Renal transplantation in patients with paraproteinemias

Patients with paraproteinemias may have a spectrum of clinical diseases with marked differences in prognosis. We report the course of 3 patients with pretransplant paraproteinemias (1 with multiple myeloma, 1 with light chain deposition disease, 1 with Waldenstrom's macroglobulinemia) and review 10 patients reported in the literature (6 with multiple myeloma, 4 with light chain deposition disease). Of the 7 patients with multiple myeloma, 2 are alive with functioning grafts. The remaining 5 died with function 14 months to 9.5 years posttransplant; infection was the cause of death in all 5. The patient with Waldenstrom's macroglobulinemia and 3 of the 5 with light chain disease are alive with function. Although recurrent disease was common, it did not necessarily result in renal dysfunction or graft loss. The collective experience from these 13 patients demonstrates that relatively long patient and graft survival can be achieved in a select group of patients with paraproteinemias. Pretransplant evaluation should exclude the presence of active disease. Patients with 'benign monoclonal gammopathy' should undergo serial reevaluations for at least 1 yr to exclude the presence of unrecognized multiple myeloma or Waldenstrom's macroglobulinemia. Posttransplant management should: (1) include a particularly low threshold for detecting infectious complications, especially with fungal pathogens, (2) avoid dehydration, hypercalcemia, hyperuricemia, and nephrotoxic drugs, and (3) maintain close follow-up for detecting recurrent disease. The data suggests transplantation is an acceptable choice for treating renal failure in patients with paraproteinemias.