Extracorporeal light chain elimination: high cut-off (HCO) hemodialysis parallel to chemotherapy allows for a high proportion of renal recovery in multiple myeloma patients with dialysis-dependent acute kidney injury

Heyne, Nils; Denecke, Barbara; Guthoff, Martina; Oehrlein, Katharina; Kanz, Lothar; Häring, Hans-Ulrich; Weisel, Katja

doi:10.1007/s00277-011-1383-0

Cited by 36 publications

(28 citation statements)

References 37 publications

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“…There are several other small studies which have highlighted the benefit of HCO haemodialysis in renal function recovery in patients with MM and severe RI (table 3) [122,123,124,125,126,127]; however, supplementation of HCO haemodialysis to current standard of care in assisting renal outcome and in doing so long-term patient outcome needs to be carefully investigated, and hence results of the EUropean trial of free LIght chain removal by exTEnded haemodialysis in cast nephropathy (EuLITE) and studies in patients with MM and renal failure due to MCN (MYRE) are awaited [128,129]. …”

Section: Treatment Of Myelomamentioning

confidence: 99%

Current Trends of Renal Impairment in Multiple Myeloma

2015

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Background: Renal impairment (RI) is a common complication of multiple myeloma (MM). Around 50% of patients with MM have RI at presentation, and up to 5% require dialysis treatment. Severe acute kidney injury (AKI) as a cause of RI is a particular challenge as historically the survival of patients who sustain this complication and require dialysis is very poor. However, in this current period, survival is improving and the focus is on optimum use of novel chemotherapies and the evaluation of extra-corporeal therapies for removal of serum immunoglobulin light chains. Summary: RI in patients with MM is commonly associated with excess monoclonal free light chain (FLC) production; myeloma cast nephropathy is the predominant renal pathology in patients presenting with severe RI secondary to AKI. The majority of patients have mild to moderate RI and recover renal function. However, patients with more severe RI, in particular those with a requirement for dialysis, are less likely to recover renal function. Rapid diagnosis and prompt institution of anti-myeloma therapy is an important determinant of renal function recovery, through targeting early and sustained reduction of involved monoclonal FLC. Novel agents are associated with excellent disease response, and bortezomib is now widely used as a first-line agent in the management of MM in patients with severe RI. Extended haemodialysis using high cut-off dialysers is more effective for extracorporeal removal of FLC than plasma exchange, and clinical trials are in process. High-dose chemotherapy with autologous stem cell transplantation does have a role in patients with severe RI but requires careful patient selection. Key Messages: RI is very common in patients with MM, and renal function recovery is associated with improved clinical outcomes. We summarise the epidemiology of MM in the UK, present the impact of RI and renal function recovery on patient outcome, and describe the current management of MM in western countries. Facts from East and West: (1) A serum creatinine level >2 mg/dl has been reported in 16, 21, 24, and 33% of patients with MM in cohort studies from Japan, Europe, China, and Korea, respectively. A creatinine clearance rate <30 ml/min was observed in 30 and 15% of patients in Chinese and Western MM cohorts, respectively. The commonest cause of severe RI in patients with MM is myeloma cast nephropathy. (2) The efficacy of novel treatments (bortezomib, carfilzomib, thalidomide, and lenalidomide) has predominantly been assessed in Western patients. Bortezomib and dexamethasone are the current standard of care for MM and severe RI in the West. Severe RI is not a contraindication to autologous stem cell transplantation (ASCT). Most of the data are from the West; there are case reports from China describing good outcomes with ASCT. The removal of FLC by high-cut-off hemodialysis is under evaluation in randomized controlled trials (RCTs) in the West. Studies in this area are not yet conducted in China. In China, new treatments, such as bortezomib, are more w...

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Section: Treatment Of Myelomamentioning

confidence: 99%

Current Trends of Renal Impairment in Multiple Myeloma

2015

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“…In a small series of 5 patients, 4 recovered kidney function [16] . In other cohorts, 14 out of 19 patients [17] tients [20] became independent of dialysis. In a large cohort of 67 MM patients, treated in different centers across Europe, 63% became independent of dialysis [21] .…”

Section: Discussionmentioning

confidence: 94%

Hemodialysis Using High Cut Off Filters in Light Chain Cast Nephropathy

Buus¹,

Rantanen²,

Krag³

et al. 2015

Blood Purif

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Background/Aim: Hemodialysis using high cutoff (HCO) filters possibly improves renal function in diseases with light chain (LC) overproduction and acute kidney injury. We established the effect of HCO dialysis on renal outcome in consecutive patients with malignant monoclonal gammopathies and LC cast nephropathy. Methods: LC concentration was measured before and after each dialysis session in 10 patients receiving HCO dialysis and bortezomib-based chemotherapy, and their renal function was monitored by plasma creatinine. Results: The number of HCO sessions ranged from 4 to 34 (mean 13). Six patients recovered kidney function, 3 regained partial function while 1 patient continued chronic dialysis. Patients with the largest reductions in LC during HCO treatments had the lowest creatinine at 6 and 9 months of follow-up. For comparison, only 2 out of 10 patients in a historic control group recovered kidney function. Conclusion: HCO dialysis combined with bortezomib results in good renal recovery with kidney function being dependent on the degree of LC lowering.

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“…Despite the significant reduction in serum FLC levels we did not observe an improvement in renal function and standard dialysis sessions were started. In previous studies median time in which dialysis was discontinued was 15-27 days and maximum time to dialysis independence was 64-120 days [2,11]. During this time patients were still treated with HCO dialyzers.…”

Section: Discussionmentioning

confidence: 98%