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presented at the Emergency Department with pain in his left testicle irradiating to the ipsilateral flank&#44; with no accompanying fever or urinary symptoms&#46; The physical examination was unremarkable except for high blood pressure&#46; The ultrasound of the kidneys and testicles-prostate was without findings&#46; We observed rapidly progressive renal function deterioration &#40;creatinine 9&#46;79mg&#47;dl&#44; 4&#46;85g&#47;24 proteinuria without active sediment&#41; and progressive anaemia &#40;Hb 8&#46;1g&#47;dl&#44; mean corpuscular volume 88fl&#44; mean corpuscular haemoglobin 31&#46;1&#44; mean corpuscular haemoglobin concentration 35&#46;4&#41;&#46; The immunological study &#40;anti-nuclear antibodies&#44; anti-neutrophil cytoplasmic antibodies&#44; anti-GBM&#44; anti-streptolysin O&#44; rheumatoid factor&#44; C3-4&#41;&#44; viral serology and tumour markers were normal&#46; Protein electrophoresis-immunofixation with immunoglobulin &#40;Ig&#41; A-kappa monoclonal band&#46; IgG 317&#44; IgA 1446&#44; IgM 15mg&#47;dl&#44; free light chains&#58; &#40;FLC&#44; Free-Lite<span class="elsevierStyleSup">&#174; </span>nephelometer&#41; kappa 4090ng&#47;ml&#44; lambda 1&#46; Uric acid 10&#46;8&#44; LDH 269&#44; calcium 10&#46;2&#44; albumin 3&#46;3&#44; B<span class="elsevierStyleInf">2</span> microglobulin 23&#44;340&#46; Liver profile&#44; lipids and other blood count were normal&#46; Nephropathy was anatomopathologically diagnosed due to kappa free light chain &#40;K-FLC&#41; casts &#40;Figure 1A&#41; and Durie-Salmon stage IIIB IgA-kappa MM&#44; and the patient was treated with bortezomib-dexamethasone along with renal replacement therapy with Theralite<span class="elsevierStyleSup">&#174; </span>high cut-off filter on alternate days&#46;</p><p class="elsevierStylePara">For two consecutive months&#44; the serum IgA figure decreased progressively and significantly&#44; which was not the case for pre-dialysis K-FLC &#40;Figure 2&#41;&#44; but in a multidisciplinary clinical session&#44; it was decided to continue with the treatment established in accordance with the Haematology department protocol and re-biopsy the kidney to assess whether to continue renal replacement therapy&#46; In the second biopsy&#44; we observed chronic mild intensity tubulointerstitial lesions &#40;Figure 1B&#41;&#46; We prescribed 6 further high cut-off dialysis cycles&#46;</p><p class="elsevierStylePara">Three months after diagnosis&#44; after 4 chemotherapy cycles&#44; bortezomib was considered to be ineffective and was replaced by lenalidomide&#44; adjusted according to renal function&#46; Due to financial constraints&#44; it was impossible to continue removing FLC by renal replacement therapy &#40;with the patient having received a total of 18 sessions&#41; and they remained on renal replacement therapy with conventional high flow dialysis&#46; The efficacy of lenalidomide was confirmed &#40;Task Force&#44; SWOG and EMBT&#41; and the patient continues to receive this drug three years after diagnosis along with renal replacement therapy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Renal failure in MM occurs in 12&#37;-20&#37; of patients&#44; with a mean survival of less than one year in dialysis&#46;<span class="elsevierStyleSup">3</span> Cast nephropathy is the most common cause of renal failure&#44; with measurement of FLC in blood being a very useful diagnostic tool&#46;<span class="elsevierStyleSup">4</span> Chemotherapy has been the key to an improved prognosis in these patients in the last decade&#44; with light chain synthesis decreasing&#44; causing the reduction of FLC deposits in the renal tubule&#44; which is ultimately responsible for the nephropathy&#46; Furthermore&#44; extracorporeal clearance techniques that remove light chains and therefore stop their contact with the renal tubule have been tested for decades as a supportive therapy&#44; without success in terms of renal function recovery&#46;<span class="elsevierStyleSup">5</span> Hutchison et al&#46;<span class="elsevierStyleSup">2 </span>improved these results with a long 8-hour haemodialysis technique using high cut-off filters in which success was determined by early