An Unprecedented Case of Autologous Stem-Cell Transplant in a Patient with Multiple Myeloma with ESKD on Peritoneal Dialysis

Introduction: Since 2011, when bundled payments changed to equal pay for peritoneal dialysis (PD) and hemodialysis (HD), home PD rates have nearly doubled. Rise in PD utilization has had no significant effect on patient mortality or morbidity. Still little is known about how PD impacts other care aspects, such as stem cell transplant. Autologous stem cell transplants (AutoSCT) in dialysis dependent patients are rare.Given the lack of studies with PD in SCT, patients are often advised to temporarily switch to HD with a central venous catheter (CVC) peri-transplant to avoid peritonitis risks. However, this recommendation is unsubstantiated and may increase serious infection risks like bacteremia. Literature search yields only one other reported case of AutoSCT in a PD patient in Spain. We present a successful AutoSCT in a PD patient without major dialysis-related issues in the US. Case Description: A 68-year-old man with advancing kidney disease started PD. One month later, he was diagnosed with IgG-Kappa Multiple Myeloma (MM) based on an elevated protein gap and anemia refractory to epoetin. Bone marrow biopsy confirmed Stage III MM. After 5 chemotherapy cycles with a combination of daratumumab, lenalidomide, and dexamethasone, he was admitted for Melphalan AutoSCT. He received standard antibacterial, antifungal, and antiviral prophylaxis with Levaquin, Fluconazole, and Acyclovir. Routine PD exit site care per ISPD guidelines was maintained. Adequate ultrafiltration and clearance were achieved throughout the hospital course. Complications included pancytopenia, hematuria, hemorrhoidal bleeding, mucositis, atrial fibrillation and COVID-19. Despite neutropenia, no PD-related infections occurred. He was discharged on day 13 post-AutoSCT and completed outpatient chemotherapy. MM remains in remission on PD 2 years post-AutoSCT. Discussion: To our knowledge this is the first successful reported case of AutoSCT in a PD patient without major dialysis-related complications in the US. With routine exit site care and SCT antimicrobials, PD appears safe for those undergoing AutoSCT obliviating the need for CVC insertion. A paradigm shift is needed for PD due to the increasing interest in home dialysis and patient preferences for renal replacement therapy. Further studies are needed to understand the risks and outcomes of patients on HD vs. PD receiving AutoSCT.