Systemic light-chain amyloidosis, peritoneal dialysis, and transplantation: Lessons from a demanding yet successful journey

Kidney involvement in systemic light-chain amyloidosis (AL-SA) is associated with rapidly declining kidney function and increased mortality. The optimal kidney replacement therapy for AL-SA patients has not been ascertained. There is some suggestion that peritoneal dialysis (PD) may be safer than intermittent hemodialysis (iHD) for these patients. However, the clinical course of these patients can be rather complex and daunting, both for the patient and for the treating physicians. There is also a lack of data describing the associated challenges and outcomes, especially with respect to the use of chemotherapy, hematopoietic stem cell transplantation (HSCT), and kidney transplantation (KT) in patients with AL-SA who are on PD for end stage kidney disease (ESKD). We present the interesting case of a 41-year-old patient on PD for ESKD due to AL-SA, for which she underwent chemotherapy and HSCT. She ultimately was able to receive a successful KT. Through this case, we aim to highlight the complexities involved in the treatment journey of patients with AL-SA and kidney disease. We present evidence for greater hemodynamic stability with PD as compared to iHD and thus gentler ultrafiltration, information on anticancer agent dosing for PD, and finally offer hope for the feasibility of PD and KT to support a better quality of life for AL-SA patients with kidney disease.