Endotoxemia after high cutoff hemodialysis for treatment of patient with multiple myeloma can be prevented by using ultrapure dialysate: A case report

Abstract

To report endotoxemia presented in a case with multiple myeloma (MM) treated by high cutoff hemodialysis (HCO-HD) being prevented by using ultrapure dialysate. A female inpatient with MM received six times HCO-HD (HCO 2100 dialyzer) within 3 weeks after initiation of a chemotherapy based on vincristine+epirubicin+dexamethasone protocol. Conventional dialysate was used in the first three times and then changed to ultrapure dialysate due to elevation of body temperature after HCO-HD. Free light chains (FLC) and endotoxin levels in blood and dialysate were monitored. After six times HCO-HD, her serum FLC λ decreased from 4689 mg/L to 492.7 mg/L, with a trend of decline of serum creatinine. The clearance, reduction ratio, and removal amount of FLC λ was 38.4 mL/min, 71.0-85.2%, and 9.06-18.02 g, respectively, in the setting of dialysate flow rate 500 mL/min, while in the setting of dialysate flow rate 200 mL/min, the removal efficacy of FLC λ was lower than the former. A rise of body temperature up to 38.5°C after treatment and endotoxemia (endotoxin levels 0.122 EU/mL) was found when using conventional dialysate (endotoxin levels 0.112-0.145 EU/mL), but not seen after changing to ultrapure dialysate. Combined with appropriate chemotherapy, HCO-HD can effectively remove and reduce blood FLC. Attention should be paid to the endotoxemia and the rise of temperature after treatment when conventional dialysate is used, which can be prevented by using ultrapure dialysate.

Assessment of the association between increasing membrane pore size and endotoxin permeability using a novel experimental dialysis simulation set-up

“…If the use of larger pore membranes would result in a substantial transmembrane transport of bacterial degradation products in settings with poor water quality, the positive effects of this type of membranes on inflammation could potentially be completely annihilated by the added inflammatory burden induced by these translocated contaminants. A case-study by Gong et al reported a risk for endotoxemia when using an HCO membrane in combination with conventional dialysis fluid (0.112–0.141 EU/ml) [ 43 ]. However these results rely on a single measurement and as reviewed by Wong et al caution should be taken when measuring endotoxin levels in blood using the LAL assay as its sensitivity and specificity for biological samples is poor [ 44 ].…”

Medium Cut-Off Membranes - Closer to the Natural Kidney Removal Function

“…The increase in the pore sizes of HCO membranes translates into an increase in both the convective and diffusive permeability, thus allowing for the removal of molecules, such as mediators of sepsis/inflammation ( 18 ), or the removal of nephro-toxic light chains of immunoglobulins ( 19 ). However, the albumin loss with this membrane is substantial, from approximately 9 to 23 g/treatment ( 20 , 21 ), and it is not indicated for use in chronic dialysis but instead is recommended mainly for acute applications ( 22 ).…”

Cytokine Removal with High Cut-Off Membrane: Review of Literature

“…At the end, 3 case reports [15,16,17], 3 studies on animals [18,19,20], 11 in-vitro/ex-vivo studies [13,21,22,23,24,25,26,27,28,29,30,] and 6 randomized clinical trials/observational studies [14,31,32,33,34,35] fulfilled optimum criteria. The main results deriving from this pool constitute this review.…”