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Shaji K. Kumar, MD

Prashant Kapoor, MD, FACP


Treatment Algorithm for Patients With Myeloma and Light Chain Cast Nephropathy

By: Joshua D. Madera, MS
Posted: Wednesday, May 24, 2023

Given the increased risk of short-term mortality in patients with multiple myeloma with co-occurring light chain cast nephropathy, research efforts have been dedicated to establishing the most effective treatment recommendations to reverse their renal failure, according to a study published in Blood Cancer Journal. At present, patients are advised to join clinical trials before following the current treatment recommendations, explained Nelson Leung, MD, and S. Vincent Rajkumar, MD, both of the Mayo Clinic, Rochester.

“Regimens used should have a high and rapid response rate; the drugs used should not require modifications for renal function and should be readily available for immediate administration,” Drs. Leung and Rajkumar suggested.

Initial therapeutic options to be considered for patients with newly diagnosed multiple myeloma and biopsy-proven light chain cast nephropathy should include bortezomib and dexamethasone (VD) or daratumumab combined with bortezomib, cyclophosphamide, and dexamethasone (VCD). The addition of daratumumab is an improvement from the standard VD/VCD combination therapy because it hastens the response. If immunomodulatory drugs are readily available, the authors recommend combination therapy with daratumumab and VTD. In addition, plasmapheresis should be commenced immediately to expedite the removal of extracorporeal light chains and reduce the serum concentration of free light chains more rapidly. However, it should be administered before daratumumab since it also contributes to daratumumab removal.

For patients with relapsed or refractory multiple myeloma, the treatment protocol becomes more complicated. If an anti-CD38 antibody drug was administered and the patient did not relapse, daratumumab or isatuximab are suitable treatment options. Furthermore, combination therapy with bortezomib, dexamethasone, and thalidomide with a 4-day continuous infusion of cisplatin, cyclophosphamide, doxorubicin, and etoposide is suggested for patients with renal impairments. However, cisplatin is usually avoided because of its renal toxicity.

Disclosure: For full disclosures of the study authors, visit

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