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Management of acute kidney injury in frail patients with biopsy-proven cast nephropathy: a combined approach with chemotherapy plus Supra-hemodiafiltration with post-adsorption endogenous reinfusion

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Abstract

Background

Patients with multiple myeloma often have kidney involvement with acute kidney injury which is frequently due to cast nephropathy. Hemodiafiltration with endogenous reinfusion (HFR) allows removal from the circulation of significant amounts of free light chains (FLCs) responsible for tubular damage.

Methods

Between 2014 and 2018, 13 patients affected by multiple myeloma (64% λ chain and 36% k), including 10 cases with biopsy-proven cast nephropathy, were treated with this technique. Each patient had high free light chains levels at diagnosis: median 8586 mg/l for λ and 4200 mg/l for k, and stage III acute kidney injury (median serum creatinine 7.5 mg/dl). We initially performed daily HFR-Supra sessions and then modulated them based on renal response (mean 10 sessions/patient). At the same time, the patients also received various chemotherapy regimens, depending on their hematological criteria.

Results

Forty-six percent of patients showed at least partial renal function recovery within the third month, thus allowing dialysis discontinuation; 38% remained on dialysis. Two patients died. The mean reduction rate of free light chains at the end of the HFR-Supra cycle was 85% (k) and 40% (λ), respectively. Serum albumin remained stable during the whole treatment.

Discussion

In our experience, the synergistic effect of chemotherapy and HFR-Supra led to a recovery of renal function in 6 out of 13 patients presenting with severe dialysis-requiring acute kidney injury. HFR-Supra allowed stable albumin levels, with high free light chains removal rate, at a relatively low costs.

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Authors and Affiliations

  1. CMID-Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy

    Stefano Murgia, Giacomo Quattrocchio, Giacomo Forneris, Marco Pozzato, Roberta Fenoglio, Michela Ferro, Emanuele De Simone, Giulio Del Vecchio, Carlo Di Benedetto & Dario Roccatello

Authors
  1. Stefano Murgia
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  2. Giacomo Quattrocchio
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  3. Giacomo Forneris
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  4. Marco Pozzato
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  5. Roberta Fenoglio
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  6. Michela Ferro
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  7. Emanuele De Simone
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  8. Giulio Del Vecchio
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  9. Carlo Di Benedetto
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  10. Dario Roccatello
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Correspondence to Dario Roccatello.

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This study was conducted retrospectively from data obtained for clinical purposes and thus it did not need ethical approval.

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Murgia, S., Quattrocchio, G., Forneris, G. et al. Management of acute kidney injury in frail patients with biopsy-proven cast nephropathy: a combined approach with chemotherapy plus Supra-hemodiafiltration with post-adsorption endogenous reinfusion. J Nephrol 35, 1243–1249 (2022). https://doi.org/10.1007/s40620-021-01226-4

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