Aggressive removal of circulating free light chains (FLC) by blood purification accompanied by chemotherapy is a promising approach for the treatment of acute renal failure due to myeloma cast nephropathy. Plasma exchange has been performed to remove serum FLC; in order to examine an alternative strategy we performed hemodiafiltration using protein-leaking dialyzers for the treatment of dialysis-dependent acute renal failure due to myeloma cast nephropathy. In the first case with κ-light chain cast nephropathy, the pre-treatment serum creatinine was 9.65 mg/dL, and the serum κ-FLC was 27 100 mg/L. Plasma exchange or hemodiafiltration was performed from Monday to Friday during the first several weeks. Chemotherapy was started with high-dose dexamethasone and then switched to bortezomib plus dexamethasone. The mean removal rates of κ-FLC were 45.8% (one plasma volume) and 66.9% (one-and-a-half plasma volumes) by plasma exchange. The removal rates of κ-FLC by hemodiafiltration (66.9%, FB210UHβ; 71.6%, PES210Dα; 75.2%, FXS220) were comparable to those by plasma exchange. In the second case with γ-light chain cast nephropathy, the pre-treatment serum creatinine was 4.14 mg/dL, and the serum γ-FLC was 4140 mg/L. The mean removal rates of γ-FLC were 60.2% (FXS140) and 64.2% (FB210UHβ) by hemodiafiltration. Both cases became dialysis-independent. The combination of an intense blood purification regimen and bortezomib plus dexamethasone therapy appears to be an efficient approach to renal recovery. Hemodiafiltration using protein-leaking dialyzers could become an alternative to plasma exchange as a method of removing FLC.
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