عنوان : نارسائي حادكليه دربيماران مبتلا به ميلوم مولتيپل و گزارش چهار مورد .

نويسندگان : دكتر مجيد مرتضوي ، دكتر جليل واعظ قراملكي ، دكتر جمال عيوضي ، دكتر اشرف فخرجو

مقدمه :

بدخيمي هاي اعضاء مختلف بدن انسان عوارض متعددي بر روي كليه ها دارند .

ميلوم مولتيپل جزو بدخيمي هاي پلاسما سل است . كه 1% كل بدخيمي هاي بدن انسان را تشكيل داده ولي با 20% نارسائي حاد كليه ها همراه است . افزايش توليد بيش از حد مقدار طبيعي زنجيره سبك در ميليوم مولتيپل به علت كاهش Endocytosis در توبول ابتدائي كه با ماكانيسمهائيكه Receptor - mediated اند مي تواند دفع بيش از حد طبيعي زنجيره سبك پروتئينها شود . ايجا د نارسائي حاد كليه هايكي به علت توكسيك بودن پروتئين هاي زنجيره سبك با مايع توبولي به توبولهابي انتهائي رسيده و در اين قسمت از توبول با پروتئين Tamm-Horsfall تشكيل سيلندر تولبولي مي دهد كه به وسيله سلولهاي بزرگ و داراي چند هسته احاطه مي شوند . فاكتورهاي كمك كننده ديگري هم در ايجاد نارسائي حاد كليه وجود دارند .

روش :

تعداد 7 مورد بيمار مبتلا به ميلوم مولتيپل و نارسائي حاد كليه ها به بخش همودياليز بيمارستان امام خميني ( ره ) معرفي شده بودند و تحت بررسي قرار گرفتند .

نتايج :

دو مورد از بيماران مونث و 5 مورد مذكر بودند . سن آنها حداقل 33 و حداكثر 73 سال داشتند . در تمامي موارد دردهاي استخواني ، تهوع و استفراغ شكايت اصلي بودند .

كراتينين خون بيماران بين 14 – 5/7 ميلي گرم درصد . هموگلوبين بين 2/9 - 2/5 گرم درصد . پروتئين Bence Jones ادراري در تمامي موارد مثبت بوده و در الكتروفورز پروتئينهاي خون M – Band ترسيم شده است .

ESR حداقل 70/30 و حداكثر 172/160 ميليمتر بودند . اسيداوريك خون بيماران بين 8/7 - 5/10 ميليگرم درصد بودند كلسيم خون بيماران در حد طبيعي بودند . بيوپسي كليه فقط در يك مورد از بيماران به عمل آمد ، كه مويد كست نفروپاتي بود . آسپيراسييون مغز استخوان در تمام بيماران به عمل آمده ميلوم مولتيپل را تشخيص دادند . ضايعات ليتيك استخواني در چهار موردبه ثبت رسيده است تمامي بيماران تحت درمان سيتوتوكسيك و همودياليز قرار گرفتند . يك بيمار بعد از يكسال و دو بيماربعد از يك ونيم سال فوت نمودند و بقيه بيماران تحت درمان مي باشند .

نتبجه گيري :

ازمرور مقالات منتشره و بيماران معرفي شده بر مي آيد كه اولا در بيماران با دردهاي استخواني و سن بالاي 33 سال به ميلوم مولتيپل فكر كرده و اقدامات تشخيص به عمل آيد . ثانيا سعي شود از عوامل تشديد كننده نارسائي حاد كليه ها كه بعدا ارائه خواهندشد اجتناب گردد .

Title of Article : Acute renal failure in patients with multiple myeloma and report of four cases

Author(s) : M.Mortazavi M.D, G.Vaezi-Garamalik M.D, J.Eivazi M.D. , A.Fakhreju M.D .

Back ground and Aims :

To evlut the effect of Multiple myeloma on renal function .

Introcuction :

Malignacies of different organs of human body have several complication on kidneys . Multiple myeloma (MM) is a plasma cell malignancy which consist 1% of all human being malignancies , and is associated with 20% of acute renal failure . Excess ptoduction of ligt chains in MM with reduction in endocytosis in proxinmal tubule with receptor mediated mechanisms can lead to loss of excess amounts of light chain proteins . Acute renal failure is due to toxicity of light chain proteins in proximal tubules and damage of them . On the other hands light chains reach with tubular fluid to distal tubules and with Tamm-Horsfall protein forms tubular cylinders . This cylinders have large and multinuclear cells . Other predisposing factors are on acute renal failure .

Method :

Seven patients with MM and ARFwere refered to Imam Khomeini hemodialysis ward and studied .

Results:

Two patient vere female and five male . Age was at least 33 and at least 73 . In al cases bone pains , nausia and vomiting were chief compliant . Serum creatinie was between 7.5 and 14 . Hemglobin was 5.2-9 mg% . Urinary Bence Jones protein was positive in all cases and in electrophoresis M-Band was curved . ESR was at least 30/10 and at last 160/172 mm . Serum uric acid was 7.8-10.5 . Serum calcum was in normal limi. Only one of patient was biopsied which show cast nephropathy . Bone marrow aspiration was down in all patients and MM was documented . Bone lysis was seen in 4 cases . All patients were on cytotoxic tirapy and hemodialysis . One patien after one year and two patient after 1.5 year died , and other . patient are under thrapy .

Conclusion :

Reviev of published arthicles and introduced patients reveals that , in patients with bone pain and age over 33 years we must think to MM and diagnostic procedures must be done , and predisposing factors for ARF ought to be eliminated .

Title : IHOP protocol in refratory ALL

Author(s) : Eivazi J,MD. Nikanfar A,MD. Sanaat Z, MD. Vaez J,MD.Asvadi I,MD .

Adressf : Tabriz,Shahid Ghazi Hospital .

Tel : 3343811-13

E-mail: jziaei@hotmail.com

Introduction & Objective :

Acute lymphoblastic leukemia is biologically & clinically a heterogenous group of diseases characterized by a malignant proliferation of immature lymphoid cells in the bone marrow . Treatment of the newly diagnosed patient with ALL,comprises four phases ; remission induction , CNS prophylaxis , postremisson consolidation and maintenance . Adult with primary refractory or relapsed ALL have poor prognosis with current salvage chemotherapies .

Methods :

To achieve complete remissions and prolonge remission duration and long-term survival , we designed a combined salvage regimen IHOP in 13 patients with refractory ALL. They treated with Ifosfamide 1 g/m² on 1-5 day , Adriamycine 70 mg/m² on day 1 , Vincristine 2 mg on day 1 , prednisolon 100 mg on day 1-5 .

Results :

Among 13 patients , 8 patients had treated with VP₁₆ 10 mg/kg on 1-3 day & CTX 50 mg/kg on day 1-2 , and 5 patients had treated with standard regimen of ALL (v,p,c) . The severity of pancytopenia with IHOP was less than VP₁₆ & CTX , none of the patient had fever . One of the patient who had treated with VP₁₆ & CTX had complete remission another patients had not response . After 6 month follow-up only two patient alived and they treated with prednisolon & vincristine monthly . One of the patients who treated with standard protocol of ALL had partial remission , he treated with VP₁₆ & CTX . After 6 month follow-up all of the patient died except the patient who described above . This result indicate that IHOP is not a promosing therapy for treatment of refractory ALL .