Case Studies

 Case 9.11 Myeloma kidney

A 76-year-old man was admitted with a history of progressive weakness over a period of several months. On examination, he was unkempt, thin, pale and acidotic. His blood pressure was 110/60. He was markedly anaemic (Hb 64g/l) with an erythrocyte sedimentation rate (ESR) of 116mm/h. His initial biochemical results showed a raised blood urea of 48mmol/l (NR 2.5-7.5) and a grossly raised serum creatinine of 1910µmol/l (NR 60-120) but a normal serum calcium. Urinary protein excretion was 2.8g/day. A diagnosis of chronic renal failure of unknown cause was made. Peritoneal dialysis was started while other investigations were performed; intravenous urography (IVU) was delayed until after urinalysis (see below).

Serum electrophoresis showed a decreased gamma fraction with a monoclonal band in the beta region. Serum immunoglobulin levels were: IgG 1.4g/l (NR 7.2-19.0); IgA 24.5g/l (NR 0.8-5.0); and IgM 0.3g/l (NR 0.5-2.0). Immunofixation of the serum and urine showed an IgA (lambda type) paraprotein in the serum, with monoclonal free lambda light chains in the urine. A bone marrow aspirate showed marked infiltration of atypical plasma cells. Radiology of the skeleton revealed osteolytic lesions in the pelvis and skull. A diagnosis of myeloma kidney was therefore made. Despite symptomatic treatment of his renal failure and cytotoxic therapy for myelomatosis, he died from renal failure 5 weeks after admission.