Hermann Goehl

Serum Free‐Light Chain Removal by High Cutoff Hemodialysis: Optimizing Removal and Supportive Care

In multiple myeloma the predominant cause of irreversible renal failure is cast nephropathy, secondary to excess kappa or lambda serum free light chains (FLCs). These molecules are efficiently cleared by hemodialysis (HD) using the Gambro HCO 1100 dialyzer. To optimize the removal of FLCs by this dialyzer we have studied the effect of dialyzers in series, dialyzer change, and hemodiafiltration in 14 patients with multiple myeloma and renal failure. The clearance rates of both kappa FLCs and lambda FLCs were significantly increased on two dialyzers from 19 (7.3-34)-15.3 (9-28) mL/min to 47 (17-79)-35.5 (20-57) mL/min, respectively. Clearance rates of both FLCs decreased over the course of the dialysis sessions (both P < 0.001). Changing the dialyzer during a HD session increased lambda FLC clearance rates (22.5 [6-41] to 37.6 [9-52] mL/min; P < 0.001) and decreased kappa FLC clearance rates (39.6 [9-72] to 19 [8-59] mL/min; P < 0.003). Ultrafiltration during HD increased the clearance rates of kappa FLCs (R 0.52, P < 0.01) but not lambda FLCs (R -0.25; P < 0.076). Hemodiafiltration increased the clearance rates of both kappa (19 [SD 6.8] to 32 [SD 9.8] mL/min) and lambda FLCs (15 [SD 7.8] to 20 [SD 7.7] mL/min). Albumin replacement requirements for 8 h of HD increased from 12 g for a single dialyzer to 45 g for two dialyzers in series (P < 0.001). Different protocols are required to optimize the removal of kappa and lambda FLCs in patients with myeloma and renal failure.

Beta2-microglobulin removal and plasma albumin levels with high cut-off hemodialysis.

Purpose. β2-microglobulin (β2MG) is pivotal to the pathogenesis of dialysis-related amyloidosis. We compared the effects of high cut-off hemodialysis (HCO-HD) with those of standard high-flux hemodialysis (HF-HD) regarding the concentration and clearance of β2MG and albumin. Design. We enrolled ten patients with acute renal failure in a double-blind, cross-over, randomized controlled trial. Procedures Each patient received four hours of HCO-HD (estimated in vivo cutoff 50–60 kDa) and four hours of HF-HD (estimated in vivo cutoff 15–20 kDa) in random order. Statistical methods and outcome measures: As data lacked normal distribution, we used non-parametric statistical analysis. Plasma and dialysate concentrations of β2MG and albumin were measured at baseline and after four hours of each study treatment. Main findings. We found significantly greater diffusive β2MG clearances for HCO-HD compared to HF-HD (at the start: 71.8 ml/min vs. 5.1 ml/min; P=0.008 and at the end: 68.8 ml/min vs. 5.7 ml/min; P=0.008). We found a reduction in plasma β2MG concentrations of -31.6% during HCO-HD compared to an increase by 25.7% during HF-HD; P=0.008. At baseline (HCO-HD: 26.0 g/L vs. HF-HD: 26.5 g/L), and at the end of both treatments, plasma albumin concentrations were comparable (HCO-HD: 25.5 g/L vs. HF-HD: 26.5 g/L; P=0.25). During HCO-HD, albumin clearance was 1.9 ml/min at the start and decreased significantly to 0.8 ml/min at the end; P=0.008. HF-HD had an albumin clearance of 0.01 ml/min. Conclusions. HCO-HD was more effective in decreasing plasma β2MG concentrations than standard HF-HD and did not reduce plasma albumin levels. Further studies of HCO-HD in the treatment of dialysis-related β2MG accumulation appear warranted. (ClinicalTrials.gov number, NCT00333593 [ClinicalTrials.gov]) (Int J Artif Organs 2007; 30: 385–92)

Contents Vol. 37, 2014

189 Selected Abstracts from the 32nd International Vicenza Course on Hemodialysis and Peritoneal Dialysis Vicenza, June 10–13, 2014 (available online only)

Contents Vol. 28, 2009

293 27th Annual Meeting of the International Society of Blood Purification (ISBP) September 17–19, 2009, Stockholm, Sweden Guest Editors: Olof Heimbürger; Bengt Lindholm; Peter Stenvinkel (Stockholm) 377 Acknowledgement to Reviewers 379 Author Index Vol. 28, 2009 381 Subject Index Vol. 28, 2009