Saudi Journal of Kidney Diseases and Transplantation

: 2020  |  Volume : 31  |  Issue : 6  |  Page : 1445--1447

Favorable kidney recovery by extracorporeal light chain removal and anti-myeloma treatments in patients with newly diagnosed multiple myeloma and acute renal failure

Giorgio Silvestrini1, Paola Tatangelo1, Laura Scaramucci2, Germana Sfara2, Francesco Bondanini1, Pasquale Niscola2, Paolo de Fabritiis2, Roberto Palumbo1,  
1 Nephrology Unit, Saint Eugenio Hospital, Rome, Italy
2 Hematology Unit and Laboratory Medicine Unit, Saint Eugenio Hospital, Rome, Italy

Correspondence Address:
Pasquale Niscola
Hematology Unit and Laboratory Medicine Unit, Saint Eugenio Hospital, Rome

How to cite this article:
Silvestrini G, Tatangelo P, Scaramucci L, Sfara G, Bondanini F, Niscola P, de Fabritiis P, Palumbo R. Favorable kidney recovery by extracorporeal light chain removal and anti-myeloma treatments in patients with newly diagnosed multiple myeloma and acute renal failure.Saudi J Kidney Dis Transpl 2020;31:1445-1447

How to cite this URL:
Silvestrini G, Tatangelo P, Scaramucci L, Sfara G, Bondanini F, Niscola P, de Fabritiis P, Palumbo R. Favorable kidney recovery by extracorporeal light chain removal and anti-myeloma treatments in patients with newly diagnosed multiple myeloma and acute renal failure. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Jun 17 ];31:1445-1447
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Full Text

To the Editor,

Renal involvement is the principal cause of morbidity for patients with multiple myeloma (MM). Acute kidney injury (AKI) is a frequent accompaniment of MM, which results in significant short-term and long-term morbidity as well as mortality which requires complex clinical management.[1],[2] In MM, severe AKI (requiring dialysis) is predominantly due to paraprotein-mediated nephrotoxicity, typically secondary to cast nephropathy (CN) induced by intratubular obstruction from precipitation of monoclonal serum-free light chains (sFLC) as well as direct tubular toxicities exerted by these endogenous proteins via stimulation of nuclear factor (NF)-KB inflammatory pathways.[1] AKI complicating MM represents a medical urgency requiring a prompt and immediate intervention in order to avoid the rapid progression of the renal insults to ire-versible kidney damages. Current mainstays of CN treatment are early removal of the precipitating factors, such as nephrotoxic drugs, acidosis, and dehydration, together with rapid reduction of sFLC levels.[1],[2],[3],[4] In addition, the proteasome inhibitor bortezomib has been found to significantly improve the response rates in MM due to its ability to rapidly reduce sFLC levels and now represents the backbone of bortezomib-based regimens highly effective to allow dialysis independence and rapid renal recovery in MM patients complicated by AKI.[56]

As an adjunct to anti-myeloma treatment, several new extracorporeal techniques have emerged as further means to reduce sFLC concentrations in the treatment of CN.[7],[8] Despite these awareness and advances in our understanding of the pathogenesis of these hemato-nephrological pathological processes as well as the need for prompt and medically complex and dedicated approaches, there is a general lack of guidelines about standardized treatment approaches to achieve improved patient outcomes.[3],[6],[9] Although a close collaboration between hematologists and nephro-logists with integrated clinical interventional plans is desirable, often, only a mere consulting role is provided. Our group now have such an integrated plan and the experiences are ongoing.[9] In the past, some attempts to remove sFLC by extracorporeal techniques were made without relevant advantage using plasma exchange and coupled plasma filtration adsorption.[10] Then, the focus was on the use of hemodialysis (HD) membranes with high cutoff (HCO) with encouraging results in some cases but never definitive.[4],[7],[8],[10] The data of two European multi-centric randomized controlled trials, with different design, undertaken to verify the effectiveness of intervention regimens based on the use of HCO membranes in a larger population, have recently been published.[7],[8] The results of the two studies are different and are difficult to compare for the different design characteristics; the EuLITE[7] study did not show significant differences in the two groups, while the MYRE study showed a better renal recovery in the group treated with HCO dialysis at six months but not at three months.[8] Here, we report our real-life experience on nine AKI-complicated newly diagnosed MM (NDMM) patients admitted in a large primary care hospital. Baseline patient characteristics are shown in [Table 1]. All NDMM patients were in advanced disease stages; all of them received a bortezomib-based regimen in association with a prompt sFLC removal by extracorporeal techniques [Table 2].[3],[4],[10] The median time to the start of dialytic therapy from AKI presentation and the dialysis treatment duration were of four (1–20) and 13 (5–19) days, respectively. After nine HD sessions performed in 13 days, 8/9 (89%) patients achieved the renal recovery, having allowed an sFLC removal higher than 60% compared to baseline concentrations. From a hematological point of view, a complete remission, a very good partial remission, a partial remission, and a stable disease were observed in two, one, five, and one patients, respectively. With a median follow-up of 12 (2–12) months, eight (89%) patients are still alive. The overall survival was of 12 (2–12) months. We used two adsorption-based techniques to achieve a reduction in sFLC by extracorporeal therapy: HD-PMMA and HFR-SUPRA.[4],[7],[8] In our experience, we achieved favorable clinical results even in NDMM patients with poor prognostic features at the onset. Our findings, along with other center experiences,[2],[3],[4],[10] should stimulate future clinical and epidemiological researches as well as the development and selection of the best extracorporeal techniques to be used in this difficult clinical setting. This is essential to achieve the optimal outcome for these complex patients at high risk of severe clinical complications and reduced survival. Finally, our experience leads us to affirm that MM, a disease with complex pathology with multi-organ damages especially for those with renal failure, should be managed by multidiscip-linary teams with fully integrated collaboration of hematologists and nephrologists[9] for the best outcome of the patients.{Table 1}{Table 2}

Conflict of Interest: None declared.


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