Journal of Onco-Nephrology

Bevacizumab is an anti-angiogenic monoclonal antibody against vascular endothelial growth factor (VEGF) and has multiple indications with known renal adverse effects, notably proteinuria, and acute kidney injury (AKI). There is insufficient knowledge about the long-term outcomes of its renal adverse effects. In this retrospective study, we reviewed the clinical course of all patients who received bevacizumab and developed therapy associated AKI, chronic kidney disease (CKD), or proteinuria. Among the 1,506 patients who received bevacizumab, the renal events attributed to bevacizumab were: 125 episodes of AKI (8.3%), 110 new-onset proteinuria events (7.3%), and new onset CKD in 112 patients (7.4%). All patients with bevacizumab-associated AKI recovered without requiring renal replacement therapy and in most patients (59%), the renal function returned to baseline. In conclusion, bevacizumab associated renal adverse effects were a common occurrence but with minimal long term adverse outcomes considering that this population is significantly impacted by their cancer prognosis. These results are helpful during counseling regarding risks and benefits of therapy discontinuation in patients who develop bevacizumab-associated adverse effects.

Hyperphosphatemia is commonly associated with kidney failure. However, many other etiologies should be considered, and include increase tubular reabsorption of phosphate, endogenous or exogenous phosphate loads and transcellular shift. We present a case of a 71-year-old male with a medical history of anemia and constipation who presented to our hospital for abdominal pain. Initial Laboratory evaluation demonstrated a severely elevated serum phosphate level, calcium level within the normal limit, and a mild elevation of serum creatinine. He underwent a bone marrow biopsy confirming a diagnosis of IgG-kappa-type Multiple Myeloma (MM). There is an established association between electrolyte abnormalities in patients with hematological malignancies, however, MM is rarely associated with hyperphosphatemia. Spurious electrolyte abnormalities present a challenge for clinicians, pseudo-hyperphosphatemia in patients with MM has been associated with laboratory artifacts. Our patient did not have clinical characteristics of hyperphosphatemia, after the new diagnosis of multiple myeloma and ruling out other etiologies leading to hyperphosphatemia, the elevated phosphorous level was attributed to a spurious etiology.

With the advancement in immunosuppressive management and graft versus host disease prophylaxis, hematopoietic stem cell transplantation from a haploidentical donor is increasingly used and has become a standard donor option for patients lacking an appropriately matched sibling or unrelated donor. Inflammatory cytokines released by activated lymphocytes and innate cells in the context of cellular therapy can cause fever, vasodilatation, and end-organ damage, collectively known as cytokine release syndrome, is a common complication in patients undergoing haploidentical stem cell transplant and in this setting referred as “haplostorm.” We present a case of acute kidney injury induced by haplostorm after receiving a haploidentical hematopoietic stem cell transplant. The patient was managed with tocilizumab and conservatively without the need for kidney replacement therapy. Over the course, the patient had a successful kidney recovery.

Chronic myeloid leukemia is a clonal disorder of myeloid origin which transforms into more aggressive phenotypes, either acute myeloid leukemia or acute lymphoblastic leukemia. The long-term outcome of chronic myeloid leukemia has significantly improved with tyrosine kinase inhibitor imatinib. In contrast, heavy chain deposition disease is a disorder of lymphoid origin due to a plasma cell clone classified under monoclonal immunoglobulin deposition disease with truncated monoclonal heavy chain deposition along basement membranes of many organs, predominantly the kidneys causing significant organ dysfunction. The connection between the two disorders seems to be vague and undefined. We report a novel case of treated chronic myeloid leukemia with imatinib in sustained clinical and cytogenetic remission who presented with heavy chain deposition disease of the kidney, causing renal dysfunction and nephrotic range proteinuria that responded to clone-directed therapy. Given these disorders’ two different cell lines, their association could be fortuitous only. However, in the light of a few dozen cases published thus far in which the prototypical plasma cell disorders multiple myeloma and monoclonal gammopathy of undetermined significance have evolved from cases of treated CML, this association seems to be genuine, the possible genesis of which is discussed in this manuscript. Long-term exposure of chronic myeloid leukemia patients to imatinib could predispose some rare, vulnerable patients to a plasma cell disorder, including heavy chain deposition disease.

Monoclonal gammopathy of renal significance (MGRS) is a pathogenic entity associated with significant morbidity, mainly end stage kidney disease. Proliferative glomerulonephritis with monoclonal immunoglobulin deposition (PGNMID), a type of MGRS, is a specific disease resulting from the deposition of a monoclonal immunoglobulin leading to kidney damage. While PGNMID has been recognized to lead to end-stage kidney disease, until recently there was no evidence to guide treatment. Here, we report a case of a patient with PGNMID who responded well to daratumumab.