Abstract
Background
Total knee arthroplasty (TKA) is a common orthopedic procedure, yet outcomes in patients with multiple myeloma (MM) remain poorly understood since there are limited studies. As a result, the aim was to assess how MM affects outcomes of patients undergoing TKA.
Methods
In this retrospective cohort study, patients with MM who underwent TKA were identified using a TriNetX national database from 2005 to 2024. These patients were matched to controls without MM using propensity score matching based on age, sex and relevant comorbidities. Postoperative complication rates, readmission, revision surgery, and mortality were analyzed over a one-year follow-up.
Results
A total of 237, 007 patients who had TKR were matched to 353 patients with MM who had TKR. MM patients were older, male (mean age 70.3 vs 67 years) and had a higher incidence of comorbidities at baseline. MM patients had significantly higher rates of wound dehiscence (1.98 % vs 0.52 %, p = .003), periprosthetic infection (2.27 % vs 0.81 %, p = .009), acute renal failure (5.95 % vs 1.96 %, p < .001), blood loss anemia (15.01 % vs 6.53 %, p < .001),DVT (2.55 % vs 1.27 p = .049), myocardial infarction (0.85 % vs 0.21 %, p = .040), pulmonary embolism (3.12 % vs 0.84 %, p < .001) and pneumonia. However, one-year mortality rates did not differ significantly between groups.
Conclusion
MM is associated with an increased risk of postoperative complications following TKA compared to control patients but not mortality. This study highlights multispecialty tailored perioperative care protocols for MM patients undergoing TKA to decrease complications.
Keywords: Arthroplasty, Replacement, Knee, Multiple Myeloma, Postoperative Complications, Retrospective Studies, Treatment Outcome, Risk Factors
1. Introduction
Multiple myeloma (MM) is the second most common hematologic malignancy globally in which malignant plasma cells produce an abnormal increase in monoclonal antibodies that can then cause blood, bone and tissue damage.1 It most commonly affects African American men 65 years and older.2,3 MM is on a spectrum of disease that can progress from monoclonal gammopathy of undetermined significance (MGUS) 1 % annually and Smoldering myeloma (SM) 10 % annually to MM.4 MM is classically diagnosed by bone marrow biopsy which shows>10 % plasma cells and features of hypercalcemia, renal failure, anemia and bone pain. The International Working Group of Myeloma also considers these high-risk features as meeting the threshold for symptomatic MM with bone marrow biopsy showing >60 % plasma cells, serum free light chain greater than 100, or one focal lesion on MRI of the spine.2,5 The incidence of MM is growing rapidly globally and it affects about 160, 000 people annually while mortality has decreased over the course of time to 106, 000 due to newer lines of medical therapy.6,7 Multiple myeloma treatment can include stem cell transplant while patients who are not transplant viable are treated with chemotherapy and immunotherapy as well as steroids.8
MM patients have a 9 times higher risk of fractures due to destruction of bone resulting in lytic lesions, increased cytokines and bone loss rom use of steroids for treatment.9 Since MM patients tend to be older and have increased risk of having osteoarthritis as well as bony destruction these patients have a higher predisposition to having joint replacements. There have been three retrospective clinical studies that studied MM patients undergoing joint replacements. Park et al. looked at total hip arthroplasty in MM patients retrospectively through a national inpatient database and Menendez et al. looked similarly at the national database comparing Total Joint Arthroplasty and MM but neither of the studies looked at total knee replacements (TKR) specifically.10,11 Salimy et al. looked at MM and TKR and THR at a single institution retrospectively but had a small cohort of patients who had TKR.12 Very few studies have examined the post-operative risks among this population. Being aware of the risk and complications among these patients while they undergo joint replacements will help physicians counsel patients. The aim of the study is to analyze the risk of patients with MM who undergo total knee arthroplasty (TKA).
2. Methods
The TriNetX research network was utilized for this retrospective cohort study. The database has aggregate data for 117 million US patients in 82 healthcare organizations in different settings. The data is obtained from electronic medical records along with payer information which is de-identified. Patients aged 18 and older who underwent primary TKA between 2005 and 2024 were identified using CPT code 27447. Multiple myeloma diagnosis was defined using the ICD-9 and ICD-10 codes listed in Appendix. We compared patients who had MM and TKR and patients who had TKR who did not have MM. Demographic data was also collected and included sex, race, marital status, age, history of diabetes, obesity and tobacco use.
