Abstract:

ABSTRACT  Objective: to report a case developed hyperendotoxemia after high cutoff hemodialysis for treatment of cast nephropathy due to multiple myeloma.  Methodology: A female aged 52 was admitted due to “progressive renal dysrenfunction, accompanied by increase of free light chain (FLC) λ levels in blood and urine” with a diagnosis as multiple myeloma and cast nephropathy. After initiation of chemotherapy based on VAD protocol, she received 6 times high cufoff hemodialysis (HCO 2100 dialyzer, HCO-HD) within 3 weeks. For the first 3 times HCO-HD, a conventional dialysate was used; while for the rest 3 times HCO-HD, an ultrapure dialysate was used. The levels of FLC λ and endotoxin in blood and dialysate were monitored before and after treatment.  Results: After 6 times HCO-HD and chemotherapy, her serum levels of FLCλ were decreased from 4689 to 493mg/L, with a tendency of declining serum creatinine. The endotoxin concentration in conventional dialysate was around 0.112~0.145EU/ml, with which HCO-HD resulted in a rise of the patient’s temperature even up to 38.5°C after treatment. A high concentration of endotoxin in blood (0.122EU/ml) was found in the 3rd time of HCO-HD. After changing to an ultrapure dialysate, which containing endotoxin 0.03EU/ml, no rise of the patient’s temperature and endotoxin level in blood was found after HCO-HD. During HCO-HD with a dialysate flow rate 500ml/min, the clearance rate, reduction ratio, and removal amount of FLC λ was 38.4ml/min, 71.0%~85.2%, and 9.06~18.02g, respectively; but during HCO-HD with dialysate flow rate 200ml/min, the removal efficacy of FLC λ was obviously lower than that of the former.  Conclusions: Combined with appropriate chemotherapy, high cutoff hemodialysis can effectively remove and reduce blood free light chain. Its efficacy is greatly affected by dialysate flow rate. We should note the endotoxemia and rise of temperature after treatment, which can be prevented by using ultrapure dialysate. 

Key words: cast nephropathy  , free light chain  , high cutoff hemodialysis  , endotoxin