Rationale: Crystalglobulinemia is a rare complication of monoclonal gammopathy wherein crystallized immunoglobulins deposit in various organs causing occlusive vasculopathy, endothelial damage, and thrombosis. It should be differentiated from light chain cast nephropathy without crystalline nephropathy through timely diagnosis with a kidney biopsy. Presenting concerns of the patient: We report a case of a 74-year-old female with polyarthralgia, chest pain, petechial rash, and acute kidney injury. Diagnoses: Kidney biopsy revealed eosinophilic casts in the tubular lumen and similar occlusive crystalline deposits within the glomerular vasculature and interlobular arteries. Bone marrow biopsy and serum electrophoresis confirmed immunoglobulin G (IgG) κ multiple myeloma. Interventions: Dialysis was initiated for severe oligoanuric acute kidney injury. The patient was treated with 5 sessions of plasmapheresis and 11 cycles of clone reduction chemotherapy with CyBorD (cyclophosphamide, bortezomib, and dexamethasone). Outcomes: This patient achieved excellent kidney recovery and is no longer dialysis dependent. Teaching points: Crystalglobulinemia should be suspected in patients with rapidly progressive acute kidney injury and monoclonal gammopathy. Timely investigation with kidney biopsy to differentiate this condition from light chain cast nephropathy and initiation of appropriate treatment can lead to remission of disease and excellent recovery of kidney function.

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Background Shared decision making (SDM) is important when considering whether an older patient with advanced CKD should be managed with dialysis or conservative kidney management (CKM). Physicians may find these conversations difficult because of the relative paucity of data on patients managed without dialysis. Methods This prospective observational study was conducted in a unit supported by a multidisciplinary Kidney Supportive Care (KSC) program, in a cohort of 580 patients (280 CKM and 230 dialysis) ≥65-years-old with CKD Stages IV and V. Survival was evaluated using logistic regression and cox-proportional-hazard models. Linear mixed models were utilised to assess symptoms over time. Results CKM patients were older (mean 84 vs. 74-years-old.; p < 0.001) and almost 2-fold more likely to have ≥ 3 comorbidities (p < 0.001). The median survival of CKM patients was lower compared to dialysis from all time-points: 14months (Interquartile range [IQR] 6–32) vs. 53(IQR 28–103) from decision of treatment modality or dialysis-start-date (p < 0.001); 15(IQR 7–34) vs. 64(IQR 30–103) months from the time eGFR ≤ 15ml/min/1.73m2 (p < 0.001); and 8(IQR 3–18) vs. 49(19–101) months from eGFR ≤ 10ml/min/1.73m2. 59% of CKM patients reported an improvement in symptoms by their third KSC-clinic visit (p < 0.001). The rate of unplanned hospitalisation was 2-fold higher in the dialysis cohort. Conclusions CKM patients survive a median of 14 months from the time of modality choice and have a lower rate of hospitalisation than dialysis patients. Although the symptom burden in advanced CKD is high, most elderly CKM patients managed through an integrated KSC program can achieve improvement in their symptoms over time. These data might help with SDM.