio (OR) 3.005 (95% confidence interval 1.163-7.976); 15-29, OR 4.225 (1.183-15.000); <15, OR 16.154 (3.831-70.920) vs ≥60, P < .001], lower serum albumin level [per 1 increase, OR 0.479 (0.256-0.871), P = .018], renal amyloidosis [OR 13.039 (4.108-44.041), P < .001] and use of acyclovir during bortezomib treatment [OR 3.689 (1.133-14.469), P = .042] were predictors of AKI. MM stages and β-2-microglobulin were not associated with increased risk of AKI. Regarding laboratory TLS, MM stage and β-2-microglobulin were higher in those with TLS than in others. In multivariate analyses, β-2-microglobulin level [OR 1.204 (1.005-1.461), P = .038] and absence of high-risk chromosome abnormalities [OR 0.143 (0.022-0.588), P = .016] were associated with higher risk of TLS. CONCLUSIONS Development of AKI was often observed in the absence of TLS in patients with MM after treatment with bortezomib. In addition, the risk factors for AKI and TLS varied widely. These findings indicate the potential nephrotoxicity of bortezomib irrespective of TLS in patients with decreased kidney function.
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Affiliation(s)
- Seung Min Song
- Nephrology Division; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Junseok Jeon
- Nephrology Division; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hye Ryoun Jang
- Nephrology Division; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kihyun Kim
- Hematology Division; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wooseong Huh
- Nephrology Division; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yoon-Goo Kim
- Nephrology Division; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Eun Lee
- Nephrology Division; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Sterner RC, Rose WN. Unique Presentation of Bortezomib-Associated Thrombotic Microangiopathy Responsive to Therapeutic Plasma Exchange and Eculizumab Therapy. Hematol Rep 2022; 14:119-125. [PMID: 35466182 PMCID: PMC9036209 DOI: 10.3390/hematolrep14020018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/26/2022] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombotic microangiopathies (TMA) are a rare group of life-threatening hematological conditions characterized by thrombocytopenia and microangiopathic hemolytic anemia. Although our understanding of the pathophysiology and the availability of diagnostic testing has improved for primary TMAs, such as thrombotic thrombocytopenic purpura, the pathophysiology underlying secondary TMAs, including drug-induced TMAs (DITMAs), remains less clear. In this case report, we present the unique case of a patient with a history of multiple myeloma that presented four months after the initiation of bortezomib therapy with a bortezomib-associated TMA that responded to therapeutic plasma exchange (TPE) with plasma replacement and eculizumab therapy. This case demonstrates the possible utility of TPE with plasma replacement and eculizumab therapy in DITMA patients that fail to respond following a trial of holding the suspected medication.
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Cassol CA, Williams MP, Caza TN, Rodriguez S. Renal and pulmonary thrombotic microangiopathy triggered by proteasome-inhibitor therapy in patient with smoldering myeloma: A renal biopsy and autopsy case report. Medicine (Baltimore) 2019; 98:e17148. [PMID: 31574818 PMCID: PMC6775360 DOI: 10.1097/md.0000000000017148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Thrombotic microangiopathy (TMA) is a group of clinical syndromes characterized by excessive platelet activation and endothelial injury that leads to acute or chronic microvascular obliteration by intimal mucoid and fibrous thickening, with or without associated thrombi. It frequently involves the kidney but may involve any organ or system at variable frequencies depending on the underlying etiology. Among its numerous causes, drug toxicities and complement regulation abnormalities stand out as some of the most common. A more recently described association is with monoclonal gammopathy. Lung involvement by TMA is infrequent, but has been described in Cobalamin C deficiency and post stem-cell transplantation TMA. PATIENT CONCERNS This is the case of a patient with smoldering myeloma who received proteasome-inhibitor therapy due to retinopathy and developed acute renal failure within one week of therapy initiation. DIAGNOSES A renal biopsy showed thrombotic microangiopathy. At the time, mild pulmonary hypertension was also noted and presumed to be idiopathic. INTERVENTIONS Given the known association of proteasome-inhibitor therapy with thrombotic microangiopathy, Bortezomib was discontinued and dialysis was initiated. OUTCOMES Drug withdrawal failed to prevent disease progression and development of end-stage renal disease, as well as severe pulmonary hypertension that eventually lead to the patient's death. LESSONS To our knowledge, this is the first reported case of pulmonary involvement by TMA associated with monoclonal gammopathy which appears to have been triggered by proteasome-inhibitor therapy. Clinicians should be aware of this possibility to allow for more prompt recognition of pulmonary hypertension as a potential manifestation of monoclonal gammopathy-associated TMA, especially in patients also receiving proteasome-inhibitors, so that treatment aiming to slow disease progression can be instituted.
