Plasma-Exchange for Cast Nephropathy: A Randomized Controlled Trial


KD Jhaveri

Study Acronym:


Hypothesis: Plasma exchange or high flux dialyzers improve recovery of renal function in patients with cast nephropathy

Introduction: Prior studies have looked at the question of using plasma exchange in myeloma patients with cast nephropathy. The largest previous RCT did not use biopsies to assure that they were treating cast nephropathy and the outcome was equivocal. Also, no studies have been done in the modern era of better chemotherapy agents

Design: Randomized controlled trial 

Arm 1: Standard chemotherapy only 

Arm 2: Standard chemotherapy + TPE 

Arm 3: Standard chemotherapy + high flux dilalysis

Outcome Measures: Independence of HD at 3 months. Change in GFR

Secondary Outcome Measures: Efficiency of plasma exchange in respect to reduced sFLC levels. Duration of HD to renal recovery. Hospital days. Death/Mortality. 

Study Population: Patients with BIOPSY proven cast nephropathy, dialysis dependent renal failure and de novo multiple myeloma 

Inclusion Criteria: Age >= 18 years Dialysis dependent acute renal failure, fulfills diagnostic criteria for the diagnosis of symptomatic de novo multiple myeloma, abnormal serum FLC ratio and a sFLC concentration > 500 mg/L --- MOST IMPORTANT ---kidney biopsy proven (cast nephropathy)

Exclusion Criteria: CKD IV, V at baseline Prior history of MM on chemotherapy Other biopsy findings( LCDD, amyloidosis, cryo. etc) Cannot tolerate HD due to cardiac status or hemodynamics Hematologic contraindications to TPE