Survival of Hemodialysis-Dependent Multiple Myeloma Patients and Factors Associated with Dialysis Independence: A Real-World Study in China
Authors: Wang Chenyun , Wang Jinuo , Yang Yang , He Donghua , Zheng Gaofeng , Han Xiaoyan , He Jingsong , Ying Jinping , Wu Wenjun , Cai Zhen 
Published: December 2024

Background: Renal impairment is a major feature of multiple myeloma (MM), where 10% of MM patients have severe renal failure requiring hemodialysis, related to high mortality. Novel drugs like bortezomib and daratumumab are safe and effective for MM patients with RI. However, the prognosis of dialysis-dependent MM patients and factors related to dialysis independence in China remain unclear.

Methods: This retrospective study included 119 MM patients requiring hemodialysis (more than 28 days of hemodialysis treatment) at the First Affiliated Hospital of Zhejiang University School of Medicine, China from January 2012 to November 2023. Hemodialysis resulting from causes other than MM were excluded. Logistic regression was employed for multivariate analysis of factors associated with dialysis independence, and Kaplan-Meier survival curves and Cox proportional hazard models were utilized for survival analysis.

Results: Among the 119 patients, 74 patients (62.2%) were male, with a median age of 64 (39 - 87) years. Hemodialysis was initiated at 88 newly diagnosed MM (NDMM) patients (73.9%), and 31 relapsed/refractory MM (RRMM) patients (26.1%). The median eGFR was 7.41 mL/min/1.73m2 (2.55 - 14.73). Severe proteinuria (24-hour urine protein quantification ≥ 3.5g/24h) was present in 12.6% (n = 15). 50.4% (n = 60) were in R-ISS stage III. Among 69 patients with available FISH test results, 19 patients (27.5%) had high-risk cytogenetic abnormalities. Anti-myeloma therapy comprised bortezomib-based (n = 83), bortezomib/ixazomib combined with immunomodulators (n = 22), and daratumumab-based (n = 11) regimens.

A total of 19 patients (16.0%) were relieved from dialysis, with a median time of 1.9 (1.0 - 9.0) months. Among them, 17 cases were NDMM patients (bortezomib-based therapy in 13 patients; bortezomib and daratumumab in 2 patients; bortezomib plus thalidomide in 2 patients). Two relapsed MM patients also successfully withdrew from dialysis (bortezomib-based in 1 patient; bortezomib and daratumumab in 1 patient). The hematologic response of the dialysis-dependent group was significantly lower than that of the independent group (at least PR rate 48.0% vs 89.5%, P = 0.001). Multivariate analysis showed that achieving at least very good partial response (VGPR, P = 0.003), lower serum β2-microglobulin (P = 0.012), and age &lt; 65 years (P = 0.040) were associated with dialysis independence.

During a median follow-up of 33.8 months (95% CI, 21.8 - 45.7 months), the median PFS and OS of the whole cohort were 28.0 and 44.6 months (95% CI, 21.4 -34.6 and 31.2 -58.0 months). In univariate analysis, baseline characteristics like high-risk cytogenetic abnormalities, high LDH (≥ 250 U/L), high bone marrow plasma cell (BMPC) ratio (≥ 20%), and moderate-to-severe proteinuria (≥ 1.0g/24h) negatively affected prognosis. High-risk cytogenetic abnormalities had poorest PFS (14.4 vs 34.5 months, P = 0.006) and OS (20.7 vs 49.7 months, P = 0.016). RRMM with dialysis dependence had worse PFS (24.4 vs 42.4 months, P = 0.035) and OS (34.3 vs not reached, P = 0.026) than newly diagnosed. Dialysis-independent group had better PFS (58.0 vs 24.4 months, P = 0.028) and OS (not reached vs 34.3 months, P &lt; 0.001). Further multivariate analysis showed reversal from dialysis (P = 0.018 and P = 0.029), achieving at least VGPR (P = 0.028 and P &lt; 0.001), and BMPC &lt; 10% (P = 0.003 and P = 0.006) were predictors of better PFS and OS for dialysis-dependent MM patients.

Conclusion: The prognosis of dialysis-dependent MM patients was poor. Achieving dialysis independence following standard anti-myeloma therapy is associated with improved outcomes. Importantly, RRMM patients who require dialysis had a worse prognosis, but this might be reversed with aggressive treatment strategies.