The term cancer survivor applies to any person diagnosed with cancer.  There are currently 12 million cancer survivors in the United States with 68 % of those expected to live at least five years.  Survival rates for patients diagnosed with Myeloma have improved significantly in the last decade due to improved diagnostics, treatment options and supportive care.   Living and feeling well while surviving cancer is a universal goal for cancer survivors.  Wellness requires an individualized approach with a focus beyond the just the cancer diagnosis including tailored screening, health promotion and management of other illnesses.    A number of health care providers from many disciplines may be involved in the continued care of patients living with Myeloma.  Patients and caregivers play a critical role in planning, monitoring and modifying their survivorship plan.

YES!  The kidneys play an important role in the health of each individual.  Their main function is to clear toxins and waste from our bodies. Approximately 25% of individuals with multiple myeloma (MM) will have temporary or permanent damage at some point during their illness.

What health conditions or medications can affect the kidneys?

Many health conditions (aside from MM) can cause the kidneys to work less efficiently. These are too numerous to list. However, more common conditions include: longstanding diabetes, high blood pressure, other plasma cell disorders such as amyloidosis, and dehydration. Enlarged prostate glands or kidney stones can also cause kidney damage.  Some medications can harm the kidneys.  These include non-steroidal anti-inflammatory agents (such as Motrin and ibuprofen), certain intravenous antibiotics (gentamycin, vancomycin), and water pills (called diuretics). Bone-building drugs called "bisphosphonates" can also damage the kidneys, so your healthcare provider will monitor your kidneys with each dose.  Intravenous contrast dye when given before a CT scan procedure can also harm the kidneys of MM patients. Therefore, this must be given in special situations, and the MM patient must drink lots of fluids.  

How does the MM affect ones' kidney?

Basically, there is a network of cells in the kidney called the glomerulus.  This is responsible for filtering "light chain" proteins before these are excreted in the urine. Too many immunoglobulins or urinary light chains can easily overwhelm the kidneys until they are unable to do their job.  The increased proteins in the urine can "clog" the kidneys and lead impaired kidney function.  

Does my healthcare provider monitor my kidneys, and what should I look for?

Your healthcare provider should be checking your serum creatinine levels each month. The normal range varies, but is generally between 0.5-1.4mg/dL of blood. If the creatinine begins to increase, your healthcare provider will review your medication list and see which medicines may have caused the rise in creatinine.  Then, he or she will determine if you have become dehydrated by not drinking adequate amounts of fluid (usually one needs about 64 ounces of fluid per day), or as a result of using water pills (diuretics) to manage your blood pressure or swelling. An elevated creatinine may be a sign that the MM is becoming active, but it may also be a result of a separate health condition.  

Notify your healthcare provider if you have any pain during urination, or change in your urinary habits. Let he or she know if you have developed any pain or blood in the urine. Drink lots of fluids to stay well hydrated. Eat a well-rounded diet with fruits, vegetables and proteins unless you have been placed on dietary restrictions. And, as always, discuss any medications and supplements with your healthcare provider to make sure these do not interact with your cancer treatment.

Depression is a major side effect that can affect you as a myeloma patient at some point in your course of treatment. Depression in a myeloma patient undergoing treatment can be challenging to diagnose as various side effects such as fatigue, pain, and anemia may appear similar in both conditions. Your healthcare team will need to distinguish the difference between the symptoms associated with your myeloma treatment or clinical symptoms of depression. While feelings of sadness and anxiety are typical with the diagnosis of cancer, 

it is imperative to discuss these symptoms with your healthcare team so they can help you appropriately. Signs and symptoms of depression include persistent sadness, anxious mood, sleeping too much, or too little, decreased appetite, weight loss or gain, restlessness, and feelings of despair or denial. Chronic disease such as cancer, medication side effects, gender, family history, situational events, biologic factors, and cognitive changes, such as poor self-esteem and negative thinking patterns, are all risk factors for depression.

