Tutorial/ MSN 621 Beth St John BSN Alverno College
Slide 2
Purpose and Objectives Purpose: To educate RNs and LPNs on the
underlying disease process of multiple myeloma and how it leads to
renal failure Objectives: Review pathophysiology of renal failure
in multiple myeloma Identify key assessment components of multiple
myeloma patient in renal failure Describe interventions for
management of multiple myeloma patient in renal failure,
emphasizing nursing sensitive patient outcomes.
Slide 3
Normal Renal Function 2 Kidneys located back of the body in the
abdominal cavity contains: nephrons, glomerulus, and tubules used
with permission Wellcome,Library, London tubules glomerulus nephron
kidney
Slide 4
Function of the Kidney: Remove waste products Regulate body
fluids and electrolytes Produces hormones Regulate blood pressure
Excrete drugs and toxins Lancaster, L. (Ed.). (2001). Core
Curriculum for Nephrology Nursing (4th ed.). Pitman, NJ: American
Nephrology Nurses' Association.
Slide 5
Function of the Kidney Remove waste products Urea : product of
protein metabolism; an excess is a sign of uremia Creatinine: end
product of creatine metabolism; an excess is a sign of advanced
kidney disease Uric acid: an end product of purine metabolism, must
be excreted because the body cannot destroy it; an excess can cause
goutpurine Beta 2 microglobulin: an end product of Class I HLAs;
complement proteins activation can lead to increase of
microglobulins ;HLAs; Lancaster, L. (Ed.). (2001). Core Curriculum
for Nephrology Nursing (4th ed.). Pitman, NJ: American Nephrology
Nurses' Association Porth, C., & Matfin, G. (Eds.). (2009).
Pathophysiology: Concepts of altered health states (8th ed.).
Philadelphia: Wolters Kluwer Health/ Lippincott Williams &
Wilkins
Slide 6
Function of the Kidney: Regulate body fluids and electrolytes
Key systems help to maintain function Cardiovascular: provides
plasma to help regulate water and electrolytes Nervous: helps fluid
balance by regulating thirst Endocrine: produces hormones to alter
water absorption
Slide 7
Function of the Kidney: Produces hormones Prostaglandins; a
group of mediators of cell function (Porth & Matfin, 2009 p.
749), produce vasodilatation, protects the kidney against the
vasoconstricting effects of sympathetic stimulation and angiotensin
II (Porth & Matfin, 2009 p. 749) Erythropoietin: a hormone that
stimulates production of RBCs; secreted in response to renal
hypoxia and possibly epinephrine, norepinephrine and prostaglandins
1,25 dihydroxycholecaciferol (activated Vitamin D): a steroid
hormone that has final activation in the kidney and is necessary
for regulation of calcium Porth, C., & Marfin, G. (Eds.).
(2009). Pathophysiology: Concepts of altered health states (eighth
ed.). Philadelphia: Wolters Kluwer Health/ Lippincott Williams
& Wilkins.
Slide 8
Function of the Kidney: Generalized Stress response activation
in the kidney o Control of vascular volume: regulation of renal
blood flow is reliant on regulation of glomerular blood flow o
Renin-angiotensin II system: release of renin from kidney in
response to SNS stimulation and release of epinephrine and
norepinephrine then leads to the production of angiotensin IISNS o
Aldosterone secretion: stimulated by high potassium levels in
plasma, also by angiotensin II, transports sodium back into cells
in order to increase potassium excretion. Lancaster, L. (Ed.).
(2001). Core Curriculum for Nephrology Nursing (4th ed.). Pitman,
NJ: American Nephrology Nurses' Association
Slide 9
Renin Angiotension system renal blood flow sodium at macula
densa afferent arteriole pressure epinephrine norepinephrine renin
(from JGA)JGA) angiotensiogen angiotensin I angiotensin II
peripheral vasoconstrictiondirect renal effects aldosterone
(adrenal cortex) renal tubular reabsorption Na+ and H2O vascular
volume MAP renal blood flow ACE negative feedback loop renin
Slide 10
Function of the Kidney: What is a function of the kidney? What
is key component of renal function? Production of erythropoietin
That is correct Production of angiotensin II that is incorrect
produced in the lung blood vessels Production of insulin That is
incorrect produced by pancreas muscle movement That is incorrect
urination That is incorrect this is done by the bladder removal of
waste products That is correct
Slide 11
Basic Concepts of Renal Failure When 75-80% of renal function
is lost, the kidneys lose their ability to regulate the internal
environment and all organ systems and physiologic processes are
affected by renal failure (Lancaster, 2001, p. 119) Uremia or the
uremic syndrome refers to the constellation of signs, symptoms and
physicochemical changes that occur with either acute or chronic
renal failure. (Lancaster, 2001, p. 120) Lancaster, L. (Ed.).
