Rousseau-Gagnon Mathieu, Agharazii Mohsen, De Serres Sacha A, Desmeules Simon
Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada; Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada.
PLoS One. 2015 Oct 14;10(10):e0140463. doi: 10.1371/journal.pone.0140463. eCollection 2015.
In cases of myeloma cast nephropathy in need of haemodialysis (HD), reduction of free light chains using HD with High-Cut-Off filters (HCO-HD), in combination with chemotherapy, may be associated with better renal recovery. The aim of the present study is to evaluate the effectiveness of haemodiafiltration (HDF) in reducing free light chain levels using a less expensive heat sterilized high-flux polyphenylene HF dialyzer (HF-HDF).
In a single-centre prospective cohort study, 327 dialysis sessions were performed using a 2.2 m2 heat sterilized high-flux polyphenylene HF dialyzer (Phylther HF22SD), a small (1.1m2) or large (2.1 m2) high-cut-off (HCO) dialyzer (HCOS and HCOL) in a cohort of 16 patients presenting with dialysis-dependent acute cast nephropathy and elevated free light chains (10 kappa, 6 lambda). The outcomes of the study were the mean reduction ratio (RR) of kappa and lambda, the proportion of treatments with an RR of at least 0.65, albumin loss and the description of patient outcomes. Statistical analysis was performed using linear and logistic regression through generalized estimating equation analysis so as to take into account repeated observation within subjects and adjust for session duration.
There were no significant differences in the estimated marginal mean of kappa RR, which were respectively 0.67, 0.69 and 0.70 with HCOL-HD, HCOS-HDF and HF-HDF (P = 0.950). The estimated marginal mean of the proportions of treatments with a kappa RR ≥0.65 were 68%, 63% and 71% with HCOL-HD, HCOS-HDF and HF-HDF, respectively (P = 0.913). The estimated marginal mean of lambda RR were higher with HCOL-HDF (0.78), compared to HCOL-HD and HF-HDF (0.62, and 0.61 respectively). The estimated marginal mean proportion of treatments with a lambda RR ≥0.65 were higher with HCOL-HDF (81%), compared to 57% in HF-HDF (P = 0.042). The median albumin loss were 7, 21 and 63 g/session with HF-HDF, HCOL-HD and HCOL-HDF respectively (P = 0.044). Among survivors, 9 out of 10 episodes of acute kidney injuries became dialysis-independent following a median time of renal replacement therapy of 40 days (range 7-181).
Therefore, in patients with acute dialysis-dependent myeloma cast nephropathy, in addition to chemotherapy, HDF with a heat sterilized high-flux polyphenylene HF dialyzer could offer an alternative to HCO dialysis for extracorporeal kappa reduction with lower albumin loss.
在需要进行血液透析（HD）的骨髓瘤管型肾病病例中，使用高通量滤器的血液透析（HCO-HD）联合化疗来降低游离轻链水平，可能与更好的肾脏恢复相关。本研究的目的是评估使用成本较低的热消毒高通量聚苯醚HF透析器进行血液透析滤过（HDF）（HF-HDF）降低游离轻链水平的有效性。
在一项单中心前瞻性队列研究中，对16例依赖透析的急性管型肾病且游离轻链升高（κ型10例，λ型6例）的患者，使用2.2平方米的热消毒高通量聚苯醚HF透析器（Phylther HF22SD）、小型（1.1平方米）或大型（2.1平方米）高通量（HCO）透析器（HCOS和HCOL）进行了327次透析治疗。研究结果包括κ和λ的平均降低率（RR）、RR至少为0.65的治疗比例、白蛋白丢失情况以及患者结局描述。通过广义估计方程分析进行线性和逻辑回归统计分析，以考虑受试者内的重复观察并对治疗时间进行校正。
κ降低率的估计边际均值在HCOL-HD、HCOS-HDF和HF-HDF组分别为0.67、0.69和0.70，差异无统计学意义（P = 0.950）。κ RR≥0.65的治疗比例的估计边际均值在HCOL-HD、HCOS-HDF和HF-HDF组分别为68%、63%和71%（P = 0.913）。与HCOL-HD和HF-HDF（分别为0.62和0.61）相比，HCOL-HDF组的λ降低率估计边际均值更高（0.78）。λ RR≥0.65的治疗比例的估计边际均值在HCOL-HDF组更高（81%），而HF-HDF组为57%（P = 0.042）。HF-HDF、HCOL-HD和HCOL-HDF组每次透析的白蛋白丢失中位数分别为7、21和63克（P = 0.044）。在幸存者中，10例急性肾损伤发作中有9例在中位肾脏替代治疗时间40天（范围7 - 181天）后不再依赖透析。
因此，对于依赖透析的急性骨髓瘤管型肾病患者，除化疗外，使用热消毒高通量聚苯醚HF透析器进行HDF可为体外降低κ轻链提供一种替代HCO透析的方法，且白蛋白丢失更低。
