NDT Advance Access originally published online on November 23, 2006
Nephrology Dialysis Transplantation 2007 22(4):1270-1271; doi:10.1093/ndt/gfl628
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Plasma exchange in the treatment of acute renal failure of myeloma
Email: eziomov{at}libero.itSir,
The article by Haubitz and Peest, ‘Myeloma—new approaches to combined nephrological–haematological management’ [1] addresses a very important issue in clinical practice. However, very little is said on the management of myeloma patients presenting with acute renal failure (ARF), particularly on the role of plasma exchange (PE) in this setting. PE has been used to reduce plasma concentrations of light chains in patients with renal insufficiency [2], and it has been recommended in the management of ARF in myeloma patients [3]. However, findings from a recent large, prospective, randomized trial of PE in the treatment of ARF in patients with newly diagnosed myeloma, failed to show any benefit [4]. We reviewed our single-centre experience over a 10-year period (January 1995–December 2005) on the effect of PE in 55 myeloma patients (31 men, 24 women: mean age 71 ± 11 years) presenting with ARF on either survival and rate of recovery of renal function. ARF was defined as a doubling of serum creatinine with respect to the basal level, over a 48 h period, and/or reduction of urine output <500 ml/24 h in spite of correction of hypovolaemia, hypercalcaemia and metabolic acidosis. Twenty-seven patients received 5–8 (median 6) PE treatments (3 on consecutive days and the others on alternate days) with 50 ml/kg body weight of 5% human albumin and saline as replacement fluid. Twenty-eight patients did not receive PE treatment and were considered as control group. VAD or dexamethasone were administered to all patients according to haematologist's prescription. Table 1 shows the baseline clinical and laboratory characteristics of the patients. No significant differences were observed between groups. Figure 1 shows Kaplan–Meier analysis for all-cause mortality (left panel), and renal death (need for dialysis) (right panel) in the two groups of patients. No significant effect of PE on either patients or renal survival was observed at 36 months. Twenty-three patients (42%) died. Causes of death were: sepsis 11%, pulmonary infection 34%, cachexia 22%, other causes 33%. Our data agree with those of Clark and Colleagues [4]. We acknowledge that our observations are neither prospective nor randomized, however, they are representative of a large and widespread clinical approach to this problem worldwide. Extension of follow-up to a 36-month period did not show any significant benefit of PE, not only on patient survival, but also on the need for haemodialysis treatment either in the short or long-term. For these reasons we agree that PE can no longer be routinely recommended [5].
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Conflict of interest statement. None declared.
Chair and Division of Nephrology
Spedali Civili and University of Brescia
Brescia
Italy
References
- Haubitz M and Peest D. (2006) Myeloma-new approaches to combined nephrological-haematological management. Nephrol Dial Transplant 21:582–590.
[Free Full Text] - El-Achkar TM, Sharfuddin AA, Dominguez J. (2005) Approach to acute renal failure with multiple myeloma: role of plasmapheresis. Ther Apher Dial 9:417–422.[CrossRef][Web of Science][Medline]
- Durie BG, Kyle RA, Belch A, et al. (2003) Myeloma management guidelines: a concsensus report from scientific advisors of the International Myeloma Foundation. Hematol J 379–398.
- Clark WF, Stewart AK, Rock GA, et al. (2005) Plasma exchange when myeloma presents as acute renal failure. Ann Intern Med 143:777–784.
[Abstract/Free Full Text] - Korbet SM and Schwartz MM. (2006) Multiple myeloma. J Am Soc Nephrol 17:2533–2545.
[Free Full Text]
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