Etiology of the Disease

Multiple Myeloma is a “malignant proliferation of plasma cells involving more than 10 percent of the bone marrow” (AFP, 1999) and is an incurable disease characterized by “wide spread bone destruction”, which affects “mostly adults over 50 years old” (BC Cancer, 2003). This disease may cause multiple bone fractures, particularly in spine and leg bones.

Cause of the disease is unknown. Multiple myeloma is the most common primary bone cancer in adults, with annual incidence of 3 to 4 cases per 100,000 people. It occurs with greatest frequency in African-Canadians and is very rare among Asians. The median age of patients at the time of diagnosis is 61 years. (Leonardo)

The risk of developing multiple myeloma appears to be higher in populations of lower socio-economic status, particularly where diagnostic services are unavailable. Agricultural workers, farmers, sheet metal workers and persons employed in the nuclear industry or who are exposed to wood dust are at increased risk of developing multiple myeloma. (AFP, 1999)

Pathophysiology and Symptoms of the Disease

Among the symptoms of Multiple Myeloma, the following prevail:

1. Severe bone pain, especially in the back
2. Height loss
3. Spontaneous bone fractures - back, rib, arm or leg
4. Fatigue and weakness
5. Anaemia
6. Improperly functioning kidneys
7. Excess of calcium in the blood (hypercalcemia) due to destruction and dissolution of the bone (BC Cancer, 2003)

a.       Severe bone pain. Bone pain is the most prevalent symptom of multiple myeloma. More than two thirds of patients complain of bone pain, frequently located in the back, long bones, skull and pelvis. Multiple myeloma is an expansion of a single line of plasma cells that replace normal bone marrow, which leads to bone lesions. These lesions are, in most cases, lytic lesions caused by tumour expansion and activation of osteoclasts by myeloma cells’ secretion. Because of low bone density, the occurence of pathologic fractures is common. (Leonardo)

b.      Height loss. Lytic processes in bones combined with activated Interleukin-6 (Leonardo) may have an important role in osteoclast activation, and so, in bone resorption. Local cavitations may be found in areas of osteoclastic activity, especially in the skull. Bones become “soft” and, as a result, will compress slightly under the body weight, which lead to height loss.

c.       Spontaneous bone fractures - back, rib, arm or leg. The pain usually involves the back and ribs; and unlike the pain of metastatic carcinoma, which is often aggravated at night, the pain of myeloma is often precipitated by movement. (Satheesh) Persistent localized pain in a patient with myeloma usually signifies a pathological fracture. The bone lesions of myeloma are caused by the proliferation of tumour cells and the activation of osteoclasts that destroy the bone. The bone lesions are lytic in nature and are rarely associated with osteoblastic new bone formation. As a result, vertebrae, sternum, ribs, skull and clavicles show characteristic osteolytic changes, which, in turn, lead to bone fractures.

d.      Fatigue and weakness. In addition to pain, patients may complain of non-specific constitutional symptoms related to hyperviscosity and hypercalcemia. Hypercalcemia may lead to renal alterations and various neurologic symptoms, such as nausea, fatigue, thirst and headaches. Among the main factors that cause patients’ weakness are: intoxication with the products of cancer cells’ metabolism, anaemia, hyponatriemia and disruptions in calcium homeostasis

e.       Anaemia. Anaemia occurs in 80% of multiple myeloma patients, generally normocytic and normochromic, caused by destruction of bone marrow with invasion of multiple myeloma cells and by inhibition of cell production in bone marrow by tumor factors. (Leonardo). Neutropenia and thrombocytopenia may develop later. In addition, mild haemolysis may contribute to the anaemia.

f.       Improperly functioning kidneys. According to Leonardo, almost half of the multiple myeloma patients have renal pathology. There are many contributing factors. Hypercalcemia is the most common cause of renal failure. Glomerular deposits of amyloid, hyperurecemia, recurrent infections and occasional infiltration of the kidney by the myeloma cells all may contribute to renal dysfunction. (Satheesh)

g.      Excess of calcium in the blood. The bone lysis results in substantial mobilization of calcium from bones, which, in turn, leads to hypercalcemia. Untreated hypercalcemia may lead to renal alterations and neurologic symptoms, such as nausea, fatigue and thirst

Effects of Pathology

Multiple myeloma effects:

a.    Fluid and electrolyte balance

Multiple myeloma leads to mobilization of calcium from bones, which will concentrate in blood plasma. Hypercalcemia, in turn, leads to hypercalciurea – higher than normal level of calcium in urine. Constant hypercalciurea for an extended period of time leads to nephrocalcinosis, renal stones, and eventually to renal failure.

