Treatment of acute renal failure secondary to multiple myeloma with chemotherapy and extended high cut-off hemodialysis

Abstract

Background and objectives: Extended hemodialysis using a high cut-off dialyzer (HCO-HD) removes large quantities of free light chains in patients with multiple myeloma. However, the clinical utility of this method is uncertain. This study assessed the combination of chemotherapy and HCO-HD on serum free light chain concentrations and renal recovery in patients with myeloma kidney (cast nephropathy) and dialysis-dependent acute renal failure.

Design, setting, participants, & measurements: An open-label study of the relationship between free light chain levels and clinical outcomes in 19 patients treated with standard chemotherapy regimens and HCO-HD.

Results: There were sustained early reductions in serum free light chain concentrations (median 85% [range 50 to 97]) in 13 patients. These 13 patients became dialysis independent at a median of 27 d (range 13 to 120). Six patients had chemotherapy interrupted because of early infections and did not achieve sustained early free light chain reductions; one of these patients recovered renal function (at 105 d) the remaining 5 patients did not recover renal function. Patients who recovered renal function had a significantly improved survival (P < 0.012).

Conclusion: In dialysis-dependent acute renal failure secondary to myeloma kidney, patients who received uninterrupted chemotherapy and extended HCO-HD had sustained reductions in serum free light chain concentrations and recovered independent renal function.

Figure 1.

Schematic of patients assessed for and treated with free light chain (FLC) removal hemodialysis (HD).

Figure 2.

Comparison of reductions in serum FLC concentrations at 5, 12, and 21 d. Results presented as patients who completed FLC removal HD with (clear boxes, n = 6) and without (shaded boxes, n = 13) a break in their chemotherapy. Patients with uninterrupted chemotherapy had a more rapid and sustained reduction in their serum concentrations of FLCs, P < 0.0001. The median percentage of presenting FLC concentration at day 5 was 63% (range 49 to 100); day 12, 81% (range 43 to 100); and day 21, 94% (range 43 to 100) in patients with interrupted chemotherapy; compared with 39% (range 29 to 63), 30% (range 12 to 73), and 15% (range 5 to 59) in those patients with uninterrupted chemotherapy.

Figure 3.

Renal recovery rates of patients who received chemotherapy and FLC removal hemodialysis. Fourteen of the 19 patients who received FLC removal HD became independent of dialysis at a median of 28 d (range 13 to 120).

Figure 4.

Kaplan-Meier survival analysis of patients treated with chemotherapy and FLC removal HD. Patients who developed complications requiring early interruption of chemotherapy (solid line, n = 6) had a significantly reduced survival compared with patients who received uninterrupted chemotherapy (broken line, n = 13); P < 0.001.