Demographic data was not matched, and patients were excluded if there were missing records in the query. Surgical and medical complications were identified using the ICD and CPT codes listed in Appendix A. This study assessed the following outcomes at 30 days: postoperative complications, including mortality, deep surgical site infection, superficial surgical site infection, wound dehiscence, periprosthetic infection, acute renal failure, blood loss anemia, cardiac arrest, deep venous thrombosis, periprosthetic mechanical complications, pulmonary embolism, periprosthetic fracture, pneumonia, stroke and transfusion requirements and manipulations under anesthesia at 4 months, Surgical date of TKR was designated as the index event from which the follow-up period began. All outcomes were compared at a postoperative follow-up of 30-days, except for the complication of a need for manipulation under anesthesia, which was measured at four months postoperatively. Information about the outcomes of interest is provided in Appendix A.
Odds ratios were calculated to compare the rates of complications between the exposure and control groups and 95 % confidence intervals were provided for all calculations. Pre-operative variables and post-operative variables were compared using chi-squared analysis and Fisher's exact test was utilized when the cell count was less than 5. P < .05 was considered statistically significant with two-sided tests.
The TriNetx Live platform was used for cohort construction. SPSS version 29 (IBM) was used for data management and statistical analysis. Microsoft Excel was used for further statistical analysis and data visualization. The corresponding author (SS) independently verified the data accuracy and statistical analysis. The TriNetX platform adheres to HIPAA and GDPR regulations to ensure data security and protect patient privacy as it contains solely de-identified aggregate information. This study was exempt from Institutional Review Board approval, as it utilized de-identified data and did not involve direct human subjects.
3. Results
A total of 237, 360 patients who had TKR between 2005 and 2024 were identified retrospectively. There were 353 patients with a history of MM who had TKR and 237, 007 patients were controls who had TKR with no history of MM. The mean age of patients with MM was compared against patients who did not have MM who had TKR. The mean age of patients with MM was 70.36 compared to the control group whose mean age was 67.00 which was significant (p < .001).
3.1. Demographics
Table 1, displays the demographic data between MM patients versus the control who had TKR. The MM patients had a higher proportion of males (55 % vs 39 %) which was significant. The control group had a higher percentage of female patients compared to the MM cohort (61 % vs 45 %). In the MM cohort, there were significantly higher African American patients who had TKR in contrast to the control cohort (18.13 % vs 9.72 %). There were higher numbers of patients in the MM group who were under the age of 65 (75.64 % vs 61.46 %). Additionally, the MM cohort had a slightly higher percentage of medical comorbidities including diabetes mellitus (28.3 vs 19.87) and tobacco use disorder (26.67 % vs 19.82 %) compared to the control cohort.
Table 1.
Patient Demographics and Comorbidities in Multiple Myeloma Patients and Control Group who underwent TKR.