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Affiliation(s)
| | | | | | - Sophia Rodriguez
- Queens Office of the Chief Medical Examiner of the City of New York, New York
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4
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Late Presentation of Carfilzomib Associated Thrombotic Microangiopathy. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2019; 7:240-243. [PMID: 31457071 PMCID: PMC6711615 DOI: 10.12691/ajmcr-7-10-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Multiple Myeloma (MM) is a plasma cell disorder characterized by abnormal proliferation of plasma cells resulting in overproduction of paraprotein. Proteasome inhibitors (PI) have been a corner stone for the treatment of MM. Thrombotic Microangiopathy (TMA) is a recent hematological adverse event that has newly been recognized in multiple PI. TMA leads to end-organ damage and infarction by microthromobi. TMA pathophysiology is not well understood and has multiple etiologies. We present a case of PI-induced TMA, along with literature review of cases diagnosed from 2008-2018. Unique to our case is the onset of presentation, more than 24 months after initiating carfilzomib. Our case highlights the need for vigilant monitoring and the importance of clinical suspicion in patients at risk for TMA.
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5
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Bortezomib therapy in patients with relapsed/refractory acquired thrombotic thrombocytopenic purpura. Ann Hematol 2016; 95:1751-6. [DOI: 10.1007/s00277-016-2804-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/28/2016] [Indexed: 10/21/2022]
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Yui JC, Van Keer J, Weiss BM, Waxman AJ, Palmer MB, D'Agati VD, Kastritis E, Dimopoulos MA, Vij R, Bansal D, Dingli D, Nasr SH, Leung N. Proteasome inhibitor associated thrombotic microangiopathy. Am J Hematol 2016; 91:E348-52. [PMID: 27286661 DOI: 10.1002/ajh.24447] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/03/2016] [Accepted: 06/07/2016] [Indexed: 12/21/2022]
Abstract
A variety of medications have been implicated in the causation of thrombotic microangiopathy (TMA). Recently, a few case reports have emerged of TMA attributed to the proteasome inhibitors (PI) bortezomib and carfilzomib in patients with multiple myeloma. The aim of this case series was to better characterize the role of PI in the etiology of drug-induced TMA. We describe eleven patients from six medical centers from around the world who developed TMA while being treated with PI. The median time between medication initiation and diagnosis of TMA was 21 days (range 5 days to 17 months). Median laboratory values at diagnosis included hemoglobin-7.5 g dL(-1) , platelet count-20 × 10(9) /L, LDH-698 U L(-1) , creatinine-3.12 mg dL(-1) . No patient had any other cause of TMA, including ADAMTS13 inhibition, other malignancy or use of any other medication previously associated with TMA. Nine patients had resolution of TMA without evidence of hemolysis after withdrawal of PI. Two patients had stabilization of laboratory values but persistent evidence of hemolysis despite medication withdrawal. One patient had recurrence of TMA with rechallenge of PI. There is a strong level of evidence that PI can cause DITMA. In evaluating patients with suspected TMA, PI use should be recognized as a potential etiology, and these medications should be discontinued promptly if thought to be the cause of TMA. Am. J. Hematol. 91:E348-E352, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Jan Van Keer
- Department of Cardiology; University Hospitals Leuven; Leuven Belgium
| | - Brendan M. Weiss
- Division of Hematology and Oncology, Abramson Cancer Center; University of Pennsylvania; Philadelphia Pennsylvania
| | - Adam J. Waxman
- Division of Hematology and Oncology, Abramson Cancer Center; University of Pennsylvania; Philadelphia Pennsylvania
| | - Matthew B. Palmer
- Department of Pathology and Laboratory Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Vivette D. D'Agati
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| | - Efstathios Kastritis
- Department of Clinical Therapeutics; National and Kapodistrian, University of Athens, School of Medicine; Athens Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics; National and Kapodistrian, University of Athens, School of Medicine; Athens Greece
| | - Ravi Vij
- Division of Hematology and Oncology; Washington University School of Medicine; St. Louis Missouri
| | - Dhruv Bansal
- Division of Hematology and Oncology; Washington University School of Medicine; St. Louis Missouri
| | - David Dingli
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Samih H. Nasr
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota
| | - Nelson Leung
- Division of Hematology; Mayo Clinic; Rochester Minnesota
- Division of Nephrology and Hypertension; Mayo Clinic; Rochester Minnesota
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Abstract
Thrombotic microangiopathy is an uncommon but reported adverse effect of a variety of antineoplastic drugs, including chemotherapy agents such as mitomycin C and gemcitabine, and newer targeted agents such as the vascular endothelial growth factor inhibitors. We present a review of thrombotic microangiopathy associated with antineoplastic agents and its implications in current cancer therapy.