(2001). Core Curriculum for Nephrology Nursing (4th ed.). Pitman,
NJ: American Nephrology Nurses' Association
Slide 12
Basic Concepts of Renal Failure Some Uremic Changes: Fluid
electrolytes imbalances fluid retention causing edema in legs,
abdomen, and face hyperkalemia, hypocalcaemia, hyperphosphatemia
hyperkalemia,hypocalcaemia, hyperphosphatemia Changes in
cardiovascular system Includes the RAAS due to decrease in renin
production interrupting feedback loopRAAS Changes in inflammatory
immune response Altered T-cell function Altered B-cell number and
function Accumulation of toxins Urea Creatinine Uric acid Beta 2
microglobulin Leukemia -Lymphoma Society. (2010, March 4). Myeloma.
Retrieved March 4, 2010, from The Leukemia & Lymphoma Society
Web site: www.leukemia-lymphoma.org
Slide 13
Basic Concepts of Renal Failure For more information on Chronic
renal failure See V. Kolmers power point
http://faculty.alverno.edu/bowneps/MSN621/MSNtuto
rialsindexfull.html
http://faculty.alverno.edu/bowneps/MSN621/MSNtuto
rialsindexfull.html
Slide 14
Background
Slide 15
Multiple myeloma Myeloma occurs in the B lymphocytes Lymphocyte
development stem cell very young b lymphocyte more developed b
lymphocyte Fully developed antibody producing plasma cell other
blood cell red cells white cells (other lymphocytes platelets other
lymphocytes T lymphocytes natural Killer (NK) cells injury to DNA
(unknown etiology) of a single cell in lymphocyte development
Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved
March 4, 2010, from The Leukemia & Lymphoma Society Web site:
www.leukemia-lymphoma.org
Slide 16
What is Myeloma? Overproduction of a single immunoglobulin by
cancerous plasma cellsimmunoglobulin Immunoglobulin is a protein
produced by bodys immune system to help fight infections(Bashey
& Huston, 2005, p. 2) Normally the body make many different
types of immunoglobulins (polyclonal)polyclonal In Myeloma the
cancerous cells are monoclonal and are usually of no use to the
bodymonoclonal These cells are called M-protein and can be detected
in urine. Research is being done to look at the various reasons for
these changes especially at certain genetic variations (such as
Chromosome 13 deletion) Bashey, A., & Huston, J. (2005). 100
Questions & answers about myeloma. Sudbury, MA: Jones and
Bartlett Publishers.
Slide 17
L L H H HH L = Light Chains H = Heavy Chains Immunoglobulin
Molecule
Slide 18
Breaks down into the heavy chains and light chains Light chains
are also called Bence Jones proteins High amounts of light chains
in the urine causes the most protein damage to the kidney
Slide 19
MM Background Clinical Features Early MM often asymptomatic
Common clinical features: C hyper-Calcemia R renal (kidney)
problems A anemia B bone pain Fatigue Recurrent infections
Neuropathy micrcosoft clip art Leukemia -Lymphoma Society. (2010,
March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia &
Lymphoma Society Web site: www.leukemia-lymphoma.org
Slide 20
Myeloma Risk Factors Clinical Risk Factors: Black Male = Female
Family history of MM Median age at dx: 70 1,2 7% before age 55 2%
before age 40 0.3% before age 30 1.Ries LAG, et al. SEER Cancer
Statistics Review, 1975-2004. National Cancer Institute. Bethesda,
MD: Available at http://seer.cancer.gov/csr/1975_2004. Accessed
April 10, 2008.http://seer.cancer.gov/csr/1975_2004. Accessed April
10 2 Jemal A, et al. Cancer Statistics, 2008. CA Cancer J Clin
2008;58:71-96 Slide used with permission from Dr. Thompson, WMH
2010
Slide 21
Myeloma risk factors: AGING Disease of the elderly risk of
myeloma is 10 times greater in those 75 to 79 compared to those 45
to 50 uncommon in people younger than 40 y/o In short, higher age
groups (especially after age 60 years)showed significantly risk of
MM for both-sexes, men and women. (Khan, Mori, Sakauchi, Matsuo,
Ozasa, & Tamakoshi, 2006, p. 579) more often in African
American than whites while Asians less likely than whites Khan,
MMH., Mori, M., Sakauchi, F., Matsuo, K., Ozasa, K., &
Tamakoshi, A. (2006). Risk factors for multiple myeloma: Evidence
from the Japan collaborative cohort (JACC) study. Asian Pacific
Journal of Cancer Prevention, 7, 575-581.