| Variable | Control | MM | P value |
|---|---|---|---|
| Sex | |||
| Male | 88,959 (39.06 %) | 191 (54.57 %) | 0.015∗ |
| Female | 138,815 (60.94 %) | 159 (45.43 %) | 0.015∗ |
| Race/Ethnicity | 159 (45.43 %) | ||
| American Indian or Alaska Native | 644 (0.27 %) | 0 (0.00 %) | NA |
| Asian | 4895 (2.07 %) | 6 (1.70 %) | NA |
| Black or African American | 23,037 (9.72 %) | 64 (18.13 %) | <0.001∗ |
| Native Hawaiian or Pacific Islander | 479 (0.20 %) | 0 (0.00 %) | NA |
| Other Race | 5764 (2.43 %) | 7 (1.98 %) | NA |
| Unknown | 24,805 (10.47 %) | 22 (6.23 %) | NA |
| White | 177,383 (74.84 %) | 254 (71.95 %) | 0.211 |
| Hispanic or Latino | 12,326 (5.20 %) | 18 (5.10 %) | 0.761 |
| Marital Status | 0.463 | ||
| Married | 70,414 (29.71 %) | 96 (27.20 %) | |
| Single | 39,951 (16.68 %) | 57 (16.15 %) | |
| Unknown | 126,642 (53.43 %) | 200 (56.66 %) | |
| Age Group | <0.001∗ | ||
| <65 years | 145,674 (61.46 %) | 267 (75.64 %) | |
| ≥65 years | 91,333 (38.54 %) | 86 (24.36 %) | |
| Diabetes | <0.001∗ | ||
| Not Present | 189,919 (80.13 %) | 253 (71.67 %) | |
| Present | 47,088 (19.87 %) | 100 (28.33 %) | |
| Obesity | 0.240 | ||
| Not Present | 154,727 (65.28 %) | 220 (62.32 %) | |
| Present | 82,280 (34.72 %) | 133 (37.68 %) | |
| Smoking Disorder | 0.003∗ | ||
| Does not use | 190,028 (80.18 %) | 261 (66.24 %) | |
| Does use | 46,979 (19.82 %) | 92 (26.67 %) | |
3.2. Postoperative outcomes
Patients in the MM group had a significantly higher rate of postoperative complications after TKR, which is displayed in Table 2. MM patients had higher risk of wound dehiscence (0.98 % vs 0.52 %, p = .003), periprosthetic infection (2.27 % vs 0.81 %, p = .009), acute renal failure (5.95 % vs 1.96 %, p < .001), blood loss anemia (15.01 % vs 6.53 %, p < .001), DVT (2.55 % vs 1.27 p = .049), myocardial infarction (0.85 % vs 0.21 %, p = .040), pulmonary embolism (3.12 % vs 0.84 %, p < .001) and pneumonia (1.98 % vs 0.15 %, p = .007). There were no statistical differences between the two groups in regard to mortality, deep surgical site infection, superficial surgical site infection, manipulation under anesthesia at 4 months following surgery, cardiac arrest/VF, periprosthetic mechanical complication, prosthetic fracture and blood transfusion.
Table 2.
Postoperative complication risks in multiple myeloma patients and control.
| Complication | Control | MM | Odds Ratio | 95 % CI | P Value |
|---|---|---|---|---|---|
| Mortality | 352 (0.15 %) | a (0.28 %) | 1.910 | 0.268–13.635 | 0.409 |
| Deep SSI | 28 (0.01 %) | 0 (0.00 %) | 1.0 | – | – |
| Wound dehiscence | 1239 (0.52 %) | 7 (1.98 %) | 3.850 | 1.818–8.153 | 0.003∗ |
| Periprosthetic infection | 1918 (0.81 %) | 8 (2.27 %) | 2.842 | 1.408–5.737 | 0.009∗ |
| Superficial SSI | 215 (0.09 %) | 0 (0.00 %) | 1.0 | – | – |
| Manipulation under anesthesia | 6694 (2.82 %) | a (1.42 %) | 0.494 | 0.204–1.196 | 0.110 |
| Acute renal failure | 4653 (1.96 %) | 21 (5.95 %) | 3.159 | 2.030–4.914 | <0.001∗ |
| Blood loss anemia | 15,483 (6.53 %) | 53 (15.01 %) | 2.528 | 1.887–3.386 | <0.001∗ |
| Cardiac arrest/VF | 106 (0.04 %) | a (0.28 %) | 6.349 | 0.884–45.617 | 0.147 |
| DVT | 3004 (1.27 %) | 9 (2.55 %) | 2.038 | 1.050–3.954 | 0.049∗ |
| Periprosthetic mechanical complication | 837 (0.35 %) | a (0.57 %) | 1.608 | 0.400–6.465 | 0.355 |
| Myocardial infarction | 498 (0.21 %) | a (0.85 %) | 4.071 | 1.302–12.726 | 0.040∗ |
| Pulmonary embolism | 1987 (0.84 %) | 11 (3.12 %) | 3.804 | 2.084–6.946 | <0.001∗ |
| Periprosthetic fracture | 556 (0.23 %) | a (0.57 %) | 2.423 | 0.602–9.752 | 0.202 |
| Pneumonia | 346 (0.15 %) | 7 (1.98 %) | 3.246 | 1.533–6.872 | 0.007∗ |
| Blood transfusion | 105 (0.04 %) | 0 (0.00 %) | 0 | 0 | 1.00 |
Patient numbers fewer than 5 are not reported to maintain patient privacy.
