Introduction:
Renal failure in multiple myeloma is a frequent complication and has a significant impact on overall survival. Severe degree of renal failure and dialysis dependency are associated with poor outcomes despite adequate chemotherapy. The role of plasmapheresis is still undefined in the era of bortezomib-based anti-myeloma therapies, and therefore, this study was undertaken.
The aim of the present study was to examine the renal and overall patient survival at one year in patients with multiple myeloma and dialysis-requiring renal failure, who were managed with plasma exchange in addition to cyclophosphamide, bortezomib and dexamethasone (VCD) therapy. The primary outcome studied was to determine the proportion of patients still requiring renal replacement therapies at one year, after the institution of plasma exchange (PE). Secondary outcomes studied were: death, re-hospitalization, and serum creatinine at one year, in this cohort of patients.
Methods:
This is a single-centre, retrospective, observational study of multiple myeloma treated between January 2022 to August 2023, at a tertiary care public sector hospital. It was a retrospective study based on hospital records. Multiple myeloma was diagnosed on the basis of International Myeloma Working Group Diagnostic Criteria for Multiple Myeloma criteria. PE was carried out if serum involved FLC > 1500 mg/L, or if renal biopsy revealed cast nephropathy, at a dose of 40 ml/kg/session over 5-7 sessions.
Results:
A total of 36 patients underwent PE along with VCD therapy in the study period, of whom 26 (72%) were males and 10 (28%) were females, median age of 56 (50-61) years, median serum creatinine at presentation was 7.5 (6.5-8.5) mg/dl at presentation. The median serum calcium was 9.1 mg/dl (8.3-10.1), and majority of the study subjects had kappa chain restriction (24/36). A total of 18 (50%) were dialysis independent at one year follow-up, of whom 8 had renal recovery at discharge from hospital, 10 others had renal recovery over the next three months, and median serum creatinine at 1 year settled to 4.2 mg/dl (3.6-6.2). A total of 8 patients required readmission and three patients died (8.3%) during the one-year follow-up. All these were for infections with four having tunnelled dialysis catheter-related bloodstream infections (2 died), two urinary tract infections, one cellulitis and one case of lower respiratory tract infection (died).
Conclusions:
Plasma exchange in contemporary settings with VCD chemotherapy, was associated with 50% renal survival and 91% overall patient survival at one year, which appears to be better than published survival rates from other myeloma cohorts with renal impairment, indicating that there is a possible role of mechanical removal of paraproteins, even in triple-drug myeloma therapy-era.
References
1.Hutchison CA, Heyne N, Airia P, et al. Immunoglobulin free light chain levels and recovery from myeloma kidney on treatment with chemotherapy and high cut-off haemodialysis. Nephrol Dial Transplant 2012.
2.Hutchison CA, Cockwell P, Stringer S, et al. Earlyreduction of serum-free light chains associates withrenal recovery in myeloma kidney. J Am Soc Nephrol.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.