Slide 22
Renal Failure in Myeloma Mechanism of inflammation and damage
Light chain cast deposition tubule obstruction (myeloma kidney) by
protein deposits Obstruction of tubules by plasmacytomaplasmacytoma
Hypercalcemia, hyperuricemia: both of which can cause inflammation
in the tubules due to high concentrations Hypercalcemia, Renal
amyloid: can cause obstruction which will cause inflammation in the
glomerulusamyloid Recurrent pyelonephritis chronic recurrent
infections that lead to chronic inflammation of the basement
membrane of the nephron tubulepyelonephritis May develop RTA2
(Fanconi syndrome)Fanconi Leukemia -Lymphoma Society. (2010, March
4). Myeloma. Retrieved March 4, 2010, from The Leukemia &
Lymphoma Society Web site: www.leukemia-lymphoma.org
Slide 23
Myeloma kidney- cast nephropathy Figure: Pathogenesis of
myeloma cast nephropathy. Ca 2 = calcium, THP = Tamm Horsfall
Protein, GFR= glomerular filtration rate casts= protein breakdown
of light chains in kidney can causes obstruction and injury to
distal tubule Scheme used with permission of Dr. C. Winearls
Slide 24
The Myeloma kidney Used with permission from Dr. C.
Winearls
Slide 25
Myeloma treatment RVD Revlimid-Velcade- dexamethasone VTD
Velcade- thalidomide- dexamethasone VAD Velcade-Adriamycin-
Dexamethasone All these are high dose chemotherapy regimens that
need monitoring in the elderly patient and in the renal
insufficient patient
Slide 26
Multiple Myeloma treatment Autologous stem cell transplant
procedure that the patients own stem cells to restore blood cells
after intense chemotherapy good response rates even including
elderly patients process involves pt in remission due to
chemotherapy pts stem cells harvested and frozen pt receives
conditioning therapy stem cells are thawed and reinfused into the
pt results start to show in 10-14 days Leukemia -Lymphoma Society.
(2010, March 4). Myeloma. Retrieved March 4, 2010, from The
Leukemia & Lymphoma Society Web site:
www.leukemia-lymphoma.org
Slide 27
Multiple Myeloma treatment: Another transplant type is
allogeneic This is when the stem cells come from a HLA matched
donor (usually a sibling but not always)HLA This is called tissue
typing and is used in many transplant procedures (not just stem
cell transplantation) The procedure is the same as for an
autologous donation just where the cells originate is different.
This treatment is in clinical trials
Slide 28
Multiple Myeloma Treatment Genetic Research is being done
looking at different genetic polymorphisms and their effects
maintenance treatment after high dose therapy - (nuclear factor B)
(Vangsted et al., 2009) treatment of myelomic bone disease -
(multiple single nucleotide polymorphisms) (Durie et al., 2009) the
role of tumor necrosis factor (Hideshima, Chauhan, Schlossman,
Richardson, & Anderson, 2001) Durie, B., Van Ness, B., Ramos,
C., Stephens, O., Haznadar, M., Hoering, A., Haessler, J.,...
Shaughnessy Jr., J. (2009). Genetic polymorphisms of EPHX1, Gsk3B,
TNFSF8 and myeloma cell DKK-1 expression linked to bone disease in
myeloma. Leukemia, 23, 1913-1919. Hideshima, T., Chauhan, D.,
Schlossman, R., Richardson, P., & Anderson, K. (2001). The role
of tumor necrosis factor alpha in the pathophysiology of human
multiple myeloma: therapeutic applications. Oncogene, 20,
4519-4527. Vangsted, A., Klausen, T., Gimsing, P., Anderson, N.,
Abildgaard, N., Grefersen, H., & Vogel, U. (2009). A
polymorphism in NFKB1 is associated with improved effect of
interferon-alpha maintenance treatment of patients with multiple
myeloma after high dose treatment with stem cell support.
Haematologica, 94(9), 1274-1282.
