Adjunctive plasmapheresis for management of myeloma cast nephropathy-a case series
Lopez-Plaza I. Adjunctive plasmapheresis for management of myeloma cast nephropathy-a case series. J Clin Apher 2017; 32(2):113.
J Clin Apher
Purpose: Among patients diagnosed with multiple myeloma, about 50 % develop renal disease for which cast nephropathy accounts for 30-80%. Deposition of the free light chains in the kidney causes tubular obstruction, inflammation and ultimate interstitial fibrosis will lead to dialysis-dependence and associated shortened survival. Therefore, early diagnosis and treatment of cast nephropathy as adjuvant to anti-myeloma chemotherapy may assist in diminishing or avoiding all together myeloma associated kidney injury. Thus far, published literature has yielded inconclusive results regarding such recommendation. We report our experience of 7 multiple myeloma patients with acute kidney injury and biopsy proven cast nephropathy that received adjuvant plasmapheresis between 2013 and 2015. Methods: We identified patients that were diagnosed with multiple myeloma and underwent standard chemotherapy and plas-mapheresis as treatment for biopsy proven cast nephropathy between the years 2013 to 2015. Plasmapheresis procedures were performed following the recommendations by the ASFA Journal of Clinical Apheresis 2013 Special Issue-Clinical Applications of Therapeutic Apheresis: An Evidence Approach, 6th edition. Briefly, a total of 10-12 procedures were planned, each procedure consisting of a one plasma volume exchange, using 5% albumin as replacement fluid, complimented with thawed plasma when fibrinogen levels pre-procedure were less than 150 mg/dL. The following data was obtained by retrospective chart review: demographics, date of multiple myeloma diagnosis, start date of chemotherapy and type of chemotherapy, para-protein profile including light chains levels pre and post treatment, renal biopsy pathology, baseline creatinine, presence of underlying chronic kidney disease, initiation and recovery from dialysis, start date and number of plasmapheresis procedures, outcome including survival, adverse events associated with plasmapheresis and renal recovery. Results: Seven patient s were identified, all meeting inclusion criteria. Six out of seven patients required dialysis; two became dialysis independent within 35 days of starting initial interventions. One patient remained dialysis independent. This patient was the only patient with a Lambda light chain gammopathy, whom incidentally had light chain deposition disease. Mean reduction in plasma light chain was 79%. Six patients underwent hematopoietic progenitor cell transplant; 2 patients expired due to recurrent disease. All live patients continue on maintenance chemotherapy, two patients relapsed. No adverse events were observed in association with plasmapheresis. Only one patient did not complete the plasmapheresis cycle. Conclusion: In our case series 42% of patients with biopsy proven cast nephropathy recovered full renal function with plasma-pheresis as an adjunctive therapy. The survival of our cohort was 71%. Although the benefit of adjunctive plasmapheresis in biopsy proven myeloma cast nephropathy is not certain, in our experience, the addition of plasmapheresis is well tolerated and may offer a renal protective advantage.