Multiple myeloma is a cancer of plasma cells, the antibody-producing white blood cells that reside in the bone marrow. As malignant plasma cells proliferate, they flood the bloodstream with abnormal proteins called free light chains, which are filtered by the kidneys and can precipitate inside the delicate tubules, causing progressive injury. Renal impairment is one of the most feared complications of the disease, affecting a substantial minority of patients at diagnosis, and it has consistently been identified as a risk factor for poorer outcomes across virtually every treatment modality. The standard of care for eligible myeloma patients includes high-dose melphalan chemotherapy followed by rescue with the patient’s own blood-forming stem cells, a procedure known as autologous hematopoietic cell transplantation. But because melphalan is partially cleared by the kidneys, patients with impaired renal function face a pharmacological dilemma: a full dose may accumulate to toxic levels, while a reduced dose may compromise the anti-cancer effect.

The Brazilian research team set out to address a gap that has persisted in the transplant literature. Most published data on transplantation in myeloma patients with renal impairment come from high-volume centers in Europe and North America, equipped with extensive intensive care capacity and multidisciplinary support. Whether similar outcomes could be achieved in resource-constrained settings, where access to dialysis, critical care beds, and broad-spectrum antimicrobials may be more limited, remained an open question. The study therefore examined outcomes at a public hospital in Brazil, capturing the realities of transplant medicine as it is practiced in much of the world rather than only in its most privileged enclaves.

The researchers defined renal impairment strictly, requiring either a serum creatinine above 2 milligrams per deciliter or a creatinine clearance below 40 milliliters per minute, thresholds that indicate serious compromise of kidney function. The 53 patients enrolled in the analysis had a median age of 59 years, and the cohort was characterized by advanced disease at presentation: 82 percent had Durie-Salmon stage IIIA or IIIB disease, and 63 percent fell into stage III of the International Staging System, the most severe category. Notably, 15 of the patients, amounting to 28 percent of the cohort, were dependent on dialysis at the time of their transplant, meaning their kidneys could no longer sustain them without mechanical blood filtration. The vast majority, 81 percent, received a reduced melphalan dose of 140 milligrams per square meter of body surface area or less, reflecting the common clinical practice of dose adjustment in the setting of renal dysfunction.

The toxicity profile documented in the study underscores how demanding this treatment is for patients with failing kidneys. Fifteen patients, or 29 percent of the cohort, experienced grade 3 or 4 overall toxicity, the most severe categories of adverse effects on standard clinical grading scales. Severe oral mucositis, the painful inflammation and ulceration of the lining of the mouth that follows high-dose chemotherapy, affected 17 percent of patients, while 13 percent suffered grade 3 or 4 diarrhea and a comparable proportion experienced severe nausea. Fourteen patients, 26 percent of the total, required admission to the intensive care unit at some point during their transplant course, a figure that highlights the considerable critical care resources consumed by this population and the fragility of patients whose kidneys cannot buffer the metabolic stresses of conditioning chemotherapy.

Perhaps the most clinically actionable finding concerns which factors predicted severe toxicity. Patients who came to transplant in only a partial response to prior therapy, rather than a very good partial or complete response, were significantly more likely to develop grade 3 or 4 toxicity, with a p-value of 0.024 indicating a statistically robust association. Low serum albumin at the time of transplant, a marker of poor nutritional status and general physiological reserve, was also linked to severe toxicity, as was receiving a melphalan dose above 140 milligrams per square meter. Taken together, these associations suggest a coherent biological picture: patients with more active disease, less nutritional reserve, and higher chemotherapy exposure are precisely those whose bodies are least equipped to withstand the conditioning regimen, and clinicians may be able to identify them in advance.

The survival statistics tell a nuanced story. Non-relapse mortality, the proportion of patients who died from causes other than their cancer, such as infections or organ failure related to the transplant itself, stood at 13 percent at 100 days, with infections being the leading cause of these early deaths. At 24 months after transplantation, 48 percent of patients had not experienced disease progression, and 65 percent were still alive. The authors note that these survival figures were comparable to those reported in prior studies conducted in better-resourced settings, a finding they describe as reassuring for centers operating under similar constraints. In other words, despite the higher complication rates and intensive care utilization, carefully selected patients with renal impairment can still derive meaningful benefit from autologous transplantation even outside the world’s wealthiest medical systems.

The analysis also identified predictors of poorer survival that may guide future patient selection. Dialysis dependence at the time of transplant was significantly associated with worse progression-free survival, with a p-value of 0.035, as were advanced disease stage by the International Staging System, with stage 2 and stage 3 disease each independently linked to shorter progression-free survival. For overall survival, the decisive factor was the comorbidity burden: patients with a higher accumulation of coexisting health conditions died more frequently, with a p-value of 0.015. These findings align with the broader understanding that transplant outcomes reflect not just the cancer itself but the whole patient, and they suggest that in resource-limited settings, where intensive care capacity is finite, prioritizing patients with better organ function, earlier-stage disease, and fewer comorbidities may maximize the benefit derived from each transplant performed.

The study’s conclusions carry practical weight for transplant physicians worldwide. The authors recommend optimizing patient selection for hematopoietic cell transplantation and reducing melphalan doses in patients with renal impairment, strategies that may be particularly warranted where healthcare resources are limited. The finding that full-dose melphalan was associated with increased severe toxicity provides quantitative support for the dose-reduction practices already common in many centers, while the link between deep pre-transplant response and lower toxicity argues for maximizing induction therapy before proceeding to transplant in patients with kidney damage. As novel agents continue to improve myeloma control before transplantation, the population of patients reaching transplant with renal impairment may evolve, but this study provides a valuable benchmark for what can currently be achieved.

Beyond its immediate clinical implications, the research fills an important gap in the global evidence base. Transplant outcomes in low- and middle-income countries are chronically underreported, leaving clinicians in those settings to extrapolate from studies conducted under very different conditions. By documenting both the challenges, including high non-relapse mortality and frequent intensive care utilization, and the achievable successes, with two-year overall survival of 65 percent, the São Paulo team has demonstrated that autologous transplantation remains a viable and defensible option for myeloma patients with renal impairment even where resources are stretched. The study was approved by the local institutional ethics board, all participants provided informed consent, and the work was conducted in accordance with the Declaration of Helsinki, with no external funding supporting the research. For the growing number of myeloma patients worldwide who present with damaged kidneys, the message is one of cautious hope: with careful selection, dose adjustment, and honest counseling about the risks, the transplant pathway remains open.

Subject of Research: Autologous hematopoietic cell transplantation outcomes in multiple myeloma patients with renal impairment

Article Title: Outcomes in patients with multiple myeloma and renal impairment undergoing autologous hematopoietic cell transplantation

Article References: Martins, L., Ribeiro, C., Gasparini, J., Otuyama, L., Mariano, L., Atanazio, M., Seguro, F., Martinez, G., Rocha, V., & Fatobene, G. (2026). Outcomes in patients with multiple myeloma and renal impairment undergoing autologous hematopoietic cell transplantation. Annals of Hematology. https://doi.org/10.1007/s00277-026-07152-4

Image Credits: AI Generated

DOI: 10.1007/s00277-026-07152-4

Keywords: multiple myeloma, renal impairment, autologous transplantation, melphalan, dialysis, non-relapse mortality, progression-free survival, overall survival, toxicity, intensive care, Brazil, hematopoietic stem cells