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Myeloma Cast Nephropathy — ESENeph MCQ

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ModerateAcute Kidney InjuryMyeloma Cast NephropathyESENeph

A 65-year-old man presents with AKI, bone pain, hypercalcaemia (corrected Ca 3.2 mmol/L), and anaemia (Hb 82 g/L). Serum protein electrophoresis shows a paraprotein band. Urine shows Bence Jones proteinuria. Kidney biopsy shows fractured casts surrounded by giant cells in the tubules. What is the diagnosis?

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Correct answer: B — Myeloma cast nephropathy (myeloma kidney)

The combination of AKI, hypercalcaemia, anaemia, paraprotein, Bence Jones proteinuria, and biopsy showing fractured casts with giant cell reaction is diagnostic of myeloma cast nephropathy. Free light chains precipitate in the tubular lumen as casts, causing obstruction and an inflammatory giant cell reaction. Management includes urgent chemotherapy to reduce light chain burden, hydration for hypercalcaemia, avoidance of nephrotoxins, and consideration of high cut-off haemodialysis to remove free light chains.

Reference: NICE NG35 2016 – Myeloma; KDIGO 2012 – AKI Guideline