In addition to his antihypertensives, he was also taking acyclovir, cita lopram, esomeprazole, zolpidem, tramadol and aspirin. He required the addition of eplerenone 25 mg daily, ni fedipine extended release 90 mg daily and selleck chemical benazepril 30 mg daily, for a total of 7 antihypertensives. Despite the 7 drug combination, he remained hypertensive aver aging 190 95 mmHg. A renal sonogram revealed a right kidney of 10. 8 and a left kidney of 10. 6 cm of longitudinal diameter with mod erately increased cortical echogenicity. Following acute re duction of blood pressure with intravenous labetalol, an ultrasound guided percutaneous kidney biopsy was per formed to evaluate the newly developed overt proteinuria.

Histological examination of the biopsy specimen on light microscopy disclosed 8 out of 17 globally sclerotic glom eruli, some mesangiolysis, moderate interstitial fibrosis and tubular atrophy, and severe arteriolar hyalino sis. There was no evidence of myeloma cast nephropathy. No thrombi were identified in the glomerular capillaries or arterioles. Congo red stain was negative. Immunofluor escence showed 4 out of 14 glomeruli with global sclerosis and one small artery that stained intensely for fibrin, C1q, IgM and C3. The corresponding H E stained cryosection showed a thrombus in that artery. The specimen was negative for linear deposition of IgG or kappa along the glomerular and tubular basement membranes. Electron microscopy of one glomerulus showed diffuse foot process effacement, endothelial cell swelling and some loops with flocculent material be tween the endothelial cell and the glomerular basement membrane.

There was no immune complex deposition or finely granular electron dense deposits along the glomerular or tubular basement membranes. In summary, the findings were consistent with TMA, glomerular podocytopathy, hypertensive related injury and chronic scarring. After the results of the kidney biopsy were reviewed and discussed, carfilzomib was discontinued. Eight weeks later, proteinuria slightly improved to 1 gram on a 24 hour urine collection. His serum creatinine remained stable at 1. 7 mg dL at that time. His arterial blood pressure improved significantly averaging 135 75 mmHg on 5 agents. Due to progression of MM and a joint deci sion of not pursuing further treatment, the patient died four months later.

Discussion We present a case of an individual who experienced abrupt worsening of hypertension and proteinuria 6 weeks after receiving carfilzomib for the treatment of refractory MM. A kidney biopsy specimen revealed a TMA lesion along moreover with podocytopathy and evidence of chronic scar ring. No previous report of renal TMA associated with carfilzomib was found in published literature. Applying the Naranjo criteria for adverse drug reactions, the present case meets the criteria of possible association with TMA.