4. Discussion
There have been limited studies looking at postoperative outcomes in MM patients who had undergone TKR. MM incidence has increased by 40 % over the last 20 years in the US alone and by 130 % worldwide.13,14 As global populations increase, the risk of MM patients having a TKR is going to increase. In this study, MM patients tended to be around 70 years of age and had a higher predisposition of males compared to the control which is very characteristic of this disease process. MM affects males more at a rate of 1.5 times more than females and average age of 69. Additionally, the MM patient had a higher percentage of African American patients, almost twice the amount of control which is also very representative of population since African American males have 2 times higher risk of MM compared to other races.14 The MM cohort had higher risk factors of diabetes and smoking. Research does not show correlation between either of these conditions and MM, but Diabetes was associated with worse prognosis in Multiple Myeloma patients which could have worsened the postoperative outcomes in this population.15,16
Compared to control, the MM cohort had a significantly higher risk of postoperative complications, but morality was not significantly affected. MM patients had a significantly higher risk of wound dehiscence compared to the control cohort. Wound dehiscence could be higher in this subgroup because of poor wound remodeling ability due to malnutrition, increased comorbid conditions including diabetes and smoking. Periprosthetic infection was significantly higher in the MM cohort, which could be multifactorial. MM patients are immunocompromised due to the chemotherapy regimen they are on and due to disease process, which leads to loss of ability to produce normal B cells or T cells to fight infection. In a Swedish MM study, the risk of bacterial and viral infection without surgery was significantly around 5 times for bacterial and 7 times for viral infections with high predisposition of sepsis and pneumonia.17 However, the patient only had an increased risk of periprosthetic infection but not Superficial or Deep SSI. In a large cohort study, post hip surgery patients had a significantly high odd ratio of SSI infection but they did not differentiate based on location if it is deep, superficial or due to prosthetics.10 Similarly in a single center study in patients undergoing THR and TKR, there was a 33.3 % risk of infection in SSI but it did not differentiate by type either.12
MM patients had a higher risk of AKI compared to control patients. MM patients at baseline have CKD due to disease processes which can be further acerbated by TKR. Blood loss anemia also has increased MM patients due to multiple factors. MM tends to cause chronic anemia at baseline due to overproduction of plasma cells which reduces the space in the bone marrow to produce other cell lines including RBC and is one of clinical criteria for diagnosis. MM leads to decrease in EPO production due to renal failure and by downregulating regulator molecules of Erythropoiesis due to increased cytokine CCL3.18 Additionally inflammatory cytokines like CCL3 and others, tend to cause anemia due to anemia of chronic disease.
MM patients had higher risk of DVT and pulmonary embolism compared to control which could be due to increased risk of coagulation in this patient population. Also, immunomodulatory agents for management of MM are associated with increased risk of DVT and PE.19 Risk of DVT and PE in study by Menendez et al. undergoing total joint arthroplasty was 3 times higher.11 Similarly, the risk of PE in our study was 3 times higher while the risk of DVT was 2 times higher.
The risk of MI was 4 times higher than the control. MM increases the risk of coronary artery vessel damage due to disease process and secondary due to chemotherapy and immunomodulatory regimen patients are taking.20 The risk of pneumonia was 13 times higher than control. MM patients have higher risk of pneumonia than control as noted in Swedish study due to impaired ability to fight infections and due to immunosuppression at baseline.17 The risk of TKA increases the risk of pneumonia significantly and in a study by Park et al., patients had a higher risk of pneumonia.10 MM patients tended to have higher risk of complications than control but they did not have increased risk of mortality.
4.1. Clinical implications and limitations
The increased risk of complications in MM patients undergoing TKR highlights having a comprehensive care plan before surgery such as adding VTE prophylaxis on this subgroup and early mobility as tolerated to decrease the risk of DVT and PE. These patients need to be counseled on these complications and have a different protocol compared to patients who do not have MM. Further, considering spinal anesthesia over general anesthesia in MM patients undergoing TKR may help to reduce the risk of pulmonary complications. Additionally, this study implies the importance of having a multidisciplinary care team to address risk of infections and cardiac complications. Even though the cost of MM patients undergoing TKR was not analyzed, the associated complication of MM patients undergoing TKR would be hypothesized to be higher. Very few studies have looked at length of stay and cost of hospitalization which could be analyzed in future studies.
