Bosphorus Med J. 2014; 1(3): 95-101

Multiple Myeloma; As an Increasingly Suspected Factor in the Etiology of Acute Kidney Injury

M. Kahraman¹, F. Türkmen¹, S. Kiremitçi¹, A. Bayrak¹, O. Akyüz¹, N. Ýlhan¹, Ö. Sadioðlu Çaðdaþ¹, D. Þenel Yýldýz¹, S. Baþ¹, G. Gümrükçü^2
1Haydarpaþa Numune Eðitim ve Araþtýrma Hastanesi, Ýç Hastalýklarý Kliniði, Ýstanbul
²Haydarpaþa Numune Eðitim ve Araþtýrma Hastanesi, Patoloji Kliniði, Ýstanbul

INTRODUCTION: Multiple Myeloma (MM) is a malignant disease characterized by malignant proliferation of plasma cells and by increase in the levels of monoclonal immunoglobulin or its fragments in blood. Early symptoms of this disease are generally bone pain particularly in the back or thorax, anemia-related fatigue, and recurrent infections. Patients with other complications such as renal failure, nephrotic syndrome, bone fracture, radiculopathy, bleeding, or hypercalcemia may refer to medical doctors in different disciplines. When multiple myeloma is not suspected at first, diagnosis can be delayed. In this
study, we examined 20 MM cases first diagnosed in our clinic.
METHODS: The prospective study has been planned to include the patients who referred to our clinic between the dates of May 2012 and November 2013 and were diagnosed with MM for the first time according to the diagnosis criteria of International Myeloma Working Group (IMWG- 2007). Routine biochemical and bacteriological tests as well as protein electrophoresis (PE), serum immunoelectrophoresis (SIEP), and urine immunoelectrophoresis (UIEP) (for those with proteinuria > 0.5 gr/day) were performed and immunoglobulin levels were measured. Interlab G26 microgel is used for PE, SIEP and UIEP; and immunoturbidimetric method and Architect system are used for immunoglobulins. Following fixation and decalcification, bone marrow biopsy samples (tru-cut) were analyzed by histochemical staining. After the routine follow-up procedure; Hematoxylin eosin, PAS, Masson trichrome were used in histochemical analysis of renal biopsy samples and immunohistochemical analysis was carried out for Kappa and Lambda. Immunofluorescence analysis was performed for IgG, IgM, IgA, C1q, c3, Fibrinojen, Kappa and Lambda.
RESULTS: Out of 1824 cases who were admitted to our clinic and treated therein between the dates of May 2012 and November 2013, 861 patients (47.2%) were diagnosed with acute kidney injury (AKI) and 20 in-patients (1.09%) were diagnosed with MM. Anemia, AKI, hypercalcemia, weight loss, bone pain and/or bone fracture, and acute kidney injury caused by nonsteroidal anti-inflammatory drugs were detected respectively in 19 (95%), 18 (90%), 15 (75%), 14 (70%), 14 (70%), and 11(55%) patients out of 20 MM patients during their admission to the clinic. Among the cases referred to our clinic, 2 cases had gastrointestinal bleeding. 18 of 20 MM patients had acute kidney injury during their admission and 2 of them developed AKI in the hospital. All the cases showed an M band in serum and their SIEP and UIEP results were positive. The rate of atypical plasma cell was found to be 10% in bone marrow biopsy. Moreover, cast nephropathy was found in three cases after renal biopsy.
DISCUSSION AND CONCLUSION: In conclusion, MM is a very important factor that must be taken into consideration in the etiology of AKI. Even though the history of a patient with AKI shows nonsteroidal anti-inflammatory drug use, the possibility of MM must be given due consideration.

Keywords: Multiple Myelom, Acute Kidney Injury, Anemia, Anti-Inflammatory Agents, Non-Steroidal

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Akut Böbrek Hasarý Etyolojisinde Önemi Artan Þüpheli; Multiple Myelom

M. Kahraman¹, F. Türkmen¹, S. Kiremitçi¹, A. Bayrak¹, O. Akyüz¹, N. Ýlhan¹, Ö. Sadioðlu Çaðdaþ¹, D. Þenel Yýldýz¹, S. Baþ¹, G. Gümrükçü^2
1Haydarpaþa Numune Eðitim ve Araþtýrma Hastanesi, Ýç Hastalýklarý Kliniði, Ýstanbul
²Haydarpaþa Numune Eðitim ve Araþtýrma Hastanesi, Patoloji Kliniði, Ýstanbul

