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Renal Failure in Multiple Myeloma. Tutorial/ MSN 621 Beth St John BSN Alverno College. Purpose and Objectives. Purpose: To educate RNs and LPNs on the underlying disease process of multiple myeloma and how it leads to renal failure Objectives:

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renal failure in multiple myeloma

Renal Failure in Multiple Myeloma

Tutorial/ MSN 621

Beth St John BSN

Alverno College

purpose and objectives
Purpose and Objectives
  • Purpose:
    • To educate RNs and LPNs on the underlying disease process of multiple myeloma and how it leads to renal failure
  • Objectives:
    • Review pathophysiology of renal failure in multiple myeloma
    • Identify key assessment components of multiple myeloma patient in renal failure
    • Describe interventions for management of multiple myeloma patient in renal failure, emphasizing nursing sensitive patient outcomes.
normal renal function
Normal Renal Function

2 Kidneys –located back of the body in the abdominal cavity

contains: nephrons, glomerulus, and tubules

  • used with permission Wellcome,Library, London

kidney

nephron

glomerulus

tubules

function of the kidney
Function of the Kidney:
  • Remove waste products
  • Regulate body fluids and electrolytes
  • Produces hormones
  • Regulate blood pressure
  • Excrete drugs and toxins

Lancaster, L. (Ed.). (2001). Core Curriculum for Nephrology Nursing (4th ed.). Pitman, NJ: American Nephrology Nurses' Association.

function of the kidney5
Function of the Kidney

Remove waste products

  • Urea : product of protein metabolism; an excess is a sign of uremia
  • Creatinine: end product of creatine metabolism; an excess is a sign of advanced kidney disease
  • Uric acid: an end product of purine metabolism, must be excreted because the body cannot destroy it; an excess can cause gout
  • Beta 2 microglobulin: an end product of Class I HLAs; complement proteins activation can lead to increase of microglobulins;

Lancaster, L. (Ed.). (2001). Core Curriculum for Nephrology Nursing (4th ed.). Pitman, NJ: American Nephrology Nurses' Association

Porth, C., & Matfin, G. (Eds.). (2009). Pathophysiology: Concepts of altered health states (8th ed.). Philadelphia: Wolters Kluwer Health/​ Lippincott Williams & Wilkins

function of the kidney6
Function of the Kidney:
  • Regulate body fluids and electrolytes
    • Key systems help to maintain function
      • Cardiovascular: provides plasma to help regulate water and electrolytes
      • Nervous: helps fluid balance by regulating thirst
      • Endocrine: produces hormones to alter water absorption
function of the kidney7
Function of the Kidney:
    • Produces hormones
  • Prostaglandins; “a group of mediators of cell function” (Porth & Matfin, 2009 p. 749), produce vasodilatation, “protects the kidney against the vasoconstricting effects of sympathetic stimulation and angiotensin II “(Porth & Matfin, 2009 p. 749)
  • Erythropoietin: a hormone that stimulates production of RBCs; secreted in response to renal hypoxia and possibly epinephrine, norepinephrine and prostaglandins
  • 1,25 – dihydroxycholecaciferol (activated Vitamin D): a steroid hormone that has final activation in the kidney and is necessary for regulation of calcium

Porth, C., & Marfin, G. (Eds.). (2009). Pathophysiology: Concepts of altered health states (eighth ed.). Philadelphia: Wolters Kluwer Health/​ Lippincott Williams & Wilkins.

function of the kidney8
Function of the Kidney:
  • Generalized Stress response activation in the kidney
  • Control of vascular volume: regulation of renal blood flow is reliant on regulation of glomerular blood flow
  • Renin-angiotensin II system: release of renin from kidney in response to SNS stimulation and release of epinephrine and norepinephrine then leads to the production of angiotensin II
  • Aldosterone secretion: stimulated by high potassium levels in plasma, also by angiotensin II, transports sodium back into cells in order to increase potassium excretion.

Lancaster, L. (Ed.). (2001). Core Curriculum for Nephrology Nursing (4th ed.). Pitman, NJ: American Nephrology Nurses' Association

renin angiotension system
Renin Angiotension system

↓ renal blood flow

↓sodium at macula densa

↓afferent arteriole pressure

epinephrine

norepinephrine

renin

(from JGA)

negative feedback

loop

↓renin

angiotensiogen

angiotensin I

ACE

↑ renal blood flow

angiotensin II

peripheral vasoconstriction

direct renal effects

↑ MAP

aldosterone

(adrenal cortex)

↑ vascular volume

renal tubular

reabsorption

Na+ and H2O

function of the kidney10
Function of the Kidney:
  • What is a function of the kidney?
  • What is key component of renal function?