Slide 29
What animal represents the common clinical features of multiple
myeloma ? Microsoft clip art correct Try again C: hyper calcemia,
R: renal failure, A: anemia, B: bone pain
Slide 30
Slide 31
Physical presentation Anemia due to myeloma cells in the bone
marrow which leads to in RBC production Bone loss- due to
excitement of the osteoclasts by the cytokines secreted from the
myeloma cellsosteoclasts cytokines Back pain due to fractures in
the vertebral body Infection due to immune system failure ; normal
immunoglobulin production is severely suppressed Fatigue due to
anemia Leukemia -Lymphoma Society. (2010, March 4). Myeloma.
Retrieved March 4, 2010, from The Leukemia & Lymphoma Society
Web site: www.leukemia- lymphoma.org
Slide 32
Labs and diagnostic tests Bone Marrow Aspiration /biopsy
examines marrow cells for abnormalities (can also be done after
treatment to check proportion of cancer cells killed by therapy)
CBC to look for anemia Serum protein electrophoresis- looks for M
proteins Urine tests 24 hour testing for protein tests- light
chains (Bence Jones protein) Leukemia -Lymphoma Society. (2010,
March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia &
Lymphoma Society Web site: www.leukemia-lymphoma.org
Slide 33
Labs and diagnostic tests Genetic testing Fluorescence in situ
hybridization (FISH) looks at changes in the chromosomes of the
myeloma cells G-banding karyotyping arrangement of chromosomes of a
cell to look for variations (number, size, shape, arrangement)
Among top SNP variations [] were those associated with drug
metabolism/detoxification/transport, (Van Ness et al., 2008, p.
12)SNP Leukemia -Lymphoma Society. (2010, March 4). Myeloma.
Retrieved March 4, 2010, from The Leukemia & Lymphoma Society
Web site: www.leukemia-lymphoma.org
Slide 34
Labs and diagnostic tests Imaging tests X-rays CT Scans X-rays
and CT scans are used to see if there any holes, breaks or thinning
of the bones (Leukemia -Lymphoma Society, 2010) Leukemia -Lymphoma
Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from
The Leukemia & Lymphoma Society Web site:
www.leukemia-lymphoma.org
Slide 35
Labs and diagnostic tests Imaging tests PET scans MRIs MRIs and
PET scans look for changes to the marrow and pockets of myeloma
cells (Leukemia -Lymphoma Society, 2010) Leukemia -Lymphoma
Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from
The Leukemia & Lymphoma Society Web site:
www.leukemia-lymphoma.org
Slide 36
What lab test is used to look for M Proteins CBC Try again
Serum electrophoresis correct Urine tests Try again FISH Try again
Looks at anemia Looks at chromosomal changes Looks at M proteins
Looks at light chains
Slide 37
Slide 38
Renal Failure in Myeloma Prevention Avoid NSAIDs : they can
affect prostaglandin levels and cause a decrease in GFR Avoid
radiographic contrast: can cause damage in GFR Avoid dehydration:
watch diuretic use Watch for hypercalcemia: high levels of calcium
can cause damage to the nephrons Itano, J., & Taoka K. (Eds.).
(2005). Core curriculum for oncology nursing (4th ed.). St Louis,
MO: Elsevier Saunders
Slide 39
Interventions Hypercalcemia / Bone Loss Encourage fluid intake
Daily weights :monitor for fluid loss, muscle mass loss due to
decrease activity Maintain mobility level (consistent with pts
activity level) Watch for changes in heart rhythm bradycardia Watch
for changes in nutritional status- nausea, vomiting, constipation
Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved
March 4, 2010, from The Leukemia & Lymphoma Society Web site:
www.leukemia-lymphoma.org
Slide 40
Interventions Hypercalcemia / Bone Loss Bisphosponates Aredia
and Zometa (Infusions), Boniva, Fosamax, Actonel (oral) Watch for
osteonecrosis of the jaw (ONJ) exposed bone in the oral cavity
Inform doctor of any pending invasive dental work Hold medicine one
month prior and do not resume till area completely healed Leukemia
-Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4,
2010, from The Leukemia & Lymphoma Society Web site:
www.leukemia-lymphoma.org
Slide 41
Interventions Hypercalcemia Prevention of ONJONJ Encourage good
oral hygiene Encourage routine dental examinations Have pt avoid
invasive procedures Leukemia -Lymphoma Society. (2010, March 4).
