Dialysis‐dependent renal failure at diagnosis continues to be associated with very poor outcome in multiple myeloma – response to M urphy et al

The study by Murphy et al supports the observation made\udby several groups regarding the benefit of the novel agents in\udboth young and elderly patients affected by multiple\udmyeloma (MM) (Kumar et al, 2008; Ludwig et al, 2008;\udTuresson et al, 2010; Pozzi et al, 2013). Their single institution\uddata collected over 18 years in 262 patients shows an\udimprovement in overall survival (OS) starting from 1995\udwith an OS not yet reached in the period 2007–2012, after\udthe introduction of bortezomib in their clinical practice.\udHowever the study clearly highlights renal insufficiency as a\udvery poor prognostic factor, with a median OS shorter than\ud1 year in patients requiring dialysis.\udIn the past few years many attempts have been made to\udclassify and stratify patients based on various refined biological\udcharacteristics, however, as clearly stated here, the clinical\udpresentation, particularly organ damage, still represents a\udnegative prognostic factor that not even modern medicine\udhas been able to overcome. The introduction of the International\udStaging System Criteria (ISS) (Greipp et al, 2005) only\udindirectly takes renal function into account, while the Durie\udand Salmon Criteria differentiates stage ‘A’ and ‘B’ MM\udbased on kidney damage (Durie & Salmon, 1975). However\udDurie-Salmon ‘B’ stage is based on a creatinine cut-off point\udof 177 lmol/l and it is unable to better differentiate between\udmoderate and severe impairment of renal damage requiring\uddialysis. It is also unable to predict the response to the\udtreatment and reversibility of the organ damage, between\udpossibly transitory kidney impairment due to dehydration,\udhyperuricaemia and hypercalacemia, and cast nephropathy.\udIn this subset of MM patients it would be beneficial to\udintroduce further parameters in the staging system (i.e. glomerular\udfiltrate; type of light chain) in order to better stratify\udthe risks and prevent treatment-related toxicity. For this reason,\udad hoc clinical trials for this group of patients are\udstrongly needed (Haynes et al, 2012).\udFinally, the Murphy study highlights the selection of\udpatients enrolled in clinical trials and the necessity to evaluate\udthe survival in the population of every day clinical practice,\udtogether with the need to develop high resolution analysis\udfrom data collected by cancer registers.\udMoreover, early diagnosis, compared with late or misdiagnosis,\udespecially for light chains MM, is mandatory to prevent\udsevere organ damage