Transplant Outcomes in Myeloma with Renal Insufficiency Improved

Autologous stem cell transplant has become safer for patients with multiple myeloma and renal insufficiency, according to the results of a single-center retrospective study¹ published in Bone Marrow Transplant. 

 “All patients transplanted recently (Era 2) survived to 100 days post-transplant and were observed to have significantly longer progression-free survival by more than 2 years,” Amanda Yan Li, of the University of Toronto, Canada, and colleagues, wrote in Bone Marrow Transplant, about improvements seen in patients with renal insufficiency undergoing transplant for myeloma.

Li and colleagues compared outcomes among 96 patients who underwent transplant for myeloma in two eras: 1998-2007 (n=45) and 2008-2016 (n=51). The more recent era reflects the adoption of bortezomib (Velcade)-based induction regimens and dose reduction of melphalan during conditioning. 

Baseline renal function was similar for patients during both time periods, with a similar number of patients on hemodialysis. The median time to transplant was significantly shorter for patients in the more modern era (7 vs 9 months; P = .045). 

Patients who underwent transplant from 2008-2016 had no transplant-related mortality compared with a rate of 13% in the older era of transplant. In addition, there were significantly more high-grade toxicities in the older transplant era. 

Patients transplanted more recently also had significantly higher post induction overall response rates (96% vs 69%; P = .0004). Post-transplant response rate was similar between the two group, but patients in the modern era were able to achieve deeper responses; 79% of patients achieved very good partial response compared with only 35% in the older transplant period (P < .0001). 

“This may be attributable to the standard use of bortezomib-based induction,” the researchers wrote. “Currently the IMWG recommends bortezomib as first line therapy in multiple myeloma patients with renal insufficiency as many studies have demonstrated high overall response rate, improved progression-free survival (PFS), overall survival (OS), and renal recovery with its use.”

There was no significant difference in OS between the 2 transplant eras. However, patients transplanted more recently has a median progression-free survival of 56 months compared with 30 months among older transplants (P = .018). 

“Aside from the increased use of bortezomib during induction, the addition of post-transplant lenalidomide maintenance may contribute to this improvement,” the researchers wrote. “Lenalidomide maintenance has been reported in various trials to prolong PFS and possibly OS, though its use in renal insufficiency is not well studied.”

References:

Li, A., Atenafu, E., Bernard, R., Masih-Khan, E., Reece, D., Franke, N., Tiedemann, R., Prica, A., Trudel, S., Kukreti, V. and Chen, C. (2019). Toxicity and survival outcomes of autologous stem cell transplant in multiple myeloma patients with renal insufficiency: an institutional comparison between two eras. [online] Blood Marrow Transplant. Available at: https://www.nature.com/articles/s41409-019-0697-8 [Accessed 7 Oct. 2019].