Since this study was retrospective, there are certain limitations. One of the limitations is the data is obtained using database and ICD codes, so if there were errors in the database it could affect the study. Another limitation is since it is a database study we cannot really assess what kind of therapy the MM patients were on for treatment or maintenance. Additionally, we cannot assess if certain risk factors were modified and if they were addressed in regards DVT prophylaxis since we could not review patient specific data. Additionally, we did not look at long term complications from TKR, but other studies have reported repeat surgery in patients with MM. These limitations highlight that future study addressing this risk factor might help to see if modifying certain variables in the complication in these patients.
5. Conclusion
To conclude, this study showed MM patients had significantly higher risk of post-surgical complications due to pathophysiology of MM and medication therapy. This study highlights the importance of having a multidisciplinary approach in treating these patients. Also, it would be beneficial to have a study to see if having a protocol for addressing these complications in the future would improve patient outcomes.
Ethical statement
This research did not require IRB approval because no PHI data was used and data was retrospectively obtained from the database. Informed consent for patient information to be published in this article was not obtained because no PHI was used in this study. The authors declare no that there is no conflict of interest.
Credit author
Dr. Sushrruti Varatharaj: Writing Original draft and conceptualization.
Dr. Senthil Sambandam: Supervision, Conceptualization and data curation.
Dr. Sruthi Priyavadhana Ramanan:Reviewing and Editing and formal analysis.
Dr. Clarissa Meza Reviewing and Editing.
Gatik Senthil: Writing and Editing paper.
Consent
The TriNetx Live platform was used for cohort construction and since no PHI was used consent was not obtained and IRB approval was not warranted.
Funding statement
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
None.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2025.103190.
Appendix A. Supplementary data
The following is/are the supplementary data to this article:
References
- 1.Kazandjian D. Multiple myeloma epidemiology and survival: a unique malignancy. Semin Oncol. 2016 Dec;43(6):676–681. doi: 10.1053/j.seminoncol.2016.11.004. Epub 2016 Nov 10. PMID: 28061985; PMCID: PMC5283695. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Rajkumar S.V. Multiple myeloma: 2022 update on diagnosis, risk stratification, and management. Am J Ematol. 2022 Aug;97(8):1086–1107. doi: 10.1002/ajh.26590. Epub 2022 May 23. PMID: 35560063; PMCID: PMC9387011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Bird S., Cairns D., Menzies T., et al. Sex differences in multiple myeloma biology but not clinical outcomes: results from 3894 patients in the myeloma XI trial. Clin Lymphoma Myeloma Leuk. 2021 Oct;21(10):667–675. doi: 10.1016/j.clml.2021.04.013. Epub 2021 Apr 24. PMID: 34059488; PMCID: PMC8528179. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Mateos MV, Landgren O. MGUS and smoldering multiple myeloma: diagnosis and epidemiology. Cancer Treat Res;169:3-12. doi: 10.1007/978-3-319-40320-5_1. PMID: 27696254.. [DOI] [PubMed]
- 5.Malard F., Neri P., Bahlis N.J., et al. Multiple myeloma. Nat Rev Dis Primers. 2024;10:45. doi: 10.1038/s41572-024-0529-7. [DOI] [PubMed] [Google Scholar]
- 6.Ludwig H., Novis Durie S., eckl A., Hinke A., Durie B. Multiple myeloma incidence and mortality around the globe; interrelations between health access and quality, economic resources, and patient empowerment. Oncologist. 2020 Sep;25(9):e1406–e1413. doi: 10.1634/theoncologist.2020-0141. Epub 2020 May 7. PMID: 32335971; PMCID: PMC7485361. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Huang J., Chan S.C., Lok V., et al. The epidemiological landscape of multiple myeloma: a global cancer registry estimate of disease burden, risk factors, and temporal trends. Lancet Haematol. 2022 Sep;9(9):e670–e677. doi: 10.1016/S2352-3026(22)00165-X. [DOI] [PubMed] [Google Scholar]