Production of erythropoietin

That is correct

Production of angiotensin II

that is incorrect

produced in the lung blood vessels

Production of insulin

That is incorrect produced by pancreas

urination

That is incorrect

this is done by the bladder

removal of waste products

That is correct

muscle movement

That is incorrect

basic concepts of renal failure
Basic Concepts of Renal Failure
  • “When 75-80% of renal function is lost, the kidneys lose their ability to regulate the internal environment and all organ systems and physiologic processes are affected by renal failure” (Lancaster, 2001, p. 119)
  • “Uremia or the uremic syndrome refers to the constellation of signs, symptoms and physicochemical changes that occur with either acute or chronic renal failure.” (Lancaster, 2001, p. 120)

Lancaster, L. (Ed.). (2001). Core Curriculum for Nephrology Nursing (4th ed.). Pitman, NJ: American Nephrology Nurses' Association

basic concepts of renal failure12
Basic Concepts of Renal Failure
  • Some Uremic Changes:
    • Fluid – electrolytes imbalances
      • fluid retention causing edema in legs, abdomen, and face
      • hyperkalemia,hypocalcaemia, hyperphosphatemia
    • Changes in cardiovascular system
      • Includes the RAAS due to decrease in renin production interrupting feedback loop
    • Changes in inflammatory –immune response
      • Altered T-cell function
      • Altered B-cell number and function
    • Accumulation of toxins
      • Urea
      • Creatinine
      • Uric acid
      • Beta 2 microglobulin

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

basic concepts of renal failure13
Basic Concepts of Renal Failure
  • For more information on Chronic renal failure
  • See V. Kolmers power point
  • http://faculty.alverno.edu/bowneps/MSN621/MSNtutorialsindexfull.html
multiple myeloma15
Multiple myeloma

injury to DNA

(unknown etiology)

of a single cell

in lymphocyte development

more developed

b lymphocyte

Fully developed

antibody producing

plasma cell

very young

b lymphocyte

stem cell

other blood cell

red cells

white cells (other lymphocytes

platelets

other lymphocytes

T lymphocytes

natural Killer (NK) cells

Myeloma occurs in the B lymphocytes

Lymphocyte development

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

what is myeloma
What is Myeloma?
  • Overproduction of a single immunoglobulin by cancerous plasma cells
  • Immunoglobulin is “a protein produced by body’s immune system to help fight infections”(Bashey & Huston, 2005, p. 2)
  • Normally the body make many different types of immunoglobulins (polyclonal)
  • In Myeloma the cancerous cells are monoclonal and are usually of no use to the body
  • These cells are called M-protein and can be detected in urine.
  • Research is being done to look at the various reasons for these changes – especially at certain genetic variations (such as Chromosome 13 deletion)

Bashey, A., & Huston, J. (2005). 100 Questions & answers about myeloma. Sudbury, MA: Jones and Bartlett Publishers.

slide17
Immunoglobulin Molecule

H

H

L

L

H

H

L = Light Chains

H = Heavy Chains

immunoglobulin molecule
Immunoglobulin Molecule
  • Breaks down into the heavy chains and light chains
  • Light chains are also called Bence Jones proteins
  • High amounts of light chains in the urine causes the most protein damage to the kidney
mm background clinical features
MM BackgroundClinical Features
  • Early MM – often asymptomatic
  • Common clinical features:
    • C – hyper-Calcemia
    • R – renal (kidney) problems
    • A – anemia
    • B – bone pain
    • Fatigue
    • Recurrent infections
    • Neuropathy

micrcosoft clip art

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

myeloma risk factors
Myeloma Risk Factors
  • Clinical Risk Factors:
    • Black
    • Male = Female
    • Family history of MM
    • Median age at dx: 701,2
    • 7% before age 55
    • 2% before age 40
    • 0.3% before age 30

1.Ries LAG, et al. SEER Cancer Statistics Review, 1975-2004. National Cancer Institute. Bethesda, MD:

Available at http://seer.cancer.gov/csr/1975_2004. Accessed April 10, 2008.

