Approximately 20% of newly diagnosed myeloma patients have significant renal impairment at the time of their diagnosis, and about 10% of these immediately require dialysis. The renal complications of myeloma are amongst the most important in terms of their potential to affect patients’ quality of life. This is particularly true for patients who need dialysis treatment.
To achieve the best possible outcomes for this important sub-group of myeloma patients it is very important for there to be a good working relationship between the Haematology and Renal teams. For many years this has been the case at St Helier Hospital, which is the base for the South West Thames Regional Renal and Transplantation Unit.
Both teams have consultants who take a special interest in the management of myeloma patients, namely myself and Corinne De Lord in Haematology and Dr David Makanjuola from the Renal Unit. There are also Clinical Nurse Specialists in both departments with a large amount of experience in the care of myeloma patients with acute and chronic kidney disease. Together we have put in place policies and joint clinics, which have delivered improved care for myeloma patients with kidney impairment.
Supports early intervention
Prompt treatment can often result in a dramatic improvement in a newly diagnosed patient’s renal function, even to the extent that the need for dialysis can be removed. With this principle in mind, there is a policy in place at St Helier Hospital to ensure that blood is urgently screened for the presence of a paraprotein or a high serum free light chain level in patients admitted acutely to the Renal Unit having presented with acute renal failure. Either myself or Dr De Lord is notified immediately about any such patient whose blood tests are suggestive of a new diagnosis of myeloma, and the appropriate investigations and treatment are immediately set in motion. Rapid treatment is required in this situation to improve renal function and possibly remove the need for dialysis, and this is achieved as a result of close liaison between the Haematology and Renal teams.
Improves patient experience and outcomes
For myeloma patients with chronic renal impairment, who have been established on treatment, there is a monthly myeloma/renal clinic at which patients are seen by consultants from both specialties. This reduces the number of clinic visits required by patients and allows a holistic approach to be taken to their management. This is particularly important as some of the drugs used to treat myeloma can be toxic to the kidneys, and expert input from the nephrologists helps the haematologists obtain the best response from their treatments while minimising toxicity. The consultants are currently reviewing how this service may need to adapt following the COVID-19 pandemic.
There are some challenging patients who require additional time for discussion outside the busy clinic setting, and for that reason, about a year ago the St Helier Hospital teams set up a monthly myeloma/renal meeting, at which such patients are reviewed. These meetings result in evidence-based management plans which can be put into operation in the clinics. Several patients have already benefited from this approach. For example, a recent discussion centred on a patient thought likely to have amyloidosis complicating his asymptomatic myeloma, and it was agreed that a renal biopsy should be performed, as the presence of amyloidosis would be an indication to commence treatment.
I feel that all haematologists running a myeloma clinic should consider setting up a similar joint service with interested colleagues from their local Renal Units. The potential improvements to patients’ outcomes are substantial, and the financial costs of setting up the service are small. The challenges are mainly practical in origin, in particular the requirement for more clinic space and the potential need to change consultant job plans to find a mutually convenient time for a joint clinic. However, if these issues can be overcome then it will not take long for the benefits for patients to become apparent.
Written by Dr Simon Stern,
Epsom & St Helier University Hospitals NHS Trust