Hospices Civils de Lyon, Department of Nephrology, Edouard Herriot Hospital, Lyon, France.
Lyon 1 Claude Bernard University, Villeurbanne, France.
Am J Nephrol. 2017;46(5):355-363. doi: 10.1159/000481461. Epub 2017 Oct 10.
In patients with cast nephropathy and acute kidney injury (AKI) requiring dialysis, the reduction of serum free light chains (FLC) using chemotherapy and intensive hemodialysis (IHD) with a high cut-off filter may improve renal and patient outcomes. We evaluated the effectiveness of a combination of chemotherapy and IHD with an adsorbent polymethylmethacrylate membrane (IHD-PMMA) on renal recovery and survival.
A single-center retrospective cohort-study was conducted. Between 2007 and 2014, patients with dialysis-dependent acute cast nephropathy treated with chemotherapy and IHD-PMMA were included. Patients had six 6-h hemodialysis sessions a week, until predialysis serum FLC fell below 200 mg/L, for a maximum of 3 weeks. Primary outcomes were renal recovery, defined as dialysis independence, and survival.
Seventeen patients were included, all with stage 3 AKI. All received chemotherapy, mostly based on bortezomib and steroids (88%). Twelve patients (71%) achieved renal recovery, usually within 60 days (92%). At 3 months, the overall hematological response rate was 57%; hematological response was maintained for at least 2 years in 86% of responders. At 6, 12, and 24 months, 76, 75, and 62% of patients were alive, respectively. Higher reduction in involved FLC by day 12 (p = 0.022) and day 21 (p = 0.003) was associated with renal recovery. Patients with FLC reduction rate >50% by day 21 experienced a lower mortality (hazard ratio 0.10, 95% CI 0.02-0.63).
In patients with dialysis-dependent myeloma cast nephropathy, early FLC removal by IHD-PMMA combined with chemotherapy was associated with high rates of renal recovery and survival.
在需要透析的铸型肾病伴急性肾损伤（AKI）患者中，使用化疗和高截止滤器的强化血液透析（IHD）降低血清游离轻链（FLC）可能改善肾脏和患者的预后。我们评估了化疗联合吸附型聚甲基丙烯酸甲酯膜（IHD-PMMA）在肾脏恢复和生存方面的疗效。
进行了一项单中心回顾性队列研究。在 2007 年至 2014 年间，纳入了接受化疗和 IHD-PMMA 治疗的依赖透析的急性铸型肾病患者。患者每周接受 6 次 6 小时血液透析，直到预透析血清 FLC 降至 200mg/L 以下，最长 3 周。主要结局是肾脏恢复，定义为透析依赖，以及生存。
共纳入 17 例患者，均为 3 期 AKI。所有患者均接受化疗，大多数基于硼替佐米和类固醇（88%）。12 例（71%）患者实现了肾脏恢复，通常在 60 天内（92%）。3 个月时，总体血液学缓解率为 57%；缓解者中 86%的缓解至少持续 2 年。6、12 和 24 个月时，患者存活率分别为 76%、75%和 62%。第 12 天（p=0.022）和第 21 天（p=0.003）的 FLC 降低与肾脏恢复相关。第 21 天 FLC 降低率>50%的患者死亡率较低（危险比 0.10，95%CI 0.02-0.63）。
在依赖透析的骨髓瘤铸型肾病患者中，IHD-PMMA 联合化疗早期清除 FLC 与高肾脏恢复率和生存率相关。
