Download Elizabeth St. John, 2010. Renal Failure in Multiple Myeloma.

Tutorial/ MSN 621
Beth St John BSN
Alverno College
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.
Normal Renal Function
2 Kidneys –located back of the body in the abdominal
cavity
contains: nephrons, glomerulus, and tubules
kidney
glomerulus

nephron
tubules

used with permission Wellcome,Library, London
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.
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 gout
 Beta 2 microglobulin: an end product of Class I HLAs;
complement proteins activation can lead to increase of
microglobulins;
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
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
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.
Function of the Kidney:

Generalized Stress response activation
in the kidney
o
o
o
Control of vascular volume: regulation of renal blood flow is
reliant on regulation of glomerular blood flow
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 II
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
Renin Angiotension system
↓ renal blood flow
↓sodium at macula densa
↓afferent arteriole pressure
epinephrine
norepinephrine
renin
(from JGA)
negative feedback
loop
↓renin
angiotensiogen
angiotensin I
ACE
↑ renal blood flow
angiotensin II
↑ MAP
peripheral vasoconstriction
direct renal effects
aldosterone
(adrenal cortex)
↑ vascular volume
renal tubular
reabsorption
Na+ and H2O
Function of the Kidney:
 What is a function of the kidney?
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
 What is key component of renal function?
removal of
waste products
That is correct
urination
That is incorrect
this is done by
the bladder
muscle
movement
That is
incorrect
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
Basic Concepts of Renal Failure
 Some Uremic Changes:
 Fluid – electrolytes imbalances
fluid retention causing edema in legs, abdomen, and face
 hyperkalemia, hypocalcaemia, hyperphosphatemia
 Changes in cardiovascular system
 Includes the RAAS due to decrease in renin production interrupting
feedback loop
 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
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
Background
Multiple myeloma
 Myeloma occurs in the B lymphocytes
 Lymphocyte development
stem cell
very young
b lymphocyte
injury to DNA
(unknown etiology)
of a single cell
in lymphocyte development
more developed
b lymphocyte
other blood cell
red cells
white cells (other lymphocytes
platelets
Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The
Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org
Fully developed
antibody producing
plasma cell
other lymphocytes
T lymphocytes
natural Killer (NK) cells
What is Myeloma?
 Overproduction of a single immunoglobulin by cancerous





plasma cells
Immunoglobulin is “a protein produced by body’s immune
system to help fight infections”(Bashey & Huston, 2005, p. 2)
Normally the body make many different types of
immunoglobulins (polyclonal)
In Myeloma the cancerous cells are monoclonal and are usually
of no use to the body
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.
Immunoglobulin Molecule
L = Light
Chains
H = Heavy
Chains
H
H
Immunoglobulin Molecule
 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
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
Myeloma Risk Factors
 Clinical Risk Factors:
 Black
 Male = Female
 Family history of MM
 Median age at dx: 701,2
 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.
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
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.
Renal Failure in Myeloma
 Mechanism of inflammation and damage
 Light chain cast deposition – tubule obstruction
(“myeloma kidney”) by protein deposits
 Obstruction of tubules by plasmacytoma
 Hypercalcemia, hyperuricemia: both of which can
cause inflammation in the tubules due to high
concentrations
 Renal amyloid: can cause obstruction which will
cause inflammation in the glomerulus
 Recurrent pyelonephritis chronic recurrent
infections that lead to chronic inflammation of
the basement membrane of the nephron tubule
 May develop RTA2 (Fanconi syndrome)
Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The Leukemia &
Lymphoma Society Web site: www.leukemia-lymphoma.org
Myeloma kidneycast nephropathy
Figure: Pathogenesis of
myeloma cast
nephropathy.
Ca2 = 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
The Myeloma kidney
 Used with permission
from Dr. C. Winearls
Myeloma treatment
RVD – Revlimid®-Velcade®-
dexamethasone
VTD – Velcade®- thalidomidedexamethasone
VAD – Velcade®-Adriamycin®Dexamethasone
All these are high dose chemotherapy
regimens that need monitoring in the
elderly patient and in the renal
insufficient patient
Multiple Myeloma treatment
 Autologous stem cell transplant
 procedure that the patient’s 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
 pt’s 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
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)
 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
Multiple Myeloma Treatment
Genetic
 Research is being done looking at different genetic
polymorphisms and their effects
 maintenance treatment after high dose therapy -
(nuclear factor κB) (Vangsted et al., 2009)
 treatment of myelomic bone disease - (multiple single
nucleotide polymorphisms) (Durie et al., 2009)
 the role of tumor necrosis factor α (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.
correct
What animal
represents the
common
clinical
features of
multiple
myeloma ?
Microsoft clip art
C: hyper calcemia, R: renal
failure, A: anemia, B: bone
pain
Try
again
Try
again
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 cells
 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.leukemialymphoma.org
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
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)
Leukemia -Lymphoma Society. (2010, March 4). Myeloma. Retrieved March 4, 2010, from The
Leukemia & Lymphoma Society Web site: www.leukemia-lymphoma.org
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
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
What lab test is used to look for M
Proteins
CBC
Try again
Looks at anemia
FISH
Try again
Looks at
chromosomal
changes
Serum
electrophoresis
correct
Urine tests
Try again
Looks at M proteins
Looks at light chains
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
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 pt’s 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
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
Interventions
 Hypercalcemia –
 Prevention of ONJ
 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
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
Burrows-Hudson, S., & Prowant, B. (Eds.). (2005). Nephrology nursing: Standards of practice and
guidelines for care. Pitman, NJ: Anthony J. Jannetti Inc.
Itano, J., & Taoka K. (Eds.). (2005). Core curriculum for oncology nursing (4th ed.).
St Louis, MO: Elsevier Saunders
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
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.
Interventions

Pain Control
 Watch NSAID intake
Lowers GFR
 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
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.
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.
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)
 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.
What Nursing Intervention helps
with prevention of renal failure
Monitor patient
for GI bleeding
Try again
Encourage
good oral
hygiene
incorrect
Catheter dressing
changes per policy
Try again
Avoid
NSAIDs
Correct
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?
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
Case Study
 With high serum calcium and protein in the urine,
what would your next steps be?
Further Labs
Serum electrophoresis to look
for light chains
What Medicine
additions or
changes?
Add bisphosphonates and hold
NSAIDS
What are
nursing
interventions?
Increase fluid intake, plan
activity with rest periods
answers are just suggestions there can be other avenues to take
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
Case Study
 What special instructions should be included
Infection
control
Keep catheter dry – no showers for
bathing
helps to prevent infections from
water borne bacteria
What Medicine
additions or
changes?
Epogen should be added
What are
nursing
interventions?
Work with dietitian to adjust
diet and fluid intake
answers are just suggestions there are other avenues for further care
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.
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
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), 835836.
 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.
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.
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
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