Role of plasma exchange in the treatment of myeloma nephropathy: experience of one institution and systematic review.

Plasmapheresis is an efficient method of removing light chains from the circulation. Several studies have shown that it improves renal function in patients with multiple myeloma and renal impairment due to cast nephropathy. The degree of renal failure has been shown to be an important predictor of morbidity and mortality in myeloma. The use of plasmapheresis remains controversial, since it does not affect plasma cells and thus further production of light chains. In addition, existing evidence does not demonstrate a clear benefit from plasmapheresis in these patients. However, data, including some of the new targeted therapies for myeloma, are lacking. Herein, we present our institution's experience in the use of plasmapheresis in patients with myeloma and renal failure, and review the existing literature.

Acute myeloid leukemia following solid organ transplantation: case report and comprehensive review.

Organ transplant recipients are at an increased risk for subsequent malignancies including hematologic malignancies. The development of acute myeloid leukemia (AML) after solid organ transplantation is a rare but well-documented event. It is thought to be a consequence of immune dysregulation secondary to the use of immunosuppressive agents. Herein, we present the management of a liver transplantation recipient who presented with AML and comprehensively review the relevant literature. A 59-year-old male patient presented with fever and cough eight years after an orthotopic liver transplantation for cirrhosis and hepatocellular carcinoma. He received methylprednisolone and mycofenolate mofetil (MMF) followed by tacrolimus and rapamycin as immunosuppression. Upon admission to our hospital, his peripheral blood demonstrated 34% blasts and pancytopenia. A bone marrow biopsy confirmed the diagnosis of myelodysplastic syndrome (MDS) in transformation to AML. He was treated with induction chemotherapy and his sirolimus was continued but he expired four weeks after from refractory disease. No specific guidelines exist for the treatment of AML in solid organ transplant recipients. Treatment should be individualized and concurrent use of chemotherapeutic and immunosuppressive agents should be carefully balanced.

Refractory DKA as first presentation of acromegaly and a potential role for continuous venovenous hemofiltration in its successful management.

Diabetic ketoacidosis is rarely encountered in acromegaly. We present a unique patient with refractory diabetic ketoacidosis (DKA) as a first presentation of acromegaly. In addition to an insulin drip and intravenous fluids, our patient was managed with octreotide therapy. As he developed acute renal failure in the context of renal hypoperfusion, continuous venovenous hemofiltration (CVVH) was instituted. After only three days of therapy, the growth hormone (GH) level dropped circa fourfold and insulin growth factor 1 (IGF-1) level dropped ninefold. We postulate a hypothetical role of CVVH in removal of plasma GH and IGF-1, similar to the clearance of other medium size molecules such as brain natriuretic peptide and procalcitonin. If this is confirmed in future studies, CVVH may have therapeutic implications for the above category of patients.

Gitelman syndrome and pregnancy.

Gitelman syndrome (GS) is an autosomal-recessive condition characterized by hypokalemia, hypomagnesemia and hypocalciuria. Very little information is available in the literature to guide the management of pregnant patients with GS. We report a case of a 27-year-old woman with GS who became pregnant and despite persistent hypokalemia and hypomagnesemia during pregnancy and labor, had a successful maternal and fetal outcome.