Management options for cast nephropathy in multiple myeloma

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.