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
Acute kidney injury (AKI) is frequent in multiple myeloma (MM) patients and strongly affects prognosis, with particularly poor outcomes in patients requiring hemodialysis. Introduction of the novel therapeutic agents to MM therapy has improved myeloma response and renal outcome. This case series reviews the efficacy of combined systemic and extracorporeal therapy to further optimize time to light chain (serum-free light chain (sFLC)) reduction and renal recovery in MM patients with dialysis-dependent AKI (n = 19). High cut-off (HCO) hemodialysis for extracorporeal sFLC removal was initiated in parallel to chemotherapy. Combined therapy resulted in early sFLC response after a median of 13 (range 4–48) days and 6 (3–22) HCO hemodialysis sessions. Time to sFLC response was shorter in patients recovering renal function. Median time to dialysis independence was 15 (4–64) days. By intent-to-treat analysis, sustained renal recovery was achieved in 73.7% (77.8% adjusted for death) of patients. In multivariate analysis, duration of AKI prior to initiation of therapy was an independent predictor of renal functional outcome. Combining HCO hemodialysis for extracorporeal sFLC elimination and effective chemotherapy is a novel treatment strategy allowing for early and sustained sFLC reduction and a high proportion of renal recovery in these patients. Timely diagnosis and onset of therapy is essential for improving renal outcome.
KeywordsMultiple myeloma Acute kidney injury Light chain elimination HCO hemodialysis Renal recovery
HCO filters were provided courtesy of Gambro Dialysatoren GmbH, Hechingen, Germany.
Conflict of interest
The authors report no conflict of interest.
- 15.Tsakiris DJ, Stel VS, Finne P, Fraser E, Heaf J, de Meester J et al (2010) Incidence and outcome of patients starting renal replacement therapy for end-stage renal disease due to multiple myeloma or light-chain deposit disease: an ERA-EDTA Registry Study. Nephrol Dial Transplant 25:1200–1206PubMedCrossRefGoogle Scholar
- 17.Rajkumar SV, Jacobus S, Callander NS, Fonseca R, Vesole DH, Williams ME et al (2010) Lenalidomide plus high-dose dexamathasone versus lenalidomide plus low-dose dexamethasone as initial therapy for newly diagnosed multiple myeloma: an open-label randomised controlled trial. Lancet Oncol 11:29–37PubMedCrossRefGoogle Scholar
- 21.Weisel KC, Heyne N, Hutchison CA, Göhl H, Risler T, Kanz L (2007) Effective light chain elimination via a high cut-off protein permeable filter in patients with light chain myeloma disease. Onkologie 30(suppl 3):80Google Scholar
- 23.Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P (2004) Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) group. Crit Care 8:R204–R212PubMedCrossRefGoogle Scholar
- 27.Kidney Disease Outcomes Quality Initiative (K/DOQI) (2002) Executive summary. Am J Kidney Dis 39(suppl 1):S17–S31Google Scholar
- 33.Dimopoulos MA, Christoulas D, Roussou M, Kastritis E, Anagnostou D, Koureas A et al (2010) Lenalidomide and dexamethasone for the treatment of refractory/relapsed multiple myeloma: dosing of lenalidomide according to renal function and effect on renal impairment. Eur J Haematol 85:1–5PubMedCrossRefGoogle Scholar
- 36.Kastritis E, Anagnostopoulos A, Roussou M, Gika D, Matsuoka C, Barmparousi D et al (2007) Reversibility of acute renal failure in newly diagnosed multiple myeloma patients treated with high dose dexamethasone containing regimens and the impact of novel agents. Haematologica 92:546–549PubMedCrossRefGoogle Scholar
- 37.Wynckel A, Vuiblet V, Schneider N, Kolb B, Melin JP, Journet J et al (2010) Comparison of plasma exchange and hemodialysis using a high cut-off membrane (HCO) for removal of immunoglobulin free light chains in multiple myeloma. J Am Soc Nephrol 21:39AGoogle Scholar