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Affiliation(s)
- Gwenalyn Garcia
- Department of Medicine, Division of Hematology/Oncology, Staten Island University Hospital, Staten Island, NY, USA
| | - Jean Paul Atallah
- Department of Medicine, Division of Hematology/Oncology, Staten Island University Hospital, Staten Island, NY, USA
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Qaqish I, Schlam IM, Chakkera HA, Fonseca R, Adamski J. Carfilzomib: A cause of drug associated thrombotic microangiopathy. Transfus Apher Sci 2016; 54:401-4. [DOI: 10.1016/j.transci.2016.03.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 02/14/2016] [Accepted: 03/10/2016] [Indexed: 01/23/2023]
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Renal Thrombotic Microangiopathy Associated with the Use of Bortezomib in a Patient with Multiple Myeloma. Case Rep Hematol 2016; 2016:6020691. [PMID: 27293920 PMCID: PMC4884801 DOI: 10.1155/2016/6020691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 04/28/2016] [Indexed: 11/18/2022] Open
Abstract
Bortezomib is a first-generation proteasome inhibitor used in the treatment of multiple myeloma (MM). A few reports have linked bortezomib exposure with the development of thrombotic microangiopathy (TMA). We describe a case of biopsy-proven renal thrombotic microangiopathy associated with the use of bortezomib in a 51-year-old man with IgG lambda MM. To our knowledge, this is the first biopsy-proven case. In addition, reexposure to bortezomib 18 months later was associated with recurrence of TMA. This supports a possible causal role of bortezomib. The exact mechanisms remain to be elucidated.
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10
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Patriquin CJ, Thomas MR, Dutt T, McGuckin S, Blombery PA, Cranfield T, Westwood JP, Scully M. Bortezomib in the treatment of refractory thrombotic thrombocytopenic purpura. Br J Haematol 2016; 173:779-85. [DOI: 10.1111/bjh.13993] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 12/21/2015] [Indexed: 12/30/2022]
Affiliation(s)
| | - Mari R. Thomas
- Department of Haematology; University College London Hospital; Cardiometabolic Programme-NIHR UCLH/UCL BRC; London UK
| | - Tina Dutt
- Roald Dahl Haemostasis and Thrombosis Centre; Royal Liverpool University Hospital; Liverpool UK
| | - Siobhan McGuckin
- Department of Haematology; University College London Hospital; London UK
| | - Piers A. Blombery
- Department of Haematology; University College London Hospital; London UK
| | - Tanya Cranfield
- Department of Haematology; Portsmouth Hospitals NHS Trust; Portsmouth UK
| | - John P. Westwood
- Department of Haematology; University College London Hospital; London UK
| | - Marie Scully
- Department of Haematology; University College London Hospital; Cardiometabolic Programme-NIHR UCLH/UCL BRC; London UK
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11
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Patel PP, Becker J, Freyer C, Griffiths E, Thompson JE, Wang ES. Rituximab-refractory thrombotic thrombocytopenic purpura responsive to intravenous but not subcutaneous bortezomib. Transfusion 2016; 56:970-4. [PMID: 26779871 DOI: 10.1111/trf.13465] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/05/2015] [Accepted: 11/09/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is often characterized by formation of antibodies against a disintegrin and metalloprotease with thrombospondin repeat, member 13 (ADAMTS13). Therapeutic plasma exchange (PEX) is the basis of TTP therapy, with additional immunosuppression to eradicate ADAMTS13 antibody-producing B cells. CASE REPORT We describe a case of a 22-year-old female with TTP refractory to PEX, high-dose corticosteroid therapy, and rituximab. Laboratory blood tests showed a severe ADAMTS13 deficiency and the presence of an inhibitor. Although one cycle of subcutaneous bortezomib resulted in clinical improvement, the patient remained PEX dependent. A second course of intravenous (IV) bortezomib resulted in a complete remission without evidence of relapse after 18 months. CONCLUSION This case confirms the efficacy of bortezomib for refractory TTP and suggests that the in vivo activity of IV bortezomib may be distinct from subcutaneous drug in this setting.
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Affiliation(s)
| | | | - Craig Freyer
- Department of Pharmacy, Roswell Park Cancer Institute, Buffalo, New York
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12
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Lodhi A, Kumar A, Saqlain MU, Suneja M. Thrombotic microangiopathy associated with proteasome inhibitors. Clin Kidney J 2015; 8:632-6. [PMID: 26413293 PMCID: PMC4581378 DOI: 10.1093/ckj/sfv059] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 06/18/2015] [Indexed: 12/14/2022] Open
Abstract
The ubiquitin proteasome pathway plays a key role in cell cycle, function and survival. Bortezomib (BTZ) and Carfilzomib (CFZ) are the first two inhibitors of the proteasome pathway, indicated in treatment of patients with multiple myeloma. In the past few years, there have been few case reports that have highlighted the association between proteasome inhibitors (BTZ and CFZ) with acute kidney injury (AKI). In most of these case reports and initial trials, the underlying mechanism of AKI has been unclear. In this article, we discuss the association and pathogenesis of proteasome inhibitors-associated AKI. We also report the first case of CFZ-associated AKI with kidney biopsy evidence of thrombotic microangiopathy and the presence of microangiopathic hemolytic anemia.
