melphalan and Hypoalbuminemia

High-dose melphalan with stem cell transplantation (HDM/SCT) extends survival and induces hematologic and clinical responses in patients with light chain (AL) amyloidosis. Eighty percent of melphalan is bound to plasma proteins (60% albumin-bound). We hypothesized that patients with profound hypoalbuminemia have a greater free melphalan fraction and more toxicity. Patients with AL amyloidosis treated with HDM/SCT between 2011 and 2014 with severe hypoalbuminemia (SH), defined as serum albumin ⩽2 g/dL were studied retrospectively. Sixteen patients with SH were identified. Forty-one patients without severe hypoalbuminemia (WSH) treated between 2011 and 2012 served as control. The incidence of acute renal failure requiring hemodialysis was 25% among patients with SH, compared with 5% among patients WSH (P=0.05). Not all patients who needed dialysis required it long term; 6.25% for SH and 2.44% for WSH (P=0.49). The rates of grade 3 or 4 febrile neutropenia and gastrointestinal toxicities were not significantly different between the groups. Engraftment kinetics were similar for both groups. Grade 4 renal toxicity and grade 3 lightheadedness were more frequent in patients with SH undergoing HDM/SCT for AL amyloidosis. Further studies into the mechanism of increased renal toxicity in patients with SH are warranted.

Topics: Case-Control Studies; Female; Hematopoietic Stem Cell Transplantation; Humans; Hypoalbuminemia; Immunoglobulin Light-chain Amyloidosis; Kidney Diseases; Male; Melphalan; Middle Aged; Renal Dialysis; Retrospective Studies; Transplantation, Autologous

Refractory pleural effusions present a challenging management problem and are associated with a poor prognosis in patients with primary systemic amyloidosis (AL). We report a series of four patients with AL who presented with bilateral pleural effusions that were refractory to diuretic therapy. After treatment with bevacizumab, an antivascular endothelial growth factor (VEGF) antibody, three of the four patients had improvement in their pleural effusions, peripheral edema, and functional status. Additional studies are needed to further define the role of bevacizumab in the management of this group of patients.

Topics: Amyloidosis; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Bevacizumab; Captopril; Chest Tubes; Combined Modality Therapy; Dexamethasone; Diuretics; Drug Resistance; Edema; Fatal Outcome; Furosemide; Humans; Hypoalbuminemia; Male; Melphalan; Metolazone; Middle Aged; Multiple Myeloma; Nephrotic Syndrome; Peripheral Blood Stem Cell Transplantation; Pleural Effusion; Prednisolone; Serum Albumin; Spironolactone; Thalidomide; Thoracostomy; Transplantation, Autologous; Vascular Endothelial Growth Factor A