treatment&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">In this case&#44; first-line chemotherapy was not effective&#44; rendering extracorporeal clearance useless&#46; The monitoring of kappa-FLC&#44; not IgA&#44; which decreased considerably from the start of treatment&#44; seemed to indicate this therapeutic failure at all stages and the short half-life of light chains meant that monitoring them allowed us to detect changes in the tumour earlier than in whole Ig&#46;<span class="elsevierStyleSup">7 </span>As such&#44; we observed how&#44; after each cycle&#44; the amount of FLC decreased significantly and increased to similar amounts in the next measurement 48 hours later&#44; which means that the clearance filter was doing its work&#44; which was not the case for the synthesis inhibitor treatment&#44; i&#46;e&#46; chemotherapy&#46; The contradiction between IgA levels and K-FLC levels and the non-inclusion of this FLC monitoring in the response protocols delayed the re-assessment of the patient&#8217;s treatment&#44; which in turn interrupted their recovery from the nephropathy&#46; So&#44; we should perhaps consider that a same clone of B cells may secrete different quantities of whole Ig and light chains&#46; Mead et al&#46; found a poor correlation between levels of whole Ig and FLC in mixed myelomas&#46;<span class="elsevierStyleSup">8</span> This&#44; or the existence of different B cell clones&#44; some of which segregate IgA and others&#44; light chains&#44; is the physiopathological explanation that we attribute to this case&#46; As such&#44; we rightfully believed that&#44; although IgA levels reflected a good response to treatment&#44; K-FLC were indicating the opposite&#46;</p><p class="elsevierStylePara">Until present&#44; FLC monitoring has not been included in standard blood protocols for response to treatment&#44; and as such&#44; in most centres&#44; only whole Ig is taken into account when assessing this response&#46; Due to the long half-life of Ig&#44; it is monitored monthly and the response is not assessed before the fourth cycle of chemotherapy&#44; that is&#44; between the third and fourth month after diagnosis&#46; The haematological argument for not advancing the abovementioned assessment is that a delay in the diagnosis of therapeutic ineffectiveness of 4-6 weeks does not really affect the final outcome&#44; as far as the medullary response is concerned&#46;<span class="elsevierStyleSup">8</span> as nephrologists&#44; we insist that the situation is different whenever there is a nephropathy due to light chains&#44; since early diagnosis-treatment <span class="elsevierStyleItalic">is</span> vital in this case&#58; we can cure medullary cell dyscrasia at a later stage&#44; but we cannot do so for renal tubular cells&#44; as demonstrated in the second biopsy carried out in our case&#46;</p><p class="elsevierStylePara">Fortunately&#44; more and more studies advocate the prognostic importance of FLC<span class="elsevierStyleSup">9</span> and the inclusion of their monitoring in these protocols&#44; which could even save a re-biopsy of the medulla&#46;<span class="elsevierStyleSup">7-11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Early chemotherapy and clearance of free light chains is fundamental in order for treatment to be effective in myeloma kidney&#46; The monitoring of free light chains in blood helps to assess the therapeutic response&#46; Good coordination between Nephrology and Haematology is essential for treatment to be effective in these patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12103&#95;16025&#95;52992&#95;en&#95;f1121034&#46;jpg" class="elsevierStyleCrossRefs"><img src="12103_16025_52992_en_f1121034.jpg" alt="Renal biopsies&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Renal biopsies&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12103&#95;16025&#95;52994&#95;en&#95;f2121033&#46;jpg" class="elsevierStyleCrossRefs"><img src="12103_16025_52994_en_f2121033.jpg" alt="Monitoring of kappa light chains and immunoglobulin A&#46; "></img></a></p><p class="elsevierStylePara">Figure 2&#46; Monitoring of kappa light chains and immunoglobulin A&#46; </p>"
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