Myeloma. Retrieved March 4, 2010, from The Leukemia & Lymphoma
Society Web site: www.leukemia-lymphoma.org
Slide 42
Interventions Fatigue / Anemia Pace daily activities Planned
rest periods Procit / Aranesp Injections if hemoglobin is less than
10 Monitor patient for GI bleeding Hematemesis Tarry stool Itano,
J., & Taoka K. (Eds.). (2005). Core curriculum for oncology
nursing (4th ed.). St Louis, MO: Elsevier Saunders Burrows-Hudson,
S., & Prowant, B. (Eds.). (2005). Nephrology nursing: Standards
of practice and guidelines for care. Pitman, NJ: Anthony J.
Jannetti Inc.
Slide 43
Interventions Infections Neupogen / GCSF (granulocyte colony
stimulating factor) increase WBC Platelet transfusions for low
platelet levels Itano, J., & Taoka K. (Eds.). (2005). Core
curriculum for oncology nursing (4th ed.). St Louis, MO: Elsevier
Saunders
Slide 44
Interventions Infections Catheter dressing changes per policy
Monitor for signs and symptoms of infection Fever (with or without
chills) Evaluate catheter site for signs of infection Redness,
swelling, drainage, warmth Administer antibiotics as ordered
Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology
nursing: Standards of practice and guidelines for care. Pitman, NJ:
Anthony J. Jannetti Inc.
Slide 45
Interventions Pain Control Watch NSAID intake Lowers GFRGFR
Pace activity with rest periods Help find comfortable position due
to back pain Bisphosphonates may help with bone pain Neurontin /
Lyrica / B complex vitamin w/ folic acid to help with neuropathic
pain Leukemia -Lymphoma Society. (2010, March 4). Myeloma.
Retrieved March 4, 2010, from The Leukemia & Lymphoma Society
Web site: www.leukemia-lymphoma.org
Slide 46
Interventions In 20% of patients diagnosed with multiple
myeloma have renal failure as a serious complication Mortality rate
in multiple myeloma patients with renal failure is approximately
30%. This is mainly due to septicemia and infections from a
compromised immune system. Goldschmidt, H., Lannert, H., Bommer,
J., & Ho, A. (2001). Renal failure in multiple myeloma "the
myeloma kidney": State of the art. Saudi Journal of Kidney Diseases
and Transplantation, 12(2), 145- 150.
Slide 47
Interventions Hemodialysis: Assess patient pre treatment-
weight, blood pressure, HR, RR, Temperature, edema, mental status,
ambulation status Evaluate patient for headache, nausea, vomiting,
fever, chills, bleeding, pain, insomnia, weakness, fatigue Reassess
patient post treatment for changes in blood pressure, HR, RR,
weight, edema Burrows-Hudson, S., & Prowant, B. (Eds.). (2005).
Nephrology nursing: Standards of practice and guidelines for care.
Pitman, NJ: Anthony J. Jannetti Inc.
Slide 48
Interventions Hemodialysis: Monitor treatment adjust during in
response to pt changes during treatment Administer medications as
ordered Include pt teaching regarding diet and fluid needs (a MM pt
might have a lower fluid restriction due to RRF or due to fluid
loss with nausea/ vomiting with chemotherapy)RRF Ask pt when last
chemo treatment was use chemo precautions with patient
Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology
nursing: Standards of practice and guidelines for care. Pitman, NJ:
Anthony J. Jannetti Inc.
Slide 49
What Nursing Intervention helps with prevention of renal
failure Monitor patient for GI bleeding Encourage good oral hygiene
Avoid NSAIDs Catheter dressing changes per policy Try again
incorrect Correct
Slide 50
Case Study Mr. C is a 68 year old black male who presents with
back pain, fatigue, and recurrent urinary tract infections for 3
months. He is currently taking naproxysen sodium for pain relief,
and has finished an antibiotic course of bactrim for the UTI What
lab tests would you consider for this patient?
