Improving the diagnostic pathway in patients presenting with acute kidney injury secondary to de novo multiple myeloma: a short report

• Published in: BMJ open quality 2021-07, Vol.10 (3), p.e001085
• Main Authors: Rana, Ritika, Pratt, Guy, Cook, Mark, Drayson, Mark Trehane, Ramasamy, Karthik, Sadler, Ross, Zhu, Doreen, Connor, Thomas, Pinney, Jennifer Helen
• Format: Article
• Language: English
• Subjects: acute kidney injury; Audits; Biopsy; Bone marrow; Chemotherapy; clinical audit; Communication; Data collection; delayed diagnosis; Health administration; Hematology; Immunology; Kidneys; Laboratories; Medical diagnosis; Multiple myeloma; Patients; Quality control; Quality improvement; Short Report
• ISSN: 2399-6641; 2399-6641
• DOI: 10.1136/bmjoq-2020-001085

Table 1 Pathway of investigations for patients presenting with de novo multiple myeloma and AKI at two tertiary referral centres First centre Second centre Referral pathway (no of patients) GP 12 (43%) GP 11 (40%) A and E 10 (36%) AMU 9 (32%) Other 6 (21%) A and E 2 (7%) Other 6 (21%) Median time to first treatment with dexamethasone (days) 5 (IQR 13–3) 5 (IQR 16–3) Median time to sFLC test request (days) 1 (IQR 2–0) 1 (IQR 1–0) Median time from sFLC request to dexamethasone (days) 4.5 (IQR 12–2) 4 (IQR 14–3) Median time to bone marrow (days) 6 (1QR 11–3) 6 (IQR 13–4) Dexamethasone prior to bone marrow (no of patients) Median time (days) Dexamethasone same day as bone marrow (no of patients) Dexamethasone post bone marrow (no of patients) Median time (days) Dexamethasone not received 6 (21%) 2 (IQR 5–1) 10 (36%) 9 (32%) 8 (IQR 14–3) 3 (11%) 10 (36%) 4 (IQR 6–2) 4 (14%) 7 (25%) 7 (IQR 14–1) 7 (25%) Renal biopsy (patients) Median time (days) 6 (21%) 2 (IQR 7–2) 5 (18%) 4 (IQR 10–2 AKI, acute kidney injury; Other, presentation to any other specialty; sFLC, serum free light chain. A sFLC level ≥500 mg/L is suggestive of cast nephropathy and requires urgent haematological assessment3–5 without the need for a kidney biopsy.4 Patients who have a prompt diagnosis of cast nephropathy and rapid intervention with chemotherapy have better outcomes.6–8 The baseline audit showed prompt requests of the sFLC test; however, there was delay in referring to the haematology team, a requirement for progression to bone marrow biopsy and start of disease-specific treatment. [...]of this intervention, we reduced the time to treatment in our patients by nearly 50%. Contributors MTD, JHP and RR planned the study; RR conducted the data collection; RR, JHP and MTD analysed data; MTD planned and delivered project intervention; RR and JHP wrote the manuscript; DZ, TC, KR and RS helped in planning the audit and data collection/analysis at Oxford University Hospitals; MC and GP had oversight and supervisory roles in the project as well as direct contribution to project implementation and manuscript review.