NIV Congres

Introduction: Acute renal failure occurs frequently in multiple myeloma (MM) and significantly affects patient prognosis.Most often acute renal failure in MM is caused by cast nefropathy, due to tubular light chain deposits. The use of high cut-off hemodialysis (HCO-HD) to rapidly remove circulating free light chains has been proposed as a novel adjunct treatment for cast nefropathy.

Methods/Results: Since 2009, 12 patients with dialysis-dependent renal failure secondary to MM were treated with HCO-HD in combination with chemotherapy (dexamethasone and bortezomib in 11 patients, dexamethasone and lenalidomide in 1 patient). Data from these 12 treatment episodes were analysed. Treatment response was defined as dialysis independence within 3 months of start of treatment.

The population’s mean age was 63 years, they were predominantly male (9/12), while the majority (8/12) of them had a new presentation of MM without a history of chronic kidney disease. Mean serum creatinine at presentation was 711 µmol/L, whereas mean free light chains (FLC) were 5500 mg/L. Seven patients had adequate thrombocyte counts allowing for safe kidney biopsies, which showed cast nephropathy in 5.

A total of 223 HCO-HD sessions were performed. 10 patients responded to treatment and were dialysis independent within 3 months (mean serum creatinine 213 µmol/L) after a mean number of 15 HCO-HD sessions (range 3-40).

The 2 non-responders both died (at 3 and 17 months after treatment). Of the responders, 2 are without recurrence and 1 is in complete remission after stem cell transplantation. In the remaining 7 responders, mean time to progression was 10 months (range 3-17 months). Mean survival up until January 2013 was 13 months, with 6 of the responders still alive.

Responders primarily had a newly diagnosed MM (7 out of 10), and all responders still alive had a newly diagnosed MM (6 out of 6).

The main complications of HCO-HD were circuit coagulation (12/223 sessions in 7 patients) and catheter-related bloodstream infections (3 events in 2 patients).

Conclusion: The use of high cut-off hemodialysis in patients with myeloma-associated acute renal failure seems to facilitate the recovery of renal function, with a low risk of complications. Despite its high costs, high cut-off hemodialysis should be considered as an adjunctive treatment in patients with myeloma-associated nefropathy. Further data on treatment efficacy and follow-up are needed, for which we propose centralisation of HCO-HD treatment and a national registry.