The following criteria are suggested before considering HCO-HD in patients with AKI due to cast nephropathy:
1. Chemo-sensitive regime; bortezomib is frequently employed
2. High serum FLC levels (>500mg/l; usually much higher)
3. Low levels of interstitial fibrosis & tubular dropout on biopsy (i.e. evidence of salvageable kidneys)
A randomized controlled trial, led by Dr. Hutchinson, in the UK is currently on-going (Eulite Trial) which will compare conventional high flux HD with HCO-HD in patients receiving chemotherapy (bortezomib or thalidomide plus dexamethasone). HCO-HD certainly appears to be more efficient than plasma exchange at reducing FLC levels but at this point, its precise role in the management of cast nephropathy is unclear. We await the Eulite trial to hopefully clarify the potential benefit of HCO dialysis in this situation.