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Affiliation(s)
- Ahad Lodhi
- Department of Nephrology, Internal Medicine , University of Iowa Hospitals and Clinics , Iowa City, IA 52246 , USA
| | - Abhishek Kumar
- Department of Nephrology, Internal Medicine , University of Iowa Hospitals and Clinics , Iowa City, IA 52246 , USA
| | - Muhammad U Saqlain
- Department of Nephrology, Internal Medicine , University of Iowa Hospitals and Clinics , Iowa City, IA 52246 , USA
| | - Manish Suneja
- Department of Nephrology, Internal Medicine , University of Iowa Hospitals and Clinics , Iowa City, IA 52246 , USA
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13
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Thrombotic thrombocytopenic purpura in a patient with lenalidomide-responsive multiple myeloma. Ann Hematol 2015; 94:1605-7. [DOI: 10.1007/s00277-015-2421-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
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14
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Chan KL, Filshie R, Nandurkar H, Quach H. Thrombotic microangiopathy complicating bortezomib-based therapy for multiple myeloma. Leuk Lymphoma 2015; 56:2185-6. [DOI: 10.3109/10428194.2014.977887] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Sullivan MR, Danilov AV, Lansigan F, Dunbar NM. Carfilzomib associated thrombotic microangiopathy initially treated with therapeutic plasma exchange. J Clin Apher 2014; 30:308-10. [PMID: 25413611 DOI: 10.1002/jca.21371] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 10/30/2014] [Indexed: 11/12/2022]
Abstract
Drug associated thrombotic microangiopathy (TMA) is a rare event causing thrombocytopenia, microangiopathic anemia, renal failure, and neurologic abnormalities. Here, we present a case of TMA that occurred during the first cycle of treatment with carfilzomib for relapsed multiple myeloma.
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Affiliation(s)
- Matthew R Sullivan
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Hematology/Oncology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexey V Danilov
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Hematology/Oncology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Frederick Lansigan
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Hematology/Oncology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Nancy M Dunbar
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Pathology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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Hobeika L, Self SE, Velez JCQ. Renal thrombotic microangiopathy and podocytopathy associated with the use of carfilzomib in a patient with multiple myeloma. BMC Nephrol 2014; 15:156. [PMID: 25267524 PMCID: PMC4190298 DOI: 10.1186/1471-2369-15-156] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 09/22/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Proteasome inhibitors are a relatively new class of chemotherapeutic agents. Bortezomib is the first agent of this class and is currently being used for the treatment of multiple myeloma. However, recent reports have linked exposure to bortezomib with the development of thrombotic microangiopathy. A new agent in this class, carfilzomib, has been recently introduced as alternative therapy for relapsing and refractory multiple myeloma. We report a case of renal thrombotic microangiopathy associated with the use of carfilzomib in a patient with refractory multiple myeloma. CASE PRESENTATION A 62 year-old Caucasian man with hypertension and a 4-year history of multiple myeloma, had been previously treated with lenalidomide, bortezomib and two autologous hematopoietic stem cell transplants. After the second hematopoietic stem cell transplant, he developed acute kidney injury secondary to septic shock and required dialysis for 4 weeks. Subsequently, his serum creatinine stabilized at 2.1 mg/dL (185.64 μmol/L). Seventeen months after the second hematopoietic stem cell transplant, he was initiated on carfilzomib for relapse of multiple myeloma. Six weeks later, he developed abrupt worsening of lower extremity edema and hypertension, and new onset proteinuria. His kidney function remained stable. Kidney biopsy findings were consistent with thrombotic microangiopathy. Eight weeks after discontinuation of carfilzomib, proteinuria and hypertension improved. Due to progression of multiple myeloma, he died a few months later. CONCLUSION In view of the previously reported association of bortezomib with thrombotic microangiopathy, the temporal association of the clinical picture with the initiation of carfilzomib, and the partial resolution of symptoms after discontinuation of the drug, we conclude that carfilzomib may have precipitated a case of clinically evident renal thrombotic microangiopathy in our patient.
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Affiliation(s)
- Liliane Hobeika
- Division of Nephrology and Hypertension, Department of Medicine, University of Louisville, 615 South Preston Street, Louisville, KY 40202, USA.
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