bs_bs_banner

Therapeutic Apheresis and Dialysis 2014; 18(3):317–319 doi: 10.1111/1744-9987.12216,12187 © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis

Letters to the Editor

A Case of Neuromyelitis Optica Spectrum Disorder With Early Successful Induction of Double Filtration Plasmapheresis

score for the right leg was 2/10 and that for the left leg was 7/10. Deep tendon reflexes showed asthenia of the bilateral knee phenomena and the ankle jerk. The Babinski reflex was right (+), left (−). No bladder or rectal disorder was present. The patient’s score on the Expanded Disability Status scale (EDSS) was 8.0 points. Examination of the cerebrospinal fluid was normal. There were no abnormal findings on brain MRI. However, there was a high-signal region on spinal cord MRI at the C4-Th7 level (Fig. 1). Based on clinical manifestations and image findings, methylprednisolone pulse therapy (500 mg, for 3 days) was administered from the first day after hospitalization. Thereafter, we administered 50 mg prednisolone (PSL) for 7 days. On the 5th hospital day, because of continued left lower limb paresis, development of bladder/rectal disorder and left Babinski reflex, double-filtration plasmapheresis (DFPP) was started for a total of 14 times, with a throughput of 5 L (due to physique of the patient) of 5% albumin solution. We chose DFPP to avoid fresh frozen plasma, and thought that he did not need plasma exchange for early induction. The patient displayed serum AQP-4 antibody-positive results throughout the course, and presented with NMO spectrum disorders, with a confirmed diagnosis (1). After 14 days of

Dear Editor, CASE The patient was a 46-year-old man. His chief complaint was weakness of the right leg and sensory disturbance. He had cold symptoms 10 days prior to hospitalization and he developed sensory disturbances of the right leg 1 week after the onset of cold symptoms. A spinal cord MRI scan showed a lesion from C6 to Th7; therefore, he was admitted on a suspicion of neuromyelitis optica. At admission, the patient had a height of 178 cm, a weight of 80 kg. Eyeballs showed eukinesia, and no particular visual field distortions. The scores for the legs in the Manual Muscle Test (MMT) were 1/5 for the left and 5/5 for the right. There were sensory disturbances in the abdominal region with a decreased score on the right being 7/10 and on the left 2/10. Sensory disturbance

C4 C3 C7

Th7

Th4

Th6

317

FIG. 1. Spinal cord MRI findings. The time-dependent change of the involved site. From the left, the extent of affected region on the first day is C4-Th7. It is expanded on the sixth day from C3 to Th6. It is then reduced to C7-Th4 on the 34th day (After 8 sessions of DFPP).

bs_bs_banner

318

Letters to the Editor

DFPP initiation, the bladder/rectal disorder and sensory disturbances were gradually improved. The patient was able to walk independently using crutches 70 days after hospitalization, and he was discharged. There are few case reports that used DFPP (2,3) for this disease. It is said that if the risk to fall into respiratory failure is serious, plasmapheresis should start (4). We judged that the effect of first steroidpulse therapy was poor, and substituted an apheresis regimen in combination with steroid-pulse therapy early, and our case succeeded.Therefore, it was essential to recognize and report the utility of DFPP in our patient. Further accumulation of data using more case studies is needed. Yukinao Sakai,1 Tomoyuki Otsuka,1 and Shuichi Tsuruoka2 1 Department of Nephrology, Nippon Medical School Musashikosugi Hospital, Kawasaki, and 2Division of Nephrology, Department of Internal Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan Email: [email protected] REFERENCES 1. Wingerchuk DM, Lennon VA, Lucchinetti CF, Pittock SJ, Weinshenker BG. The spectrum of neuromyelitis optica. Lancet Neurol 2007;6:805–15. 2. Yoshida H, Ando A, Sho K et al. Anti-aquaporin-4 antibodypositive optic neuritis treated with double-filtration plasmapheresis. J Ocul Pharmacol Ther 2010;26:381–5. 3. Munemoto M, Otaki Y, Kasama S et al. Therapeutic efficacy of double filtration plasmapheresis in patients with antiaquaporin-4 antibody-positive multiple sclerosis. J Clin Neurosci 2011;18:478–80. 4. Gwathmey K, Balogun RA, Burns T. Neurologic indications for therapeutic plasma exchange: 2011 update. J Clin Apher 2012;27:138–45.

Double-Filtration Plasmapheresis for Treatment of Acute Renal Failure in a Multiple Myeloma Patient Dear Editor, About one-half of multiple myeloma (MM) patients suffer from renal insufficiency, which is the second cause of death in this patient population (1). The common causes of renal insufficiency in MM patients are cast nephropathy, acute tubulointerstitial nephropathy, acute tubular necrosis (2),

Ther Apher Dial, Vol. 18, No. 3, 2014

and the standard treatment strategy remains plasma exchange (3,4). We treated a MM patient accompanied by acute renal failure (ARF). Therapeutic intervention was carried out by double-filtration plasmapheresis (DFPP). DFPP proved to be effective and led to rapid remission of the ARF. A 55-year-old Chinese woman suffered from fatigue and dizziness for about one and a half months. Upon admission, physical examination found pale appearance only. The laboratory findings were as follows: hemoglobin 7.2 g/dL and platelet count 76 × 103/μL. Erythrocyte sedimentation rate (ESR) was more than 130 mm/h. Serum calcium 3.56 mmol/L, blood urea nitrogen (BUN) 15.7 mmol/L, creatinine 253 μmol/L, uric acid 458 mmol/L, total protein 128.6 g/L, and serum globulin 102.4 g/L. Immunoglobulin G (IgG) was 9957 mg/dL and κ light chain was 2540 mg/dL. M-protein was detected in blood and urine. Bone marrow puncture found plasma cells were 16%, and 80% were immature. Bone marrow biopsy indicated plasma cell myeloma. The patient was diagnosed with IgG type MM and ARF. After drug treatment, serum calcium and uric acid became normal, but creatinine rose to 542 μmol/L on day 4 after admission. Plasma exchange was recommended, but there was not enough plasma. On day 5, DFPP procedure was carried out using a Plasauto-IQ machine (Asahi Medical Company, Tokyo, Japan). Processed plasma volume was 4000 mL. After DFPP, creatinine decreased from 594 to 453 μmol/L, serum globulin decreased from 103.6 to 52.7 g/L, IgG decreased from 10 086 to 4372 mg/dL, and κ light chain decreased from 2730 to 1950 mg/dL. On day 6, serum creatinine was 391 μmol/L. On day 7, the second DFPP was performed. As a result, serum creatinine decreased from 375 to 268 μmol/L, serum globulin decreased from 62.5 to 36.8 g/L, IgG decreased from 5680 to 2365 mg/dl, and κ light chain decreased from 1800 to 1250 mg/dL. On day 8, serum creatinine was 185 μmol/L. Then, she received chemotherapy (VD program: bortezomib [1–1.3 mg/m2, days 1, 4, 8, 11] plus dexamethasone [20 mg/day, days 1–14]) and serum creatinine decreased to 133 μmol/L. Over the next year, the disease course was smooth and serum creatinine levels were maintained from 117 to 136 μmol/L (Fig. 1). This MM patient suffered from ARF. Drug therapy corrected hypercalcemia and hyperuricemia, but renal function degraded, so we attempted DFPP. After the first DFPP, IgG decreased by almost 56.7% and κ light chain decreased by 28.6%. Renal function improved immediately. Serum creatinine decreased from 594 to 453 μmol/L and further to 391 μmol/L © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis