The latter was diagnosed after suffering a T7 compression fracture. At that time, his kidney function was normal and his blood pres sure was fairly well controlled on four agents. As initial therapy for MM, he received melphalan for conditioning, four cycles of lena lidomide and dexamethasone, followed by autologous HSCT. Three months later, his kidney function remained ABT-888 within normal limits. He subsequently developed a few episodes of volume depletion associated with transient increases in serum creatinine level, after which his serum creatinine stabilized at a level of 1. 4 mg dL. Ten months after HSCT, he was started on bortezomib, cyclophosphamide and dexamethasone due to progression of MM. He received five cycles of VCD. His blood pressure remained fairly well con trolled with no changes to his anti hypertensive regimen.

Fifteen months after the first HSCT and 1 month after completing VCD, he underwent a second autologous HSCT for relapse. This time, the hospital course was com plicated with septic shock and a severe bout of AKI, with serum creatinine peaking at 7. 4 mg dL. After requiring four weeks of acute hemodialysis, he partially regained kidney function, ultimately being dis charged from the hospital with a new baseline serum creatinine of 2. 1 mg dL. At the time of discharge, his antihypertensive regimen was modified to avoid blockade of the renin angiotensin system in the setting of AKI. Accordingly, he was switched to hydral azine 50 mg three times daily, diltiazem extended release 360 mg daily, metoprolol 200 mg twice daily and a cloni dine patch 0.

3 mg 24 h. Seventeen months after the second HSCT, a follow up bone marrow biopsy specimen revealed persistent plasma cell infiltration. As a result, he was initiated on carfilzomib, thal idomide 100 mg daily and dexamethasone 20 mg per week. Six weeks after the initiation of chemotherapy, the patient developed abrupt worsening of lower extremity edema and his hypertension became more difficult to control. After being stable with four agents averaging a blood pressure of 142 74 mmHg during previous office visits, he presented with a blood pressure of 206 100 mmHg. His physical examination also revealed pallor, but otherwise no additional abnormalities. Laboratory data showed, hemoglobin 8. 2 g dL, plate let count 53 K cumm, serum creatinine 2.

1 mg dL, lactate dehydrogenase 183 IU L, hapto globin 23 mg dL, total bilirubin 0. 6 mg dL, C3 112. 3 mg dL, C4 54. 4 mg dL, albumin 2. 8 g dL, serum kappa free light chain 82. 4 mg dL, serum lambda free light chain 0. 69 mg dL, serum free kappa lambda ratio 119. 42. Urinalysis showed 300 mg dL protein on dipstick but no hematuria or pyuria. Urine protein electrophoresis showed elevated kappa light chain in the gamma zone at 11. 9 mg dL and a this 24 hour urine collection revealed 2. 6 grams of protein.