2 Jemal A, et al. Cancer Statistics, 2008. CA Cancer J Clin 2008;58:71-96

Slide used with permission from Dr. Thompson, WMH 2010

myeloma risk factors aging
Myeloma risk factors: AGING
  • Disease of the elderly
  • risk of myeloma is 10 times greater in those 75 to 79 compared to those 45 to 50
  • uncommon in people younger than 40 y/o
  • In short, higher age groups (especially after age 60 years)showed significantly risk of MM for both-sexes, men and women. (Khan, Mori, Sakauchi, Matsuo, Ozasa, & Tamakoshi, 2006, p. 579)
  • more often in African American than whites while Asians less likely than whites

Khan, MMH., Mori, M., Sakauchi, F., Matsuo, K., Ozasa, K., & Tamakoshi, A. (2006). Risk factors for multiple myeloma: Evidence from the Japan collaborative cohort (JACC) study. Asian Pacific Journal of Cancer Prevention, 7, 575-581.

renal failure in myeloma
Renal Failure in Myeloma
  • Mechanism of inflammation and damage
    • Light chain cast deposition – tubule obstruction (“myeloma kidney”) by protein deposits
    • Obstruction of tubules by plasmacytoma
    • Hypercalcemia, hyperuricemia: both of which can cause inflammation in the tubules due to high concentrations
    • Renal amyloid: can cause obstruction which will cause inflammation in the glomerulus
    • Recurrent pyelonephritis chronic recurrent infections that lead to chronic inflammation of the basement membrane of the nephron tubule
    • May develop RTA2 (Fanconi syndrome)

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

myeloma kidney cast nephropathy
Myeloma kidney-cast nephropathy

Figure: Pathogenesis of myeloma cast nephropathy.

Ca2 = calcium, THP = Tamm Horsfall Protein, GFR= glomerular filtration rate

casts= protein breakdown of light chains in kidney can causes obstruction and injury to distal tubule

Scheme used with permission of Dr. C. Winearls

the myeloma kidney
The Myeloma kidney
  • Used with permission from Dr. C. Winearls
myeloma treatment
Myeloma treatment
  • RVD – Revlimid®-Velcade®- dexamethasone
  • VTD – Velcade®- thalidomide-dexamethasone
  • VAD – Velcade®-Adriamycin®-Dexamethasone

All these are high dose chemotherapy regimens that need monitoring in the elderly patient and in the renal insufficient patient

multiple myeloma treatment
Multiple Myeloma treatment
  • Autologous stem cell transplant
  • procedure that the patient’s own stem cells to restore blood cells after intense chemotherapy
  • good response rates even including elderly patients
  • process involves
    • pt in remission due to chemotherapy
    • pt’s stem cells harvested and frozen
    • pt receives conditioning therapy
    • stem cells are thawed and reinfused into the pt
    • results start to show in 10-14 days

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

multiple myeloma treatment27
Multiple Myeloma treatment:
  • Another transplant type is allogeneic
  • This is when the stem cells come from a HLA matched donor (usually a sibling but not always)
  • This is called tissue typing and is used in many transplant procedures (not just stem cell transplantation)
  • The procedure is the same as for an autologous donation – just where the cells originate is different.
  • This treatment is in clinical trials
multiple myeloma treatment genetic
Multiple Myeloma TreatmentGenetic
  • Research is being done looking at different genetic polymorphisms and their effects
    • maintenance treatment after high dose therapy -(nuclear factor κB) (Vangsted et al., 2009)
    • treatment of myelomic bone disease - (multiple single nucleotide polymorphisms) (Durie et al., 2009)
    • the role of tumor necrosis factor α(Hideshima, Chauhan, Schlossman, Richardson, & Anderson, 2001)

Durie, B., Van Ness, B., Ramos, C., Stephens, O., Haznadar, M., Hoering, A., Haessler, J., ... Shaughnessy Jr., J. (2009). Genetic polymorphisms of EPHX1, Gsk3B, TNFSF8 and myeloma cell DKK-1 expression linked to bone disease in myeloma. Leukemia, 23, 1913-1919.