Renal failure is present in approximately 20% of patients with multiple myeloma. Renal function impairment is usually caused by "myeloma kidney" and is reversible in 50% of patients, particularly when it is moderate and related to hypercalcemia.

Symptoms of hypercalcemia include:

§  fatigue

§  constipation

§  depression

§  confusion

§  muscle pain

§  nausea and vomiting

§  dehydration

§  increased urination

§  irregular heartbeat (arrhythmia)

Three specific mechanisms provide homeostatic regulation of calcium:

1.      Gastrointestinal tract – via diet and under the influence of vitamin D -- provides the only exogenous source of calcium

2.      Kidneys – retain body calcium by reabsorption of urinary filtrate

3.      Bones – as a reservoir for 99% of the body’s calcium

In multiple myeloma, the proliferation of abnormal plasma cells produces large quantities of a variety of immunoglobulins. These may produce “changes in tubular function, which result from tubular reabsorption of the freely filtered low-molecular-weight tumor products” (RTDM). These in turn interfere with normal metabolism of proximal tubular cells after their reabsorption. This “toxicity produces Fanconi’s syndrome”, which is a complex “proximal tubulopathy associated with multiple reabsorption defects” (RTDM), and renal tubular acidosis, which may be of a proximal or distal variety.

As a result, dysfunction of two out of the three mechanisms of homeostatic regulation of calcium leads to severe hypercalcemia, renal failure and, eventually, to the death of a patient.

b.   Other homeostatic mechanisms

Other homeostatic mechanisms are not as severely affected as the ones mentioned above. However, due to the fact that human body is a well-balanced system with all organs and systems working in conjunction with each other, we can state that multiple myeloma leads to metabolic acidosis.

Renal tubular acidosis is caused by tubular dysfunction due to the myeloma protein in multiple myeloma. With this condition, the PH of a patient’s blood is below 5.5 (MedScape) Since volume depletion often accompanies acidosis, mild azotemia is common. Severe acidosis may cause circulatory shock, due to impaired myocardial contractility and peripheral vascular response to catecholamines, and progressive increase of symptoms.

Self-Care Requisites Affected By the Disease

The disease affects almost all self-care requisites of patients with multiple myeloma.

Due to the fact that most of the patients with multiple myeloma develop the symptoms of hypercalcemia and kidney dysfunction, one of the most important self-care requisites affected by this disease is maintaining an adequate intake of water.

Patients are required to consume up to 4000 ml of fluids daily, particularly before IVP. This is a bit too much for an average person. Taking into consideration that patients with multiple myeloma are weakened by anemia and renal complications, such as pyelonephritis and nephrocalcinosis, this simple task can be very difficult to accomplish for them. At the same time, it is very important for the multiple myeloma patients to maintain fluid and electrolyte balance within normal limits.

The second very important self-care requisite is preventing hazard to life, functioning and well-being. The research on symptoms and complications of multiple myeloma has shown that almost all organs of the multiple myeloma patients are more or less affected by the disease. For example, more than half of the patients develop symptoms of acute respiratory infections – pneumonia and tracheobronchitis. For such patients it is very important to achieve adequate air intake and gaseous exchange, which could be evidenced through clearing lung sounds, normal blood gas levels, absence of sputum and relief of other symptoms.

Because of bone demineralization, some patients may develop bone lesions and, as a result, bone fractures. However, skeletal fractures could be prevented with exercise. On the other hand, almost 90% of patients with myeloma develop anemia and suffer from pain. Patients are just too afraid to do any exercises – even a simple walk – they are afraid that they might fall down and break another bone. Orthopedic interventions, which help control pain and improve functioning and mobility, and pain control measures, such as medication and radiation could help patients in preventing hazard to life, functioning and well-being.

