Impact of free light chain hemodialysis in myeloma cast nephropathy: A case–control study

Abstract

New very high permeability dialysis membranes have been developed to enable the clearance of free light chains in myeloma cast nephropathy. These new dialysis techniques, in combination with chemotherapy, should allow improved prognosis in patients with myeloma cast nephropathy. We report a prospective observational study comparing patients who underwent hemodialysis in our center in 2009 for cast nephropathy revealing multiple myeloma vs. patients treated for the same condition during the same period in other centers in our region. The main difference in the management protocols was the use of high cutoff (HCO) membranes in our center. We described the clinical features, the management protocols, and the outcomes as of June 1, 2010. In 2009, five patients were treated for myeloma cast nephropathy with HCO hemodialysis in our center. At 386 ± 100 days follow-up, one patient died, while three of the five patients recovered their renal function, allowing cessation of hemodialysis. During the same period, five patients were treated for myeloma cast nephropathy in other centers in our region. At 398 ± 131 days follow-up, four patients died, and none of the patients recovered renal function, allowing cessation of hemodialysis. In our study, light chain clearance allowed recovery of renal function and cessation of hemodialysis in three of five patients with acute kidney injury secondary to myeloma cast nephropathy. A randomized trial comparing this technique with conventional hemodialysis techniques should be conducted to raise the level of proof for this therapeutic option. The overall prognosis, including quality of life and cost-effectiveness, of HCO hemodialysis should also be examined.

High cutoff versus high-flux haemodialysis for myeloma cast nephropathy in patients receiving bortezomib-based chemotherapy (EuLITE): a phase 2 randomised controlled trial

“…Since 2007, there has been a focus on high cutoff haemodialysis (HCO-HD) for removal of sFLC; HCO-HD relies on use of a highly permeable dialysis membrane that is very effective in clearing both FLC isotypes 17 and is more effective than plasma exchange because it can be used for longer treatment sessions. 18 Uncontrolled clinical trials 11,[19][20][21] have shown a high frequency of renal recovery in patients who were dialysis-dependent and received HCO-HD. However, the effect of novel chemotherapy was not evaluated in these studies, and a 2017 randomised controlled trial, 22 in which all patients received a multiple myeloma treatment containing bortezomib and dexamethasone, showed no differences in the primary outcome of independence from dialysis at 90 days between the group randomly assigned to receive HCO-HD and the group randomly assigned to receive high-flux haemodialysis (HF-HD), although increased overall renal recovery was reported in patients who received HCO-HD.…”

Onco-Nephrology

“…Renal recovery was correlated with improved survival. One small case control study has also shown improved rates of renal recovery and dialysis discontinuation with HCO hemodialysis (40). The promising benefits of HCO hemodialysis are being tested combined with bortezomib-based chemotherapy in the multicenter RCT European Trial of Free Light Chain Removal by Extended Hemodialysis in Cast Nephropathy.…”

Endotoxemia after high cutoff hemodialysis for treatment of patient with multiple myeloma can be prevented by using ultrapure dialysate: A case report

“…[10][11][12][13][14][15][16] It was first reported to treat CN caused by MM in 2007 by Hutchison et al 8 Afterwards, the same unit has performed series researches to study the factors affecting clearance in HCO-HD and the relationship between the removal of FLC by HCO-HD and clinical outcomes. 13,18,19 However, what is proved critically important for reduction of blood FLC and improvement of outcome in these noncontrol studies is effective chemotherapy; the role of HCO-HD in these issues is still waiting to be confirmed by the results of the ongoing randomized control trial. 13,18,19 However, what is proved critically important for reduction of blood FLC and improvement of outcome in these noncontrol studies is effective chemotherapy; the role of HCO-HD in these issues is still waiting to be confirmed by the results of the ongoing randomized control trial.…”

“…6,7,17 The preliminary results showed that early HCO-HD combined with chemotherapy may contribute to improvement of renal function in patients with MM-caused CN through decreasing blood FLC concentration. 13,18,19 However, what is proved critically important for reduction of blood FLC and improvement of outcome in these noncontrol studies is effective chemotherapy; the role of HCO-HD in these issues is still waiting to be confirmed by the results of the ongoing randomized control trial. 17 Our experience for HCO-HD in one case showed HCO-HD combined with chemotherapy greatly decreased The clearance of FLC l measured in this patient was 38.4 mL/min at the start of HD, which is higher than that reported by Hutchison et al using one HCO1100 filter (surface area 1.1 m 2 ) and is comparable with that using two HCO1100 filters in series.…”