Hideshima, T., Chauhan, D., Schlossman, R., Richardson, P., & Anderson, K. (2001). The role of tumor necrosis factor alpha in the pathophysiology of human multiple myeloma: therapeutic applications. Oncogene, 20, 4519-4527.

Vangsted, A., Klausen, T., Gimsing, P., Anderson, N., Abildgaard, N., Grefersen, H., & Vogel, U. (2009). A polymorphism in NFKB1 is associated with improved effect of interferon-alpha maintenance treatment of patients with multiple myeloma after high dose treatment with stem cell support. Haematologica, 94(9), 1274-1282.

slide29
correct

What animal represents the common clinical features of multiple myeloma ?

Microsoft clip art

C: hyper calcemia, R: renal failure, A: anemia, B: bone pain

Try again

Try again

physical presentation
Physical presentation
  • Anemia – due to ↑ myeloma cells in the bone marrow which leads to ↓ in RBC production
  • Bone loss- due to excitement of the osteoclasts by the cytokines secreted from the myeloma cells
  • Back pain – due to fractures in the vertebral body
  • Infection – due to immune system failure ; normal immunoglobulin production is severely suppressed
  • Fatigue – due to anemia

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

labs and diagnostic tests
Labs and diagnostic tests
  • Bone Marrow Aspiration /biopsy – examines marrow cells for abnormalities (can also be done after treatment to check proportion of cancer cells killed by therapy)
  • CBC – to look for anemia
  • Serum protein electrophoresis- looks for M proteins
  • Urine tests – 24 hour testing for protein tests- light chains (Bence Jones protein)

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

labs and diagnostic tests33
Labs and diagnostic tests
  • Genetic testing
  • Fluorescence in situ hybridization (FISH) looks at changes in the chromosomes of the myeloma cells
  • G-banding karyotyping arrangement of chromosomes of a cell to look for variations (number, size, shape, arrangement)
  • “Among top SNP variations […] were those associated with drug metabolism/detoxification/transport, (Van Ness et al., 2008, p. 12)

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

labs and diagnostic tests34
Labs and diagnostic tests
  • Imaging tests
    • X-rays
    • CT Scans
      • “X-rays and CT scans are used to see if there any holes, breaks or thinning of the bones” (Leukemia -Lymphoma Society, 2010)

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

labs and diagnostic tests35
Labs and diagnostic tests
  • Imaging tests
    • PET scans
    • MRIs
      • “MRIs and PET scans look for changes to the marrow and pockets of myeloma cells” (Leukemia -Lymphoma Society, 2010)

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

what lab test is used to look for m proteins
What lab test is used to look for M Proteins

CBC

Try again

FISH

Try again

Looks at anemia

Looks at chromosomal changes

Serum electrophoresis

correct

Urine tests

Try again

Looks at M proteins

Looks at light chains

renal failure in myeloma38
Renal Failure in Myeloma
  • Prevention
    • Avoid NSAIDs : they can affect prostaglandin levels and cause a decrease in GFR
    • Avoid radiographic contrast: can cause damage in GFR
    • Avoid dehydration: watch diuretic use
    • Watch for hypercalcemia: high levels of calcium can cause damage to the nephrons

Itano, J., & Taoka K. (Eds.). (2005). Core curriculum for oncology nursing (4th ed.). St Louis, MO: Elsevier Saunders

interventions
Interventions
  • Hypercalcemia / Bone Loss –
    • Encourage fluid intake
    • Daily weights :monitor for fluid loss , muscle mass loss due to decrease activity
    • Maintain mobility level (consistent with pt’s activity level)
    • Watch for changes in heart rhythm – bradycardia
    • Watch for changes in nutritional status- nausea, vomiting, constipation

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

interventions40
Interventions
  • Hypercalcemia / Bone Loss –
    • Bisphosponates – Aredia® and Zometa® (Infusions), Boniva®, Fosamax®, Actonel® (oral)
      • Watch for osteonecrosis of the jaw (ONJ)– exposed bone in the oral cavity
        • Inform doctor of any pending invasive dental work
        • Hold medicine one month prior and do not resume till area completely healed

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

interventions41
Interventions
  • Hypercalcemia –
    • Prevention of ONJ
      • Encourage good oral hygiene
      • Encourage routine dental examinations
      • Have pt avoid invasive procedures

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

interventions42
Interventions
  • Fatigue / Anemia
    • Pace daily activities
    • Planned rest periods
    • Procit® / Aranesp® Injections if hemoglobin is less than 10
    • Monitor patient for GI bleeding
      • Hematemesis
      • Tarry stool

Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology nursing: Standards of practice and guidelines for care. Pitman, NJ: Anthony J. Jannetti Inc.

