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The optimal treatment for the monoclonal gammopathies of renal significance is not known, but there is consensus among experts that treatment should be specific for the underlying clone. The majority of patients with proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) do not have an identifiable clone, and prior studies have found poor renal outcomes for patients with PGNMID treated with a variety of regimens. Here we present a retrospective case series of 19 patients with PGNMID with a more uniform, clone-directed approach. A circulating paraprotein was detected in 37% of patients, and the overall clone detection rate was 32%. Treatment was directed at the underlying clone or, for patients without a detectable clone, empirically prescribed to target the hypothesized underlying clone. Of the 16 patients who underwent treatment, the overall renal response rate was 88%, and 38% of patients experienced complete renal response (proteinuria reduction to under 0.5 gm/24 hours) with initial treatment. All patients were End Stage Renal Disease-free at last follow-up (median 693 days after diagnosis), and treatment was well tolerated. Thus, a clone-directed approach may lead to novel, targeted treatment strategies that could significantly improve outcomes for patients with PGNMID.

Patients with cancer are at risk for acute and chronic renal injury. The insult could be from the malignancy directly or a paraneoplastic process or due to treatment. In addition, cancer and its treatments can also lead to electrolyte and acid-base disorders, as well as hypertension. Monitoring kidney function in patients with cancer is important for early detection and management of these complications. This is also important for patients on newer cancer treatments whose renal effects may not be well known. In patients for whom nephrotoxicity is anticipated, specific precautions can be taken for its prevention. This chapter discusses direct tumor involvement of the kidney and treatment-associated kidney disease and closes by examining tumor lysis syndrome and kidney disease after hematopoietic cell transplantation.

BACKGROUND: Kidney transplant (KT) recipients experience high rates of early (≤30 days) hospital readmission (EHR) after KT, and existing studies provide limited data on modifiable discharge factors that may mitigate EHR risk. METHODS: We performed a retrospective cohort study of 468 adult deceased donor KT recipients transplanted between 4/2010 and 11/2013 at five United States transplant centers. We fit multivariable mixed effects models to assess the association of two potentially modifiable discharge factors with the probability of EHR after KT: 1) weekend discharge, and 2) days to first scheduled follow-up. RESULTS: Among 468 KT recipients, 38% (n=178) experienced EHR after KT. In fully adjusted analyses, compared to weekday discharges, KT recipients discharged on the weekend had a 29% lower risk of EHR (adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.41–0.94). Compared to follow-up within two days of discharge, KT recipients with follow-up within three to six days had a 28% higher probability of EHR (aOR 1.28, 95% CI 1.13–1.45). CONCLUSIONS: These findings suggest that clinical decisions related to the timing of discharge and follow-up modify EHR risk after KT, independent of traditional risk factors.