GÝRÝÞ ve AMAÇ: Multiple myelom (MM), plazma hücrelerinin malign proliferasyonu ve kanda monoklonal immünglobulin veya fragmanlarýnýn artýþý ile karakterize malign bir hastalýktýr. Özellikle sýrt veya toraksta kemik aðrýlarý, anemiye baðlý halsizlik, tekrarlayan enfeksiyonlar genellikle baþlangýç bulgularý olup, hastalar renal yetmezlik, nefrotik sendrom, kemik kýrýklarý, radikülopati, kanama, hiperkalsemi ile farklý disiplindeki hekimlere baþvurabilirler. Akla gelmediði zaman tanýda gecikmeler olabilir. Bu çalýþmamýzda ilk kez kliniðimizde taný alan 20 MM olgusunu irdeledik.
YÖNTEM ve GEREÇLER: Prospektif tasarlanan çalýþmamýza Mayýs 2012 - Kasým 2013 tarihleri arasýnda
Uluslararasý Myelom Çalýþma Grubu (International Myeloma Working Group/IMWG-2007) taný kriterlerine göre ilk kez MM tanýsý konulan olgularýn alýnmasý planlandý. Rutin biyokimyasal ve bakteriyolojik tetkikler, protein elektroforezi (PE), immünglobulin düzeyleri, serumda immünelektroforez (SÝF) ve idrar immünelektroforez (ÝÝF) (>0.5gr/gün proteinürisi olanlara) istendi. PE, SÝF, ÝÝF Ýnterlab G26 mikrogel ile, immünglobulinler immünotürbidimetrik yöntemle Architect sistemle bakýldý. Alýnan kemik iliði tru-cut biyopsi materyalleri gerekli fiksasyon ve dekalsikasyon basamaklarýndan geçirildikten sonra; gerekli histokimyasal boyalarla incemeler yapýldý. Böbrek biyopsi materyalleri rutin takip prosedürü uygulandýktan sonra; histokimyasal incelemede Hematoksilen Eozin, PAS, Mason trichrom ve immünhistokimyasal incelemede Kappa ve Lambda ile çalýþýldý.
BULGULAR: Ýmmunfloresan incelemede ise IgG, IgM, IgA, C1q, c3, Fibrinojen, Kappa ve Lambda ile çalýþýldý. Mayýs 2012 – Kasým 2013 tarihleri arasýnda kliniðimize yatýrýlarak tedavi edilen 1824 olgunun; 861’inde (%47,2) birlikte ABH saptanmýþ olup, yatýrýlarak tedavi edilen olgularýn 20’sinde (%1,09) MM tanýsý konmuþtur. MM tanýsý konulan olgularýn baþvuru sýrasýnda 19(%95)’unda
anemi, 18(%90)’inde ABH, 15(%75)’inde hiperkalsemi, 14(%70)’ünde kilo kaybý, 14(%70)’ünde kemik aðrýlarý ve/veya kemik kýrýklarý, 11(%55)’inde nonsteroid antiinflamatuvar (NSAÝ) ilaç kullanýmý ile birlikte ABH tablosu saptandý. Ýki olgu gastrointestinal kanama ile baþvurdu. MM tanýlý hastalarýn 18’inde hastaneye yatýþýnda ABH mevcut olup, 2 olguda hastanede ABH geliþti. Tüm olgularýmýzda serumda M bandý saptanmýþ olup, olgularýn hepsinde SÝF ve ÝÝF birlikte pozitif bulundu. Kemik iliði biyopsisinde atipik plazma hücre oraný %10 bulundu. Ayrýca çalýþmamýzda renal biopsi yapýlan 3 olguda cast nefropatisi saptandý.
TARTIÞMA ve SONUÇ: Sonuç olarak; MM, günümüzde ABH etyolojisinde mutlaka düþünülmesi gereken bir þüphelidir. ABH tanýlý hastalarýn öykülerinde NSAI ilaç kullanýmý olsa da MM araþtýrýlmalýdýr.

Anahtar Kelimeler: Multiple Myelom, Akut Böbrek Hasarý, Anemi, Non-steroid antiinflamatuvar ilaçlar

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