Kidney failure as an unusual initial presentation of biclonal gammopathy (IgD multiple myeloma associated with light chain disease) – A case report

Violeta Rabrenović; Zoran Mijušković; Slobodan Marjanović; Milorad Rabrenović; Dragan Jovanović; Svetlana Antić; Ljiljana Ignjatović; Milica Petrović; Dejan Pilčević

doi:10.2298/5482

Violeta Rabrenović Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia; Medical Faculty of the Military Medical Academy, University of Defense, Belgrade, Serbia
Zoran Mijušković Medical Faculty of the Military Medical Academy, University of Defense, Belgrade, Serbia; Institute of Medical Biochemistry, Military Medical Academy, Belgrade, Serbia
Slobodan Marjanović Medical Faculty of the Military Medical Academy, University of Defense, Belgrade, Serbia; Clinic of Hematology, Military Medical Academy, Belgrade, Serbia
Milorad Rabrenović Center of Hyperbaric Medicine, Military Medical Academy, Belgrade, Serbia
Dragan Jovanović Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia; Medical Faculty of the Military Medical Academy, University of Defense, Belgrade, Serbia
Svetlana Antić Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
Ljiljana Ignjatović Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
Milica Petrović Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia
Dejan Pilčević Clinic of Nephrology, Military Medical Academy, Belgrade, Serbia; Medical Faculty of the Military Medical Academy, University of Defense, Belgrade, Serbia

DOI: https://doi.org/10.2298/5482

Keywords: kidney failure, acute, multiple myeloma, diagnosis, differential, biopsy, histological techniques,

Abstract

Introduction. Immunoglobulin D (IgD) myeloma is a rare disease, about 2% of all myelomas, even rarer when accompanied with another multiple myeloma in biclonal gammopathy. We presented a case of biclonal gammopathy – associated manifestation of IgD myeloma and light chain disease in a patient who initially had renal failure. Case report. 37-year-old male approximately one month before hospitalization began to feel malaise and fatigue along with decreased urination. Laboratory analysis revealed azotemia. A dialysis catheter was placed and hemodialysis started. The patient was then admitted to our hospital for further tests and during admission, objective examination revealed pronounced paleness with hepatosplenomegaly and hypertension (170/95 mmHg). Laboratory analysis showed erythrocyte sedimentation rate 122 mm/h, expressed anemic syndrome (Hb 71 g/L) and renal failure dialysis rank: creatinine 1,408 μmol/L, urea31.7 mmol/L. There was two M components in serum protein electrophoresis: IgD lambda and free light chain lambda. Proteinuria was nephrotic rank (5.4 g/24 h), whose electrophoresis revealed 2 M components – massive in α 2 fraction of 71%; 7% in the discrete β fraction, beta 2M /serum 110 mg / L, in urine 1.8 mg/L – extremely high; IgL kappa / lambda index 1 : 13 (reference value ratio 2 : 1). The findings pointed to double myeloma disease: IgD myeloma and Bence Jones lambda myeloma. Bone biopsy confirmed IgD myeloma lambda 100% infiltration medulla predominantly plasmablasts. The treatment continued with hemodialysis 3 times per week with chemotherapy protocol bortezomib, doxorubicin, dexamethasone. After 4 cycles of chemotherapy, there was a decrease of IgD, λ – light chains, reduction in proteinuria (1.03 g/24 h), so hemodialysis was reduced to once per week. Six months after treatment initiation the patient underwent autologous bone marrow transplantation. In a 2-year follow-up period double myeloma disease showed complete remission. Conclusion. The presented rare form of double myeloma disease with initial renal insufficiency underscores the importance of careful observation and teamwork that can alter the course of this serious disease.

References

Rajkumar VS. Multiple myeloma: 2013 update on diagnosis, risk-stratification, and management. Am J Hematol 2013; 88(3): 226−35.

Mahto M, Balakrishnan P, Koner BC, Lali P, Mishra TK, Saxena A. Rare case of biclonal gammopathy. Int J Case Rep Images 2011; 2 : 11−4.

Sinclair D. IgD myeloma: clinical, biological and laboratory fea-tures. Clin Lab 2002; 48(11−12): 617−22.

Kyle RA, Morie A, Gertz MA, Witzig TE, Lust JA, Lacy MQ, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003; 78(1): 21−33.

Lin TL, Shih LY, Dunn P, Wang PN, Wu JH, Kao MC. Immu-noglobulin D multiple myeloma. Chang Gung Med J 2000; 23(8): 451−7.

Chang H, Chou W, Lee S, Huang J, Hung Y. Myelomatous pleural effusion in a patient with plasmablastic myeloma: a case re-port. Diagn Cytopathol 2009; 37(3): 205−7.

Batuman V. The pathogenesis of acute kidney impairment in patients with multiple myeloma. Adv Chronic Kidney Dis 2012; 19(5): 282−6.

Duvic C, Sarret D, de Revel T, Hérody M, Didelot F, Labaye J, et al. IgD myeloma manifesting as acute renal insufficiency. Rev Med Interne 2000; 21(9): 799−803.

Leung N, Rajkumar SV. Renal manifestations of plasma cell disorders. Am J Kid Dis 2007; 50(1): 155−65.

Tharp AM, Woodruff RD, Shihabi ZK. IgD-kappa myeloma: an unusual case. Ann Clin Lab Sci 2003; 33(1): 97−100.

Hasegawa M, Kondo F, Yamamoto K, Murakami K, Tomita M, Na-beshima K, et al. Evaluation of blood purification and borte-zomib plus dexamethasone therapy for the treatment of acute renal failure due to myeloma cast nephropathy. Ther Apher Dial 2010; 14(5): 451−6.

Hutchison CA, Heyne N, Airia P, Schindler R, Zickler D, Cook M, et al.. Immunoglobulin free light chain levels and recovery from myeloma kidney on treatment with chemotherapy and high cut-off haemodialysis. Nephrol Dial Transplant 2012; 27(10): 3823−8.

Pisani F, Petrucci MT, Giannarelli D, Bongarzoni V, Montanaro M, de Stefano V, et al. IgD multiple myeloma a descriptive report of 17 cases: survival and response to therapy. J Exp Clin Cancer Res 2012; 31: 17.

Maisnar V, Hájek R, Ščudla V, Gregora E, Büchler T, Tichý M, et al. High-dose chemotherapy followed by autologous stem cell transplantation changes prognosis of IgD multiple myeloma. Bone Marrow Transplant 2007; 41(1): 51−4.

Kim MK, Suh C, Lee DH, Min CK, Kim SJ, Kim K, et al. Immu-noglobulin D multiple myeloma: response to therapy, survival, and prognostic factors in 75 patients. Ann Oncol 2011; 22(2): 411−6.