Itano, J., & Taoka K. (Eds.). (2005). Core curriculum for oncology nursing (4th ed.). St Louis, MO: Elsevier Saunders

interventions43
Interventions
  • Infections
    • Neupogen® / GCSF (granulocyte colony stimulating factor) – increase WBC
    • Platelet transfusions for low platelet levels

Itano, J., & Taoka K. (Eds.). (2005). Core curriculum for oncology nursing (4th ed.). St Louis, MO: Elsevier Saunders

interventions44
Interventions
  • Infections
    • Catheter dressing changes per policy
    • Monitor for signs and symptoms of infection
      • Fever (with or without chills)
      • Evaluate catheter site for signs of infection
        • Redness, swelling, drainage, warmth
    • Administer antibiotics as ordered

Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology nursing: Standards of practice and guidelines for care. Pitman, NJ: Anthony J. Jannetti Inc.

interventions45
Interventions
  • Pain Control
    • Watch NSAID intake
      • Lowers GFR
    • Pace activity with rest periods
    • Help find comfortable position due to back pain
    • Bisphosphonates may help with bone pain
    • Neurontin® / Lyrica® / B complex vitamin w/ folic acid – to help with neuropathic pain

Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org

interventions46
Interventions
  • In 20% of patients diagnosed with multiple myeloma have renal failure as a serious complication
  • Mortality rate in multiple myeloma patients with renal failure is approximately 30%. This is mainly due to septicemia and infections from a compromised immune system.

Goldschmidt, H., Lannert, H., Bommer, J., & Ho, A. (2001). Renal failure in multiple myeloma "the myeloma kidney": State of the art. Saudi Journal of Kidney Diseases and Transplantation, 12(2), 145-150.

interventions47
Interventions
  • Hemodialysis:
    • Assess patient pre treatment- weight, blood pressure, HR, RR, Temperature, edema, mental status, ambulation status
    • Evaluate patient for – headache, nausea, vomiting, fever, chills, bleeding, pain, insomnia, weakness, fatigue
    • Reassess patient post treatment for changes in blood pressure , HR, RR, weight, edema

Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology nursing: Standards of practice and guidelines for care. Pitman, NJ: Anthony J. Jannetti Inc.

interventions48
Interventions
  • Hemodialysis:
    • Monitor treatment – adjust during in response to pt changes during treatment
    • Administer medications as ordered
    • Include pt teaching regarding diet and fluid needs (a MM pt might have a lower fluid restriction due to RRF or due to fluid loss with nausea/ vomiting with chemotherapy)
    • Ask pt when last chemo treatment was – use chemo precautions with patient

Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology nursing: Standards of practice and guidelines for care. Pitman, NJ: Anthony J. Jannetti Inc.

what nursing intervention helps with prevention of renal failure
What Nursing Intervention helps with prevention of renal failure
  • Monitor patient for GI bleeding
  • Catheter dressing changes per policy

Try again

Try again

  • Encourage good oral hygiene
  • Avoid NSAIDs

incorrect

Correct

case study
Case Study
  • Mr. C is a 68 year old black male who presents with back pain, fatigue, and recurrent urinary tract infections for 3 months. He is currently taking naproxysen sodium for pain relief, and has finished an antibiotic course of bactrim for the UTI
  • What lab tests would you consider for this patient?
case study51
Case Study
  • CBC showed
    • WBC 3.23,RBC 3.26, HGB 10.5, HCT 30.1
  • BMP Results
    • Na 135, K+ 4.1, CL 113, CO2 21, Glucose 82, Bun 59, Creatinine 3, Ca 10.5,
  • Urinanalysis was positive for blood and protein
case study52
Case Study
  • With high serum calcium and protein in the urine, what would your next steps be?

Serum electrophoresis to look for light chains

  • Further Labs
  • What Medicine additions or changes?

Add bisphosphonates and hold NSAIDS

  • What are nursing interventions?