Slide 51
Case Study CBC showed WBC 3.23,RBC 3.26, HGB 10.5, HCT 30.1 BMP
Results Na 135, K+ 4.1, CL 113, CO2 21, Glucose 82, Bun 59,
Creatinine 3, Ca 10.5, Urinanalysis was positive for blood and
protein
Slide 52
Case Study With high serum calcium and protein in the urine,
what would your next steps be? Further Labs What Medicine additions
or changes? What are nursing interventions? Serum electrophoresis
to look for light chains Add bisphosphonates and hold NSAIDS
Increase fluid intake, plan activity with rest periods answers are
just suggestions there can be other avenues to take
Slide 53
Case Study Patient now complains of nausea, anorexia, edema on
legs. A 24 hour creatinine clearance shows >2mg/dl. Hemodialysis
is started via a Left IJ permacath
Slide 54
Case Study What special instructions should be included
Infection control What Medicine additions or changes? What are
nursing interventions? Keep catheter dry no showers for bathing
helps to prevent infections from water borne bacteria Epogen should
be added Work with dietitian to adjust diet and fluid intake
answers are just suggestions there are other avenues for further
care
Slide 55
In Conclusion: Multiple myeloma accounts for approximately.88%
of pts with ESRD according to the USRDS. (Gertz, 2005) Early
diagnosis and treatment of renal failure is key to decrease
mortality in these pts. Gertz, M. (2005). Managing Myeloma Kidney.
Annals of Internal Medicine, 143(11), 835-836.
Slide 56
In Conclusion: By helping the pt monitor diet, activity,
infection control and pain management the nurse can influence the
outcome of treatment. Patient teaching is a major component of
compliance to treatment not only in the management of MM but in the
management of renal failure
Slide 57
References Bashey, A., & Huston, J. (2005). 100 Questions
& answers about myeloma. Sudbury, MA: Jones and Bartlett
Publishers. Burrows-Hudson, S., & Prowant, B. (Eds.). (2005).
Nephrology nursing: Standards of practice and guidelines for care.
Pitman, NJ: Anthony J. Jannetti Inc. Durie, B., Van Ness, B.,
Ramos, C., Stephens, O., Haznadar, M., Hoering, A., Haessler,
J.,... Shaughnessy Jr., J. (2009). Genetic polymorphisms of EPHX1,
Gsk3B, TNFSF8 and myeloma cell DKK-1 expression linked to bone
disease in myeloma. Leukemia, 23, 1913-1919. Gertz, M. (2005).
Managing Myeloma Kidney. Annals of Internal Medicine, 143(11), 835-
836. Goldschmidt, H., Lannert, H., Bommer, J., & Ho, A. (2001).
Renal failure in multiple myeloma "the myeloma kidney": State of
the art. Saudi Journal of Kidney Diseases and Transplantation,
12(2), 145-150. Hideshima, T., Chauhan, D., Schlossman, R.,
Richardson, P., & Anderson, K. (2001). The role of tumor
necrosis factor alpha in the pathophysiology of human multiple
myeloma: therapeutic applications. Oncogene, 20, 4519-4527. Itano,
J., & Taoka K. (Eds.). (2005). Core curriculum for oncology
nursing (4th ed.). St Louis, MO: Elsevier Saunders.
Slide 58
References Khan, MMH., Mori, M., Sakauchi, F., Matsuo, K.,
Ozasa, K., & Tamakoshi, A. (2006). Risk factors for multiple
myeloma: Evidence from the Japan collaborative cohort (JACC) study.
Asian Pacific Journal of Cancer Prevention, 7, 575-581. Lancaster,
L. (Ed.). (2001). Core Curriculum for Nephrology Nursing (4th ed.).
Pitman, NJ: American Nephrology Nurses' Association. Leukemia
-Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4,
2010, from The Leukemia & Lymphoma Society Web site:
www.leukemia-lymphoma.org Porth, C., & Matfin, G. (Eds.).
(2009). Pathophysiology: Concepts of altered health states (eighth
ed.). Philadelphia: Wolters Kluwer Health/ Lippincott Williams
& Wilkins. Thompson, M. (2008, April). Medical complications of
multiple myeloma. Power point presentation presented at the
Educational Program (Pro HealthCare), Waukesha, WI.
Slide 59
References Van Ness, B., Ramos, C., Haznadar, M., Hoering, A.,
Haessler, J., Crowley, J., Jacobus, S.,... Gupta, R. (2008).
Genomic variation in myeloma: design, content, and initial
application of the Bank On A Cure SNP Panel to detect associations
with progression-free survival. Biomed Cental Medicine, 6(26).
Retrieved June 8, 2010, from BioMed Central Web site:
www.biomedcentral.com Vangsted, A., Klausen, T., Gimsing, P.,
Anderson, N., Abildgaard, N., Grefersen, H., & Vogel, U.
(2009). A polymorphism in NFKB1 is associated with improved effect
of interferon- alpha maintenance treatment of patients with
multiple myeloma after high dose treatment with stem cell support.
Haematologica, 94(9), 1274-1282. Winearls, C. (1995). Acute Myeloma
Kidney. Kidney International, 48, 1347-1361.