Screening for Depression. There are several questionnaires available that your provider may use to assist in screening for depression. Once depression is correctly diagnosed, your clinician may find it necessary to start an antidepressant, or may refer you to a specialist such as a psychiatrist who specializes in oncology patients. It is also important to differentiate between depression and anxiety. If you have an oncology social worker available to you, they can be a valuable resource to assist you with related challenges of financial difficulties, such as insurance and housing issues, as well as social support. Many social workers are licensed counselors and can provide their services for patients and family members through counseling and group support sessions, usually without charge. Many cities also have local chapters with disease specific support groups such as monthly multiple myeloma support group meetings.  To find a local support group (or to start one in your area) please all the IMF Hotline at 1-800-452-CURE for assistance (818-487-7455 outside of the US and Canada.)  These meetings can be beneficial for both patients and caregivers. The NLB recommends asking the following questions during routine screening at all provider encounters to detect depression or other cognitive changes:

• Over the past two weeks have you felt down, depressed or hopeless?
• Over the past two weeks have you felt little interest or pleasure in doing things?

Please be sure to report any of these symptoms to your healthcare team.

Steroids have been in integral part of myeloma therapy for many years and they continue to be used today, often in combination with novel agents (thalidomide -Thalomid, lenalidomide - Revlimid and bortezomib - Velcade).Steroids can cause a wide variety of side effects affecting nearly every system of the body.Education, early identification and management of these side effects can contribute to the success of steroid-containing regimens for the treatment of myeloma and other associated disorders.

Possible Side Effects

One of the most common side effects associated with steroid use is difficulty sleeping (insomnia).Steroids should be taken early in the morning so that the medication will wear off by evening.It is possible some pharmacologic intervention may be necessary, including taking a hypnotic or sedative.Other causes of insomnia need to be considered as well, such as pain.  You should be aware of the signs and symptoms of infection, as steroids may mask the signs of infection.our provider should be notified if you are experiencing fevers (>100.5), shaking chills with or without fever, dizziness, shortness of breath or low blood pressure. 

 Medications to prevent infection, such as antibiotics or antiviral agents, may be prescribed.  You should also be aware of possible fluid retention (edema/swelling) in your legs or feet.  If you experience edema, elevate the affected limbs, use compression stockings, and increase activity.  If necessary, pharmacologic intervention with diuretics may be recommended.  Another side effect of steroid use is heartburn (dyspepsia).  Steroids should be taken with food and irritating or acidic food should be avoided.You may also benefit from over the counter or prescription medications, like Protonix.

These are just a few of the potential side effects associated with steroid use.  Contact your healthcare provider if any of the side effects are not manageable.  They may prescribe additional medication or modify your treatment plan.  You should never stop taking steroids without notifying your provider.

You might also be interested in: "Steroid-Associated Side Effects in Patients With Multiple Myeloma: Consensus Statement of the IMF Nurse Leadership Board"

Myeloma renal disease is a condition caused by long term effects of multiple myeloma.  "Renal" refers to the kidneys, which is one of the many body systems that can be harmed by multiple myeloma.  The disease creates a great burden on the kidneys in a variety of ways.  You are probably aware that the malignant plasma cells in the bone marrow  produce an antibody that is released into the bloodstream.  This antibody is a protein and there can be very high levels of protein in the blood of myeloma patients.   

Additionally, multiple myeloma can cause the breakdown of bone and the subsequent release of excess calcium into the bloodstream.  The kidneys work to filter the body's blood supply and the excess protein and calcium that are present in the blood can put a "strain" on the kidneys.  They have to work exceptionally hard to filter the abnormally high levels of protein and/or calcium in the blood.  These conditions can cause "renal dysfunction" or "renal insufficiency," which means that the kidneys are no longer able to handle their jobs.  In severe cases, this can lead to renal failure, which means the kidneys are shutting down.  Patients may have to undergo dialysis so machines can perform the blood filtering function for the body.

How can you help to protect your kidneys?  An important thing to remember is that you should not let yourself become dehydrated.   It is crucial that you stay well hydrated (e.g., making sure you drink enough plain water) as this will continuously flush your kidneys which will help them function properly.   You should avoid taking NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen and you should avoid IV contrast dye (particularly the IV dye used with CT scans) as these substances are taxing to the kidneys.  You will want to seek advice from your oncologist before using these substances.  

