Extracorporeal light-chain elimination in myeloma with simple medium cutoff membrane hemodialysis: a retrospective cohort study

Abstract

Background: We determined the efficacy of free light chain (FLC) removal by regular dialysis equipment (high-flux filtration) with medium cutoff (MCO) membrane hemodialysis (HD) as an adjuvant treatment to standard chemotherapy for patients with acute kidney injury complicating multiple myeloma (MM) and its impact on further dialysis dependency.

Methods: Sixty patients with acute dialysis-dependent renal failure secondary to MM were treated with MCO-HD (55 patients) or HCO (high cutoff)-HD (5 patients) as a control. FLC serum concentration, total protein, immunoglobulins, and LDH were measured throughout the dialysis therapy. The kidney function of the patients was followed up for 1 year.

Results: The median age was 69 years; 25 female and 35 male patients were enrolled. HD significantly reduced FLC kappa levels in the MCO/HCO group by 58%/84% (MCO/HCO group; p < 0.05) and FLC lambda by 39%/33% (MCO/HCO group; p < 0.05). Single HD data (MCO) showed a relative reduction of 70% in kappa and 37% in lambda FLC concentration, as expected by the different sizes of the light chains. Renal function improved significantly and continuously from starting creatinine 5.7/3.8 mg/dl (MCO/HCO group) before HD to 1.4/2.0 mg/dl (MCO/HCO group; p < 0.001) after 1 year. No significant alteration of total protein, immunoglobulins, and LDH concentrations by HD (HCO and MCO group) was observed. After 1 year, 37 of 60 patients were alive and 34 of them were off dialysis.

Conclusion: FLC elimination with MCO-HD is effective, technically easy, and less cost-intensive as compared with HCO-HD. Kidney function recovery in MM patients is achievable.

Keywords: acute kidney injury; dialysis; free light chains; medium cutoff hemodialysis; multiple myeloma.

Figure 1

Exemplary histology patient with Multiple Myeloma (MM) showing casts subtype free light chain (FLC) lambda. (A) overview 4× magnification PAS-staining, (B) PAS-staining 10 × magnification, (C) HE-staining 4 × magnification, (D) lambda – immunohistochemistry 10× magnification (E) kappa – immunohistochemistry 10 × magnification.

Figure 2

Relative reduction (%) of kappa and lambda FLC over all with (A) Medium Cut-Off Hemodialysis (MCO-HD) and (B) High Cut-off Hemodialysis (HCO-HD) as well as histologically confirmed CAST cases with (C) MCO-HD and (D) HCO-HD; Relative Reductions (RR) are calculated as pre-post dialysis serum concentration divided by pre-dialysis serum concentration *100 %; *p < 0.05, **p < 0.01 each.

Figure 3

Multiple dialyses with HCO membrane: overall alteration of (A) total protein (reduction, not significant) and (B) LDH (constant) before (= pre = white bar) and after (= post = striped bar) dialysis sessions.

Figure 4

Single dialysis with MCO membrane in different myeloma subtypes: relative reduction of FLC kappa is significantly higher in all subgroups compared to lambda (%); *p < 0.05, **p < 0.001 each kappa vs. lambda FLC reduction.

Figure 5

Single dialyses with MCO membrane: no significant alteration of (A) IgA, (B) IgG, (C) IgM, (D) total protein and (E) LDH before (= pre = white bar) and after (= post = striped bar) MCO-HD.

Figure 6

Single dialysis relative reduction (%) in MCO-HD (pre-post)/pre*100%; *p < 0.05, **p < 0.01 each.

Figure 7

Patient flow chart: 37/60 patients received dialysis sessions for less than two weeks, 17/60 for a period of three months, 3/60 up to 6 months and 3/60 continuously (three times per week) after starting dialysis. After one year, 37 of 60 patients reached follow-up and were alive, 34 were off dialysis.

Figure 8

(A): Creatinine trend after MCO-HD; pre = pre MCO-HD, d1 = 1 day, d14 = 14 days, m1 = 1 month, m3 = 3 months, y1 = 1 year after first MCO-HD *p < 0.05; **p < 0.001 each vs. pre-HD. (B): Creatinine trend after HCO-HD; pre = pre MCO-HD, d1 = 1 day, d14 = 14 days, m1 = 1 month, m3 = 3 months, y1 = 1 year after first HCO-HD *p < 0.05; **p < 0.001 each vs. pre-HD.