Hemodialysis: An Appropriate Therapy in Myeloma-Induced Renal Failure Alexandra Sharland,* MB,BS, BSc(Med), FRACP, Leonie Snowdon, RN, Douglas E. Joshua, BSc, MB,BS, DPhil, FRACP, FRCPA, John Gibson, MB,BS, PhD, FRACP, FRCPA, and David J. Tiller, MB,BS, FRACP 0 To determine whether vigorous treatment with dialysis is of benefit to patients with myeloma-induced renal failure at presentation, we retrospectively reviewed outcomes in a group of patients diagnosed with multiple myeloma between January 1986 and September 1993. Increased age (P = 0.003), presence of renal impairment (P = 0.006), and failure to enter plateau phase (P < 0.001) were independently associated with shortened survival. However, there was no difference in outcome between patients with severe renal failure, those treated with dialysis, and those with milder renal impairment (median survival, 22 months in both groups), nor was reversibility of renal failure associated with any survival advantage. The lack of correlation between severity or reversibility of the renal failure and survival suggests that there may be characteristics of some patients or their underlying myeloma that are responsible both for renal impairment and for adverse prognosis. In this study, neither age, clinical stage, labeling index, nor response to treatment was able to account for the difference in outcome between patients with and without renal failure. The prolongation of life achieved in the dialysis patients such that their median survival was identical with that of the group with milder renal impairment was considered to represent a significant benefit to these patients and to justify the offer of dialysis to all patients requiring it. 0 1997 by the National Kidney Foundation, Inc. INDEX WORDS: Multiple myeloma; renal failure; dialysis; prognosis. T HE ETIOLOGY of renal failure in multiple myeloma is multifactorial, although almost all cases are associated with elevated serum cal- cium levels or Bence-Jones proteinuria.’ Renal impairment is found at diagnosis in up to 56% of patients2 and often may be the presenting fea- ture in otherwise well patients.3 Prognosis in these reported patients was ini- tially very poor, with almost all dying within a few months of presentation.4,5 Later studies sug- gest a more optimistic outlook, with survivals in the range of 11 to 25 months,6-11 but renal failure at presentation continues to be associated with a worse outcome than does presentation with nor- mal renal function.2 Whether this adverse prog- nosis is due to the renal failure per se or to the linkage of renal failure with more advanced and aggressive myeloma is not clear.” From the Departments of Renal Medicine and Haematol- ogy, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia. Received October 15, 1996; accepted in revised form July 9, 1997. *Present address: Liver Immunobiology Laboratory, Cen- tenary Institute of Cancer Medicine and Cell Biology, Camp- erdown, Sydney, Australia. Address reprint requests to Alexandra Sharland, MB,BS, BSc(Med), FRACP, Centenary Institute of Cancer Medicine and Cell Biology, Locked Bag #6, Newtown, NSW, 2042, Australia. E-mail: a.sharlund@centenary.usyd.edu.au 0 1997 by the National Kidney Foundation, Inc. 0272-6386/97/3006-0009$3.00/O Reversibility of renal impairment is described in approximately 50% of patients with multiple myeloma. 12,13 Some investigators8z9z’3X’4 have re- ported an increased duration of survival in pa- tients whose renal failure was reversed with treat- ment, whereas others”,” found that reversibility did not confer a survival advantage. The improvement in outcome for patients with myeloma and renal failure over the last 15 years has been generally attributed to widespread avail- ability of dialysis, in addition to specific treat- ments for the plasma cell dyscrasia. However, limited data are available on the prognosis of patients treated vigorously with dialysis, as is the policy in our institution. We therefore undertook a retrospective review of outcome in our patients with multiple myeloma, with particular reference to the relationships between severity and revers- ibility of renal impairment, treatment with dial- ysis, and survival. PATIENTS AND METHODS The medical records of patients diagnosed with multiple myeloma (according to the guidelines of the Chronic Leukae- mia and Myeloma Task Force of the National Cancer Insti- tuteJ6) between January 1986 and September 1993 were re- viewed. Records containing information about the patient’s renal function at the time of diagnosis and follow-up for at least 12 months or until death were selected for further study. One hundred forty patients were thus identified. The mean age of the patients at diagnosis was 62 years (range, 29 to 87 years); 77 were men and 63 were women. There were no 786 American Journal of Kidney Diseases, Vol 30, No 6 (December), 1997: pp 786-792