Plasmapheresis as a co-treatment in acute renal failure secondary to myeloma kidney
Plasmaféresis como tratamiento adyuvante en el fallo renal agudo secundario al riñón del mieloma
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Levy, V. Camarero Temiño, G. Torres Torres, B. Hijazi Prieto" "autores" => array:4 [ 0 => array:4 [ "Iniciales" => "F." "apellidos" => "Levy" "email" => array:1 [ 0 => "federicolevy@yahoo.com.ar" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "V." "apellidos" => "Camarero Temiño" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "G." "apellidos" => "Torres Torres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "B." "apellidos" => "Hijazi Prieto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Unidad de Plasmaféresis. Servicio de Nefrología, Complejo Asistencial de Burgos, Burgos, Burgos, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Plasmaféresis como tratamiento adyuvante en el fallo renal agudo secundario al riñón del mieloma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "19418078_f1_p283.jpg" "Alto" => 343 "Ancho" => 541 "Tamanyo" => 29787 ] ] ] ] "textoCompleto" => "<p class="elsevierStylePara">Dear Editor:</p><p class="elsevierStylePara">Acute renal failure is a relatively frequent complication in patients with multiple myelomas (MM). This complication is associated with a poor prognosis and shortened survival time.</p><p class="elsevierStylePara">There are many factors in its aetiology, including reduced volume, hypercalcaemia, tubulointerstitial nephritis and more rarely, hyperviscosity syndrome. However, the main cause of kidney damage is the excess of monoclonal production of light chains that cause obstruction on the tubular level; this is known as myeloma kidney.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">The main treatment for these patients is chemotherapy, which aims to reduce production of light chains. In those cases where there is renal failure secondary to intratubular deposits, haemodialysis and plasmapheresis constitute an adjuvant treatment option. The objective of these techniques is to eliminate the greater part of the light chains circulating in the plasma.</p><p class="elsevierStylePara">In the literature, evidence for the benefits of treatment with plasma exchange techniques is limited, although several studies do exist that show that plasmapheresis is more effective than haemodialysis.<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">We present a case of acute renal failure secondary to myeloma kidney, with a good response to plasmapheresis, which led to recovery of renal function.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical case</span></p><p class="elsevierStylePara">Female patient aged 59 years, with a history of hypertension and type-2 diabetes mellitus, diagnosed with monoclonal IgG gammopathy with progression subsequent to IgG lambda multiple myeloma. From the moment of diagnosis, various chemotherapy treatment schemes were administered, with no response. Six years after diagnosis, we were consulted for acute renal failure with conserved diuresis. The patient was in stage IIIB, with analysis showing Bence Jones proteinuria and plasma creatinine of 7mg/dl.</p><p class="elsevierStylePara">Replacement therapy with combined conventional haemodialysis and plasmapheresis was initiated on a schedule of three sessions per week for one month, and one session per week thereafter. Initially, a plasma exchange volume of 3L was used, which was later increased to 4Lwhen the patient changed to weekly sessions. The substitution liquid used was 5% albumin. Treatment resulted in a reduction in plasma creatinine of more than 50% and stable values were maintained, which allowed us to discontinue replacement therapy with haemodialysis.</p><p class="elsevierStylePara">Plasma levels of lambda light chains at the moment when treatment began were higher than 1,750mg/dl. With the start of adjuvant treatment, reductions of more than 60% were obtained in each plasmapheresis session. As we observe from figure 1, a rebound effect occurs between sessions, but the pre-plasmapheresis values are lower each time.</p><p class="elsevierStylePara">At present, the patient continues with chemotherapy with little response, and is awaiting evaluation for a bone marrow transplant. Meanwhile, she is continuing with adjuvant treatment with plasmapheresis without major complications and with a stable renal function.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">The evidence when evaluating the effectiveness of plasmapheresis in patients with acute renal failure secondary to myeloma kidney is still debateable. However, many studies show an improvement in renal function and thus demonstrate the beneficial role played by plasmapheresis as an adjuvant treatment.</p><p class="elsevierStylePara">There is still no consensus in the literature regarding the number of sessions, the interval or the treatment dose.</p><p class="elsevierStylePara">In our patient’s case, it was determined according to the clinical evolution and it is still being maintained, as we still hope for a response to the chemotherapy.</p><p class="elsevierStylePara">Given the recovery of renal function, despite the persistent production of light chains, we can say that plasmapheresis is a treatment option for acute renal failure secondary to myeloma kidney.</p><p class="elsevierStylePara"><a href="grande/19418078_f1_p283.jpg" class="elsevierStyleCrossRefs"><img src="19418078_f1_p283.jpg"></img></a></p><p class="elsevierStylePara">Figure 1. </p>" "pdfFichero" => "P-E-S-A194-EN.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "19418078_f1_p283.jpg" "Alto" => 343 "Ancho" => 541 "Tamanyo" => 29787 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Russell JA, Fitzharris BM, Corringham R, et al. Plasma exchange v peritoneal dialysis for removing Bence Jones protein. Br Med J 1978;2:1397. <a href="http://www.ncbi.nlm.nih.gov/pubmed/719420" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Clark AD, Sentí A, Soltar R. Renal failure and multiple myeloma: patogenesis and treatment of renal failure and managment of underlying myeloma. Blood Rev" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "1999;13:79-90." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Clark WF, Stewart AK, Rock GA, et al. Plasma exchange when myeloma presents as acute renal failure: a randomized, controlled trial [see comment] [summary for patients in Ann Intern Med 2005;143(11):I20; PMID: 16330784]. Ann Intern Med 2005;143:777-84." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Hutchison CA, Cockwell P, Reid S, et al. Efficient removal of immunoglobulin free light chains by hemodialysis for multiple myeloma: in vitro and in vivo studies. J Am Soc Nephrol 2007;18:886-95. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17229909" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Szczepiokkowski ZM, Bandarenko N, Kim HC, et al. Guidelines on the use of therapeutic apheresis in clinical practice¿ Evidence-based approach from the Clinical Applications Committee of the American Society for Apheresis. J Clin Apher 2007;22:106-75. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17394188" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Leung N, Gertz MA, Zeldenrust SR, et al. Improvement of cast nephropathy whit plasma exchange depends on the diagnosis and on reduction of serum free ligth chains. Kidney Int 2008;73:1282-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18385667" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000002900000003/v0_201502091629/X2013251409004728/v0_201502091629/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002900000003/v0_201502091629/X2013251409004728/v0_201502091629/en/P-E-S-A194-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251409004728?idApp=UINPBA000064" ]
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