If it is noted that you are hypercalcemic (have a high level of calcium in your blood as determined by a blood test), then your physician will want to treat you without delay to lower your calcium level so that the kidneys are not damaged.  We are also going to check your kidney function before administering bisphosphonates, which are the bone-strengthening agents used in multiple myeloma patients.  These drugs are excreted by the kidneys so if your kidneys are not functioning optimally, you may need dose adjustments of these drugs or your physician may choose not to administer these agents.

It is important to note that those patients with myeloma renal disease can take actions to relieve some of the burden on their kidneys.  There are many treatment options available for myeloma patients and many patients will also see an improvement in their kidney function as the disease is controlled.

Have you found yourself not leaving the house or being too far from a bathroom out of fear of having an "accident"?  Diarrhea is defined as an abnormal increase in the amount of fluid in stool.  There are many causes for diarrhea.  Some people have baseline disorders like Crohn's Disease, Irritable Bowel Syndrome (IBS) or allergies that result in diarrhea.  For those receiving treatment for MM, diarrhea can be the result of irritation to the bowel lining from chemotherapy or infection.  Bortezomib use is commonly associated with diarrhea where thalidomide and lenalidomide are more commonly associated with constipation.

Severe or prolonged diarrhea can result in the loss of important electrolytes like potassium.  The increased loss of fluids can cause dehydration and kidney problems. Bowel incontinence, or uncontrollable diarrhea, can lead to emotional distress and limited freedom.  It may also result in the need for a change in treatment, dose, or schedule.

Darrhea should always be reported to your health care provider. Diarrhea with abdominal cramping may indicate an infection and the need for additional treatment. Clostridium difficile (C. diff) is an infection that can be associated with symptoms of diarrhea and abdominal cramping. People who have been receiving antibiotics and/or chemotherapy are at greatest risk for this infection.  Ironically, the treatment for this antibiotic-related infection is an antibiotic (i.e. metronidazole or vancomycin).  Symptom management may include hydration and electrolyte replacement.  It is important to stay well hydrated to replace the fluid that is lost. If stool sample is negative or there is no concern for infection, over the counter medications to control diarrhea may be started.  Loperamide (Immodium) is used to slow down bowel motion to allow for more fluid to be absorbed from the bowel, thereby reducing diarrhea.  Fiber binding agents (i. e. Metamucil or Citrucil) act like a sponge to absorb extra fluid. 

Diarrhea is not an easy topic to discuss and bowel incontinence can be embarrassing.  Despite this, diarrhea can result in hospitalization, change in treatment, and reduced quality of life.  Do not hesitate to discuss with your health care provider even between scheduled visits.

You have many items on the "To Do" list, but you just do not have the energy to get them all done.  Activities that normally take you no time take all day to complete.  You are experiencing fatigue.  Fatigue is subjective and very individual.  In simplest terms, it is the feeling of being more tired than the level of activity exerted. Fatigue often interferes with day to day functioning.

Fatigue may be related to medical conditions such as anemia (low hemoglobin), low thyroid function or infection.  It is one of the most commonly reported symptoms at the time of diagnosis of multiple myeloma.  Active myeloma, treatment and side effects like dehydration or uncontrolled pain cause fatigue.  Steroids are often used in myeloma treatment.  They initially can cause insomnia and hyperactivity with a rebound effect of being fatigued.  Depression also contributes to fatigue.

Your health care provider may ask you to rate your level of fatigue at baseline, or the start of treatment, and then throughout your treatment.  It is important to offer the information and discuss your level of fatigue with your healthcare provider.  If the level of fatigue is out of the norm for your level of hemoglobin or cycle of treatment, this may lead to more testing to find another cause.   

Managing fatigue can be done by taking a proactive approach.  If fatigue is due to a medical condition like depression, anemia or infection, treatment of the underlying condition will improve energy.  Maintaining proper nutrition, hydration and participating in a regular scheduled exercise program have also been found to be beneficial to improve energy.   Becoming aware of how you react to medications will help in planning activities and adjusting your schedule for times when you will have more/less energy.  Fatigue may not be life threatening, but it alters quality of life and should be discussed with your health care provider.