Purpose of review: This article reviews the relevance of the following areas to the contemporary management of cast nephropathy in multiple myeloma: immunoassays that quantify immunoglobulin free light chain (FLC), novel chemotherapy agents and high cut-off (protein-permeable) haemodialysis, which are under evaluation in patients with cast nephropathy and multiple myeloma.
Recent findings: Clonal serum FLC can be measured with high sensitivity and specificity and used to rapidly screen for cast nephropathy. A sustained decrease in serum FLC levels within 3 weeks of starting treatment is associated with renal recovery; novel chemotherapy agents can maximize this early response. Although plasma exchange does not produce clinical benefit, pilot studies of high cut-off haemodialysis show high efficacy for serum FLC removal.
Summary: If a patient with cast nephropathy and severe acute kidney injury remains dialysis-dependent, the prognosis is poor. A prompt diagnosis and commencement of effective chemotherapy is a critical determinant of renal recovery. A randomized controlled trial of high cut-off haemodialysis in patients with cast nephropathy, who all receive bortezomib-based chemotherapy, is underway.