Department of Medicine, Renal Section, Boston Medical Center, Boston, MA, USA.
Nephrology and Hypertension Institute, Samson Assuta University Hospital Ashdod, Ashdod, Israel.
Nephrol Dial Transplant. 2022 Jun 23;37(7):1281-1288. doi: 10.1093/ndt/gfab189.
Acute kidney injury (AKI) is a common complication after high-dose melphalan and autologous stem cell transplantation (HDM/SCT) in patients with light chain (AL) amyloidosis. However, its incidence, predictors and outcomes are not well known.
This observational study included 223 patients with AL amyloidosis who underwent HDM/SCT. AKI was defined as an increase in serum creatinine to ≥1.5 times the baseline occurring within the first 30 days of HDM/SCT.
The median age was 58 years (range: 30-77). Kidney and cardiac involvement were present in 86.1% and 56.8%, respectively. The median estimated glomerular filtration rate (eGFR) was 83.5 mL/min/1.73 m2 (range: 9-213) and proteinuria was 2899 mg/day (range: 0-19 966). AKI occurred in 29.1% of patients. Dialysis was initiated in 15 patients (6.7%) and of these 12 (80%) were able to discontinue dialysis. Most of the episodes of AKI occurred within the first 2 weeks; with a median follow-up of 4.5 years (range: 0.1-16.5), AKI was associated with increased overall mortality [hazard rato (HR) = 4.53, 95% confidence interval (CI) 2-10.23]. The 10-year overall survival was 87.1% without AKI, versus 56.9% with AKI. AKI was also associated with an increased risk for end-stage kidney disease (ESKD) (HR = 4.6, 95% CI 1.44-14.38). The risk of developing ESKD at 10 years was 18.9% with AKI, versus 8.1% without AKI. Several risk factors were found and using multivariate logistic regression, a prediction model was developed that included three readily available variables: eGFR <60 mL/min/1.73 m2, interventricular septal thickness in diastole >12 mm and albumin <3 g/dL. This model was able to predict AKI development with an area under the curve of 0.8.
AKI is common in the post-HDM/SCT period and it leads to increased risk for ESKD and death. Our prediction model is an easily deployable tool in clinical settings as part of the discussion with patients who are being prepared for HDM/SCT.
急性肾损伤（AKI）是轻链（AL）淀粉样变性患者接受大剂量马法兰和自体干细胞移植（HDM/SCT）后的常见并发症。然而，其发病率、预测因素和结果尚不清楚。
本观察性研究纳入了 223 例接受 HDM/SCT 的 AL 淀粉样变性患者。AKI 的定义为 HDM/SCT 后 30 天内血清肌酐升高至基线值的 1.5 倍以上。
中位年龄为 58 岁（范围：30-77 岁）。肾脏和心脏受累分别为 86.1%和 56.8%。中位估算肾小球滤过率（eGFR）为 83.5 mL/min/1.73 m2（范围：9-213），蛋白尿为 2899 mg/天（范围：0-19966）。29.1%的患者发生 AKI。15 例（6.7%）患者开始透析，其中 12 例（80%）能够停止透析。大多数 AKI 发作发生在第 2 周内；中位随访 4.5 年（范围：0.1-16.5），AKI 与全因死亡率增加相关[风险比（HR）=4.53，95%置信区间（CI）2-10.23]。无 AKI 患者的 10 年总生存率为 87.1%，而 AKI 患者为 56.9%。AKI 也与终末期肾病（ESKD）的风险增加相关（HR=4.6，95%CI 1.44-14.38）。10 年时 AKI 患者发展为 ESKD 的风险为 18.9%，无 AKI 患者为 8.1%。发现了几个危险因素，使用多变量逻辑回归，建立了一个包括三个易于获得的变量的预测模型：eGFR <60 mL/min/1.73 m2、舒张期室间隔厚度>12 mm 和白蛋白<3 g/dL。该模型能够以 0.8 的曲线下面积预测 AKI 发生。
AKI 在 HDM/SCT 后很常见，可导致 ESKD 和死亡风险增加。我们的预测模型是一种在临床环境中易于部署的工具，可作为与准备接受 HDM/SCT 的患者讨论的一部分。
