What are some possible urgent problems that may need to be addressed immediately at diagnosis?

What are possible urgent problems that may need to be addressed immediately at diagnosis?

So myeloma patients can present with a few emergencies. This can include kidney failure. Some patients present with severe kidney failure. They're no longer able to excrete the toxins that have accumulated in the body because their kidneys are failing. This may require some urgent therapy, like dialysis, in the short term at least, hopefully until we can get patients diagnosed and treated to then try to rescue the kidney. That's one example of an emergency.

High calcium level. Some patients present with high calcium levels as a result of their disease. In that case, we typically give a lot of IV fluids and may administer certain medications to lower the calcium level, which are usually done in the hospital, such as bisphosphonates or denosumab, to manage the high calcium and prevent symptoms.

They can also present with bone lesions, which can be fractures or tumors from plasma cells growing in any part of the body. We particularly worry about lesions near the spinal cord. Patients may physically present with back pain and may have a plasmacytoma, which is a collection of plasma cells. If it is pushing against the spinal cord, there is a risk of injury and paralysis. In this case, we typically want to diagnose very quickly, usually starting patients on steroid medications to help calm inflammation and reduce plasma cell activity, often involving colleagues from radiation oncology or neurosurgery depending on urgency.

What is plasmapheresis?

Plasmapheresis is a way of filtering out some of these abnormal proteins from the blood. It's similar to dialysis, but it filters out these bad proteins. This is done in some circumstances, particularly in cases of kidney failure driven by very high concentrations of abnormal light chains in the blood. As we diagnose patients and start treatment, plasmapheresis can be a short-term way to clear those proteins. However, if it's not followed by myeloma therapy, the effects won't last long. Thus, early diagnosis and treatment are crucial.

When we think about myeloma emergencies at diagnosis, two things come to mind. First, severe fractures. If the abnormal protein affects the bones, it could cause pathologic fractures, potentially in the spinal cord. If vertebral fractures occur, there can be nephrological damage if not treated promptly. The risk of neurological damage depends on the fracture location.

This typically involves a team approach. A neurosurgeon might be needed for bony involvement with pathologic fractures in the spine, and radiation oncology might be consulted for targeted radiation treatment of spinal lesions. Systemic treatment is also necessary to address plasma cell involvement and prevent lesion progression.

There's also the risk for renal disease. If someone has kidney failure, we treat that as an emergency in myeloma. The key is to start systemic treatment as soon as possible, which may involve hospital admission for expedited workup. Early intervention can often reverse renal failure.

When is dialysis necessary?

Whether someone needs dialysis depends on the severity and acuteness of the renal failure. Consulting with a nephrologist is important to determine if dialysis is currently necessary or if it's heading in that direction.

Why does myeloma affect kidneys?

Myeloma can affect the kidneys in several ways. If free light chains are significantly elevated, they are excreted through the kidneys and can become toxic, leading to a condition called light chain nephropathy. This is one of the classic manifestations of myeloma affecting the kidneys. Additionally, very high calcium levels, another manifestation of myeloma, can also adversely affect kidney function.