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Paraprotein ESA-Resistant Anaemia CKD — ESENeph MCQ

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ModerateChronic Kidney DiseaseParaprotein ESA-Resistant Anaemia CKDESENeph

A 60-year-old man with CKD G4 develops worsening anaemia (Hb 78 g/L) despite adequate iron and ESA therapy. He has a new monoclonal band on serum protein electrophoresis. Free light chain ratio is abnormal. What should be investigated?

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Correct answer: D — Investigate for myeloma or monoclonal gammopathy as cause of CKD and/or ESA-resistant anaemia

New paraproteinaemia with ESA-resistant anaemia in CKD should raise suspicion for myeloma or a related monoclonal gammopathy (MGRS – monoclonal gammopathy of renal significance). Myeloma may be the underlying cause of CKD (cast nephropathy, amyloidosis, LCDD, or light chain proximal tubulopathy). The anaemia may be from marrow infiltration or myeloma-related inflammation. Investigation includes serum/urine immunofixation, free light chains, bone marrow biopsy, and skeletal survey or low-dose CT. Consider kidney biopsy if the cause of CKD is unclear.

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