Successful treatment of myeloma kidney by diuresis and plasmaphoresis.

A 29-year-old Englishman developed a lump on his head in September 1974. Three months later he presented with nocturia and tiredness. He looked ill, with a fluctuant swelling 3 cm by 3 cm over the right parietal bone; tenderness over the left ribs and lower thoracic spine; and some anterior angulation at D8. Haemoglobin was 6-0 g/dl, white blood count 4-1 x 109/1 (4100/mm3), erythrocyte sedimentation rate 69 mm in 1 hour. Immunoelectrophoresis showed a monoclonal excess of IgG (44 g/l) with low IgA and JgM. Bence Jones protein was present in the urine (1-2 g/24 h). Skeletal survey showed widespread lytic deposits. The diagnosis of multiple myeloma was confirmed by narrow aspirate, showing 20 % primitive plasma cells. His blood urea was 44-8 mmol/l (270 mg/100 ml); creatinine 1220 ,umol/l (13-8 mg/100 ml); plasma calcium 2-2 mmol/l (8-9 mg/100 ml); urine specific gravity 1031, urate 0 50 mmol/l (8-4 mg/100 ml). Urine osmolality was 310 mmol/kg (310 mosmol/kg), 24-hour urine calcium and urate were not elevated. There was no amino-aciduria. He was treated initially with melphalan 5 mg daily for one week. Renal biopsy showed myeloma kidney with tubular casts, tubular dilatation, and atrophy with surrounding inflammation. The glomeruli were normal, and there was no amyloid or vascular change. Over the next two weeks the renal function deteriorated (blood urea rising to 78 mmol/l (470 mg/100 ml)) despite saline repletion, and he developed pleural and pericardial effusions, drowsiness, and confusion. He was treated with peritoneal dialysis from 31 December 1974 to 7 January 1975; simultaneously a diuresis was induced with 5 litres daily of intravenous saline, and frusemide, 500 mg daily. Urine pH was above 6. On 2 January 1975 plasmaphoresis was performed, exchanging 1180 ml plasma for plasma protein fractions, at which his IgG fell from 44 g/l to 5-5 g/l, and Bence Jones proteinuria ceased. He improved greatly, the blood urea and creatinine continuing to fall after dialysis was stopped. Nine months later he is well and working normally; the haemoglobin 12 g/dl, blood urea 10-0 mmol/l (60 mg/100 ml), creatinine 160 ,umol/l (1-8 mg/100 ml), crea-tinine clearance 66 ml/min, IgG 93 g/l, 24-hour urine protein 300 mg. He is maintained on intermittent courses of melphalan.