Hemodiafiltration with ultrafiltrate regeneration reduces free light chains without albumin loss in multiple myeloma patients

M Victoria Pendón-Ruiz de Mier, Raquel Ojeda, M Antonia Álvarez-Lara, Ana Navas, Corona Alonso, Javier Caballero-Villarraso, Pedro Aljama, Miguel A Álvarez, Sagrario Soriano, Mariano Rodríguez, Alejandro Martín-Malo, M Victoria Pendón-Ruiz de Mier, Raquel Ojeda, M Antonia Álvarez-Lara, Ana Navas, Corona Alonso, Javier Caballero-Villarraso, Pedro Aljama, Miguel A Álvarez, Sagrario Soriano, Mariano Rodríguez, Alejandro Martín-Malo

Abstract

Background: Acute kidney injury (AKI) occurs in 12-20% of multiple myeloma (MM) patients. Several studies have shown a reduction of free light chains (FLC) using hemodialysis with High-Cut-Off membranes. However, this technique entails albumin loss. Hemodiafiltration with ultrafiltrate regeneration is a technique that includes a process of adsorption. The aim of this study was to evaluate the effectiveness of hemodiafiltration with ultrafiltrate regeneration in reducing FLC levels without causing albumin loss.

Methods: This is an observational study (2012 to 2018) including nine patients with MM (5 kappa, 4 lambda) and AKI. All patients were treated with chemotherapy and hemodiafiltration with ultrafiltrate regeneration. Blood Samples (pre and post-dialysis) and ultrafiltrate were collected pre and post-resin at 5 min after initiation of the session and 5 min before the end of the procedure.

Results: The serum levels of kappa and lambda were reduced by a 57.6 ± 10% and 33.5 ± 25% respectively. Serum albumin concentration remained unchanged after the procedure. In the ultrafiltrate, the mean FLC reduction ratio shortly after initiation of the dialysis procedure was: 99.2 and 97.06% for kappa and lambda respectively, and only 0.7% for albumin; and at the end of the session the percent reduction was: 63.7 and 33.62% for kappa and lambda respectively, and 0.015% for albumin. Patients clinical outcome was: 33.3% recovered renal function, 22.2% died during the first year and 44.4% required maintenance dialysis.

Conclusions: Hemodiafiltration with ultrafiltrate regeneration reduces FLC levels without producing a significant loss of albumin; and, FLC removal is maintained throughout the session. Therefore, hemodiafiltration with ultrafiltrate regeneration may be considered an effective adjunctive therapy in patients with MM.

Keywords: Acute kidney failure; Adsorption; Albumin loss; Dialysis; Free light chains; Myeloma.

Conflict of interest statement

MAA reports grants, personal fees and non-financial support from Celgene, personal fees from Amgen, personal fees from Janssen, outside the submitted work; and AMM reports personal fees from Vifor pharma, personal fees from Medtronic, outside the submitted work. Rest of authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Diagram of hemodiafiltration with regeneration of the ultrafiltrate by adsorption in resin. 1: High permeability filter (Convection). 2: Resin cartridge (Adsorption). 3: Low permeability filter (Diffusion). Protocol of samples extraction: The blood samples were obtained from the arterial port of the central venous catheter before (pre) (a) and immediately after (post) (b) the completion of the dialysis procedure (a total of 2 samples). Ultrafiltrate, pre (c) and post (d) resin, samples were taken at 5 min after starting the session (2 samples) and 5 min before the end of the session (2 samples). A total of six samples were collected during the procedure: 2 arterial blood samples and 4 samples of ultrafiltrate.

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