Novel renal replacement strategies for the elimination of serum free light chains in patients with kappa light chain nephropathy

Abstract

Multiple myeloma (MM) is a malignancy with excessive production of monoclonal proteins. At disease presentation 30% of MM patients have significant renal impairment which may progress to renal failure requiring dialysis. Besides chemotherapy extracorporeal elimination procedures such as plasma exchange have been applied as adjuvant strategies to eliminate free light chains from circulating blood, however the efficacy was poor with older techniques. We report about a highly efficient method to eliminate serum free light chain (sFLC) using a newly designed protein leaking membrane in patients suffering from sFLC induced acute renal failure. The protein leaking membrane (HCO 1100) is characterized by increased pore size facilitating elimination of middle molecules such as sFLC kappa (22.5 kD). The HCO 1100 membrane was applied in a hemodialysis and hemodiafiltration mode and compared to standard procedures (high flux hemodialysis, hemodiafiltration and plasma exchange). Hemodiafiltration with the protein leaking membrane HCO 1100 was superior to all other extracorporeal replacement strategies in eliminating sFLC-kappa from circulating blood. A median blood reduction rate of 40.8% (range 13.9%-66.4%) was achieved during hemodiafiltration. The corresponding peak clearance rate was 25 ml/min. Importantly, the poorest elimination rate was achieved by plasma exchange followed by standard high flux hemodialysis. Extracorporeal elimination strategies with the protein leaking membrane HCO 1100 may be a promising adjuvant treatment strategy for patients with sFLC nephropathy requiring dialysis. Hemodiafiltration and to lesser extend also hemodialysis with the HCO 1100 hemofilter are able to eliminate substantial amounts of sFLC kappa in MM patients.

Figure 1

Reduction rate (%) of sFLC kappa during two sessions of plasma exchange. Treatment time was 2.5 hour per session (Patient 1).

Figure 2

Reduction rate (%) of sFLC kappa with hemodialysis using the high flux membrane PF 140H. Treatment time is shown in hours (Patient 1).

Figure 3

Reduction rate (%) of sFLC kappa with hemodialysis using the protein leaking membrane HCO1100. Treatment time is shown in hours (Patient 2).

Figure 4

Reduction rate (%) of sFLC kappa by hemodialysis. Treatment time is shown in hours (Patient 3).

Figure 5

Reduction rate (%) of sFLC kappa with hemodiafiltration applying the HCO 1100 and PF210H hemofilter. Treatment time is shown in hours (Patient 3).

Figure 6

Elimination of sFLC kappa with hemodialysis using protein leaking filter. Treatment time is shown in hours (Patient 4).

Figure 7

Elimination of sFLC kappa using hemodiafiltration with protein leaking hemofilter HCO 1100. Treatment time is shown in hours (Patient 4).

Figure 8

Box-Whiskers-Plot: Summary of median sFLC kappa reduction rates by different renal replacement strategies.