 

Basic Conditioning Factors

Conditioning factor	How it may or may not affect the promotion and maintenance of a client’s health
Age	Age has high impact on promotion and maintenance of client’s health. Statistically, the average age of a patient with multiple myeloma is over 50 years. Moreover, in the later years of life, “chronic diseases and conditions become more likely.” (CHCS, p.22). Therefore, if a client has multiple myeloma complicated by other chronic diseases it worsens the clinical manifestation of multiple myeloma.
Gender	Even though there is a slight difference in number of male and female patients with multiple myeloma, this difference is not significant enough to state that gender influences the clinical picture of multiple myeloma.
Developmental state	Developmental state of the patient could have a heavy impact on promotion and maintenance of a client’s health. However, due to the fact that most of the patients are in their later years of life, most of them belong to the same stage of development. Therefore, developmental state has minor influence and does not affect the promotion and maintenance of health for the clients with multiple myeloma.
Family system factors	Some of the self-care requisites, such as human functioning and development, and balance between solitude and social interaction, are best fulfilled within a client’s family. Support by the family, reassuring is very important to alleviate a sense of isolation. In addition, the health state of other family members would have a great impact on clients with multiple myeloma.
Socio-cultural orientation	Socio-cultural orientation is very important since it determines not only clients’ attitude towards their health condition, but also sometimes determines possession or absense of auxiliary chronic diseases and complications.
Patterns of living	Smoking, drug abuse, “stress, under-exercising and so on all have their health risks” (CHCS, p.24). All of these worsen the clinical manifestation of multiple myeloma and therefore, have great affect on promotion and maintenance of clients’ health
Material resources	Without proper supply of material resourses there are less chances for clients with multiple myeloma to survive
Environmental factors	Among environmental factors, I would like to highlight physiochemical features and community features, since, to my mind, these features affect the promotion and maintenance of clients’ health the most. Bad environment combined with poorly developed community features lead to high negative impact on clients’ health. On the other hand, healthy environment in conjunction with, say, sophisticated and easily accessible sport facilities would greatly improve one’s health
Health state	Health state of a person has huge impact on the promotion and maintenance of this person’s health. It greatly influences the health requirements and self-care practices.
Health system factors	Health system factors have huge impact on the promotion and maintenance of clients’ health. Services provided and treatment prescribed depends heavily on the level of the health care system. For example, clients with multiple myeloma in Canada would receive quality care and adequate treatment as required by the most modern theories of treatment of multiple myeloma. At the same time, in the third world countries some of the clients would be left on their own dealing with the disease.

List of Resourses

1. American Family Physician, April 1, 1999.  Retrieved September 1^st from www.aafp.org/afp/990401ap/1885.html
2. BC Cancer Agency. Retrieved September 1^st from http://www.bccancer.bc.ca/PPI/TypesofCancer/MultipleMyeloma/default.htm
3. Leonardo SА & Marcelo Papelbaum Retrieved September 5^th from http://www.medstudents.com.br/hemat/hemat6.htm
4. Sorenson Steven, published by eMedicine.com, December 7, 2001 Retrieved September 5^th from http://www.emedicine.com/radio/topic460.htm
5. §  Satheesh Kumar “Multiple Myeloma: A homeopathic approach”, Retrieved September 5th from http://www.pulsemans.com/pm.14.htm
6. §  The Multiple Myeloma Research Foundation, “About Myeloma”, Retrieved September 5th http://www.multiplemyeloma.org/about_myeloma
7. §  Joan Blade, “Renal Failure In Myeloma”, October 1, 2000, Retrieved September 5^th from http://www.myeloma.org/myeloma
8. Multiple Myeloma Cancer Centre, Retrieved September 12^th from http://www.cancercenter.com/treatmentOptions/
9. Renal Tubular Dysfunction In Malignancy, Retrieved September 12^th from cnserver0.nkf.med.ualberta.ca/cn/Schrier/Volume4/chapter5
10. Renal Tubular Acidosis Syndromes, MedScape, Southern Medical Association, 2000 Retrieved September 12^th from www.medscape.com/viewarticle/410658_3
11. Donna M. Wilson, “The Canadian Health Care System”, 1995