Safety and efficacy of autologous hemopoietic progenitor cell collection in tandem with hemodialysis in multiple myeloma with myeloma cast nephropathy

Abstract

Autologous hemopoietic progenitor cell (HPC) collection is the most frequent indication for an apheresis procedure in patients with multiple myeloma, up to 10% of whom may also require hemodialysis because of myeloma kidney. We investigated whether HPC collection could be performed in tandem with hemodialysis, to avoid extra outpatient visits for extracorporeal procedures, without compromising the efficacy of the hemodialysis, the HPC collection efficiency (CE) or patient safety. Four dialysis-dependent patients with multiple myeloma underwent 5 large volume leukapheresis HPC collections in tandem with hemodialysis. Under our protocol, all of the blood processed through the apheresis instrument was dialyzed against a standard calcium-rich bath prior to being returned to the patient, therefore no supplemental calcium was needed. No significant changes in pulse rate (P = 0.625) or mean arterial pressure (P = 0.188) were noted between the start and end of the procedures. The patients exhibited no signs or symptoms of hypocalcemia or other adverse effects. Calculated urea reduction ratios ranged between 62.5 and 73.9%, and HPC CE was between 53 and 84% for 4 of the 5 procedures, indicating that there was no compromise of either procedure when performed in tandem. Ionized calcium measured at the beginning, midpoint and end of every procedure did not change (P = 0.954). The two patients who proceeded to autologous HPC transplant engrafted on Days 11 and 10, respectively. We conclude that autologous HPC collection can safely be performed in tandem with hemodialysis without compromising the efficacy of dialysis, HPC CE, or patient safety.

Autologous hematopoietic cell transplantation for multiple myeloma patients with renal insufficiency: a center for international blood and marrow transplant research analysis

“…Several reports have shown that both the use of aggressive induction regimens incorporating the proteasome inhibitors and the use of AHCT is safe and effective in patients with myeloma presenting with renal insufficiency. ( 5 – 13 ) Patients generally are treated with dose reductions in HDM although there is single institutional data that HDM at 200 mg/m 2 is safe and effective in patients with RI with creatinine clearance 30 to 60 ml/min. ( 14 ) The International Myeloma Working Group recommends restricting the dose of melphalan to 100-140 mg/m 2 as grade C evidence.…”

Therapeutic plasma exchange performed in tandem with hemodialysis without supplemental calcium in the apheresis circuit

“…We found that, in tandem hemodialysis/HPC collection, because the processed blood from the apheresis circuit returns to the patient through the dialyzer, and the dialysis bath includes 2.5 meq/L of ionized calcium, patient plasma ionized calcium remains stable. Thus, even without the direct addition of calcium to the apheresis circuit hypocalcemic toxicity is avoided . We report herein that return of the blood/albumin mixture through the dialyzer during tandem hemodialysis/TPE mitigates the fall in patient plasma ionized calcium and thus protects against hypocalcemic toxicity.…”

“…Hemodialysis was performed concurrently with TPE using a Gambro Phoenix 2 Hemodialysis System (Gambro, Lakewood, CO) and an Optiflux F160 NR polysulfone dialyzer (Fresenius Medical Care, Waltham, MA) as recently described without heparin in the dialysis circuit. All blood returning from the apheresis instrument passed through the dialysis circuit prior to entering the venous return port of the patient's venous access device . The parallel set‐up of the hemodialysis and apheresis tubing circuits for the tandem procedures is depicted in Figure .…”

“…We have previously demonstrated that TPE and HPC collection can be performed in tandem with hemodialysis without compromising the efficacy of either the apheresis or dialysis procedure . We found that, in tandem hemodialysis/HPC collection, because the processed blood from the apheresis circuit returns to the patient through the dialyzer, and the dialysis bath includes 2.5 meq/L of ionized calcium, patient plasma ionized calcium remains stable.…”

Prophylactic infusion of calcium gluconate to prevent a symptomatic fall in plasma ionized calcium during therapeutic plasma exchange: A comparison of two methods

“…[9][10][11] All methods of providing prophylactic calcium supplementation may not be equally effective in cytapheresis procedures and TPE. For example, when peripheral blood hematopoietic progenitor collection is performed in tandem with hemodialysis without supplemental calcium gluconate infusion, the hemodialysis serves to maintain a stable level of [Ca 2+ ] in the patients' plasma 12 ; when plasma exchange is performed in tandem with hemodialysis under similar circumstances, plasma [Ca 2+ ] significantly decreases. 13 We describe herein a study that compares the efficacy of two methods of calcium gluconate prophylaxis during TPE.…”