Increase fluid intake, plan activity with rest periods

answers are just suggestions there can be other avenues to take

case study53
Case Study
  • Patient now complains of nausea, anorexia, edema on legs. A 24 hour creatinine clearance shows >2mg/dl. Hemodialysis is started via a Left IJ permacath
case study54
Case Study
  • What special instructions should be included

Keep catheter dry – no showers for bathing

helps to prevent infections from water borne bacteria

  • Infection control
  • What Medicine additions or changes?

Epogen should be added

  • What are nursing interventions?

Work with dietitian to adjust diet and fluid intake

answers are just suggestions there are other avenues for further care

in conclusion
In Conclusion:
  • Multiple myeloma accounts for approximately .88% of pts with ESRD according to the USRDS. (Gertz, 2005)
  • Early diagnosis and treatment of renal failure is key to decrease mortality in these pts.

Gertz, M. (2005). Managing Myeloma Kidney. Annals of Internal Medicine, 143(11), 835-836.

in conclusion56
In Conclusion:
  • By helping the pt monitor diet, activity, infection control and pain management the nurse can influence the outcome of treatment.
  • Patient teaching is a major component of compliance to treatment – not only in the management of MM but in the management of renal failure
references
References
  • Bashey, A., & Huston, J. (2005). 100 Questions & answers about myeloma. Sudbury, MA: Jones and Bartlett Publishers.
  • Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology nursing: Standards of practice and guidelines for care. Pitman, NJ: Anthony J. Jannetti Inc.
  • Durie, B., Van Ness, B., Ramos, C., Stephens, O., Haznadar, M., Hoering, A., Haessler, J., ... Shaughnessy Jr., J. (2009). Genetic polymorphisms of EPHX1, Gsk3B, TNFSF8 and myeloma cell DKK-1 expression linked to bone disease in myeloma. Leukemia, 23, 1913-1919.
  • Gertz, M. (2005). Managing Myeloma Kidney. Annals of Internal Medicine, 143(11), 835- 836.
  • Goldschmidt, H., Lannert, H., Bommer, J., & Ho, A. (2001). Renal failure in multiple myeloma "the myeloma kidney": State of the art. Saudi Journal of Kidney Diseases and Transplantation, 12(2), 145-150.
  • Hideshima, T., Chauhan, D., Schlossman, R., Richardson, P., & Anderson, K. (2001). The role of tumor necrosis factor alpha in the pathophysiology of human multiple myeloma: therapeutic applications. Oncogene, 20, 4519-4527.
  • Itano, J., & Taoka K. (Eds.). (2005). Core curriculum for oncology nursing (4th ed.). St Louis, MO: Elsevier Saunders.
references58
References
  • Khan, MMH., Mori, M., Sakauchi, F., Matsuo, K., Ozasa, K., & Tamakoshi, A. (2006). Risk factors for multiple myeloma: Evidence from the Japan collaborative cohort (JACC) study. Asian Pacific Journal of Cancer Prevention, 7, 575-581.
  • Lancaster, L. (Ed.). (2001). Core Curriculum for Nephrology Nursing (4th ed.). Pitman, NJ: American Nephrology Nurses' Association.
  • Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org
  • Porth, C., & Matfin, G. (Eds.). (2009). Pathophysiology: Concepts of altered health states (eighth ed.). Philadelphia: WoltersKluwer Health/​ Lippincott Williams & Wilkins.
  • Thompson, M. (2008, April). Medical complications of multiple myeloma. Power point presentation presented at the Educational Program (Pro HealthCare), Waukesha, WI.
references59
References
  • Van Ness, B., Ramos, C., Haznadar, M., Hoering, A., Haessler, J., Crowley, J., Jacobus, S., ... Gupta, R. (2008). Genomic variation in myeloma: design, content, and initial application of the Bank On A Cure SNP Panel to detect associations with progression-free survival. Biomed Cental Medicine, 6(26). Retrieved June 8, 2010, from BioMed Central Web site: www.biomedcentral.com
  • Vangsted, A., Klausen, T., Gimsing, P., Anderson, N., Abildgaard, N., Grefersen, H., & Vogel, U. (2009). A polymorphism in NFKB1 is associated with improved effect of interferon- alpha maintenance treatment of patients with multiple myeloma after high dose treatment with stem cell support. Haematologica, 94(9), 1274-1282.
  • Winearls, C. (1995). Acute Myeloma Kidney. Kidney International, 48, 1347-1361.
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