- 8.Monteith B.E., Sandhu I., Lee A.S. Management of multiple myeloma: a review for general practitioners in oncology. Curr Oncol. 2023 Apr 22;30(5):4382–4401. doi: 10.3390/curroncol30050334. PMID: 37232792; PMCID: PMC10217377. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Mellton L.J., 3rd, Kyle R.A., Achenbach S.J., Oberg A.L., Rajkumar S.V. Fracture risk with multiple myeloma: a population-based study. J Bone Miner Res. 2005;20(3):487–493. doi: 10.1359/JBMR.04113. [DOI] [PubMed] [Google Scholar]
- 10.Park K.J., Menendez M.E., Mears S.C., Barnes C.L. Patients with multiple myeloma have more complications after surgical treatment of hip fracture. Geriatr Orthop Surg Rehabil. 2016;7(3):158–162. doi: 10.1177/2151458516658330. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Menendez ME, Park KJ, Barnes CL. Early postoperative outcomes after total joint arthroplasty in patients with multiple myeloma. J Arthroplast. 31(8):1645-1648. doi:10.1016/j.arth.2016.01.02.. [DOI] [PubMed]
- 12.Salimy M.S., Blackburn A.Z., Alpaugh K., Lozano-Calderón S.A., Bedair H.S., Melnic C.M. Postoperative outcomes in total hip and total knee arthroplasty for patients who have multiple myeloma. J Arthroplast. 2023 Nov;38(11):2269–2274. doi: 10.1016/j.arth.2023.05.019. Epub 2023 May 20. PMID: 37211290. [DOI] [PubMed] [Google Scholar]
- 13.Fazio M., Del Fabro V., Parrinello N.L., et al. Multiple myeloma in 2023 ways: from trials to real life. Curr Oncol. 2023 Nov 3;30(11):9710–9733. doi: 10.3390/curroncol30110705. PMID: 37999125; PMCID: PMC10670159. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Padala S.A., Barsouk A., Barsouk A., et al. Epidemiology, staging, and management of multiple myeloma. Med Sci. 2021 Jan 20;9(1):3. doi: 10.3390/medsci9010003. PMID: 33498356; PMCID: PMC7838784. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Shah U.A., Moshier E., Derkach A., et al. Prevalence and impact of diabetes on survival of patients with multiple myeloma in different racial groups. Blood Adv. 2024 Jan 9;8(1):236–247. doi: 10.1182/bloodadvances.2023010815. PMID: 37772981; PMCID: PMC10918423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Andreotti G., irmann B.M., Cozen W., et al. Pooled analysis of cigarette smoking and risk of multiple myeloma from the international multiple myeloma consortium. Cancer Epidemiol Biomarkers Prev. 2015 Mar 1;24(3):631–634. doi: 10.1158/1055-9965.EPI-14-1145. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Blimark C.H., Carlson K., Day C., et al. A population-based study on 8,672 multiple myeloma patients diagnosed 202021 from the Swedish myeloma registry. Haematologica. 2024 Jul 18;110(1):163. doi: 10.3324/haematol.2024.285645. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Liu L., Yu Z., Cheng H., et al. Multiple myeloma hinders erythropoiesis and causes anaemia owing to high levels of CCL3 in the bone marrow microenvironment. Sci Rep. 2020 Nov 25;10(1) doi: 10.1038/s41598-020-77450-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Covut F., Sanfilippo K.M. Mitigating the risk of venous thromboembolism in patients with multiple myeloma receiving immunomodulatory-based therapy. Hematol Am Soc Hematol Educ Prog. 2022 Dec 9;2022(1):363–367. doi: 10.1182/hematology.2022000414. PMID: 36485142; PMCID: PMC9820182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Bringhen S., Milan A., Ferri C., et al. European hematology association, the European myeloma network and the Italian society of arterial hypertension. Cardiovascular adverse events in modern myeloma therapy - incidence and risks. A review from the European Myeloma Network (EMN) and Italian Society of Aterial Hypertension (SIIA) Haematologica. 2018 Sep;103(9):1422–1432. doi: 10.3324/haematol.2018.191288. Epub 2018 Jul 26. PMID: 30049825; PMCID: PMC6119131. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.