Controlled plasma exchange trial in acute renal failure due to multiple myeloma

Abstract

We studied 29 patients affected by acute renal failure due to multiple myeloma with Bence-Jones proteinuria greater than 1 g/day to evaluate the effectiveness of plasma exchange in the treatment of severe myeloma nephropathy. Renal failure was severe enough to require dialysis in 24 cases, while the remaining 5 patients showed serum creatinine levels greater than 5 mg/dl. The patients were randomly allocated to Group I (15 patients undergoing plasma exchange together with corticosteroids, cytotoxic drug, hemodialysis only when needed) or to Group II (14 patients undergoing peritoneal dialysis together with corticosteroids and cytotoxic drug). In Group I Bence-Jones proteinuria decreased dramatically (P less than 0.01) with a significant increase in urine output (P less than 0.001), while Group II presented a slight reduction in Bence-Jones proteinuria without a significant increase in daily diuresis. Thirteen out the 15 Group I patients recovered renal function reaching serum creatinine levels less than or equal to 2.5 mg/dl in most cases. Only two patients in Group II improved renal failure well enough to stop dialysis. The one-year survival rate was significantly higher in Group I (66%) than in Group II (28%, P less than 0.01). We conclude that plasma exchange associated to chemotherapy rapidly removes large amounts of light chains, improves both renal function and long-term survival expectancies.

Urinary Albumin Excretion Patterns of Patients with Cast Nephropathy and Other Monoclonal Gammopathy–Related Kidney Diseases

“…These differences are important to keep in mind when designing clinical trials in which renal outcomes are the endpoints. This may explain why different trials in ARF in myeloma patients produced different results (14)(15)(16)(17)(18).…”

Pathogenesis and treatment of renal failure in multiple myeloma

“…A rapid removal of nephrotoxic light chains with plasma exchange, in combination with antimyeloma therapy, could prevent irreversible renal failure by avoiding further renal damage. Two studies suggested that plasma exchange was of benefit; 43,44 however, a prospective comparison of forced diuresis and chemotherapy (10 patients) versus forced diuresis, chemotherapy and plasma exchange (11 patients) found only a trend in favor of the plasma exchange group. 45 On the other hand, a large randomized trial showed no conclusive evidence that plasma exchange improved the outcome in patients with MM and acute renal failure.…”

Principles of Separation

“…Nonetheless, the clinical benefit of TPE remains controversial. A frequently cited study from 1988 concluded that TPE achieved removal of large amounts of Bence Jones proteins and, in conjunction with chemotherapy, improved kidney function and long-term survival (35). Bence Jones proteinuria significantly decreased.…”

“…Although light chains lack criteria for target molecules effectively removed by TPE (e.g., large molecular weight, intravascular location, low rate of turnover), TPE is the most efficient available way to rapidly remove large amounts of light chains (35). TPE, by removing circulating light chains, reduces their filtered load, potentially diminishing renal injury.…”