Renal allografts in plasma cell myeloma hematopoietic cell graft recipients: on the verge of an explosion?
Renal dysfunction is a common complication of plasma cell myeloma (PCM) that may be severe enough to necessitate hemodialysis. Although high-dose chemotherapy and hematopoietic cell transplant (HCT) appears superior to conventional chemotherapy in likelihood of achieving CR and is associated with improvement in and, at times, reversal of renal dysfunction, many patients remain dialysis-dependent presenting the challenge of renal transplantation in this population. We reviewed the published literature and summarize the outcomes on dual organ (HCT and renal allograft) transplantation in patients with PCM and dialysis-dependent renal failure. In a literature review of 14 reports, 26 of 166 dialysis-dependent patients became dialysis-independent. Our review includes a very heterogenous patient population but suggests that HCT and renal allograft may be feasible in a subset of PCM patients with dialysis-dependent renal failure. Although there is a concern for renal allograft rejection upon withdrawal of immunosuppression, data suggest that resumption of antirejection therapy leads to stable renal function. Bortezomib potentially can be used as maintenance treatment in patients who have not achieved a CR while preventing renal allograft rejection. The literature that describes dual transplants has included patients with long-term follow-up (>7 years in some patients). It is possible, however, that there may be publication bias with only favorable results being reported. More research is necessary to further delineate the subset of PCM patients most likely to benefit from renal transplant. A special registry for data collection for long-term follow-up may be useful to improve future patient survival.