Journal of the American Society of Nephrology 1445 Removal of Plasma Porphyrins with High-Flux Hemodialysis in Porphyria Cutanea Tarda Associated with End-Stage Renal Disease1 Richard W. Carson,2 Earl J. Dunnigan, Thomas D. Karl E. Anderson DuBose, Jr., Douglas E. Goeger, and R.w. Carson, Division of Nephrology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX E.J. Dunnigan, Mid-Dakota Clinic, Bismark, ND ID. DuBose, Jr., Division of Nephrology, Department of Internal Medicine, University of Texas Health Sciences Center, Houston, TX D.E. Goeger, K.E. Anderson, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX (J. Am. Soc. Nephrol. 1992; 2:1445-1450) ABSTRACT Plasma porphyrin levels are markedly increased in patients with porphyria cutanea tarda (PCT) associ- ated with end-stage renal disease. Conventional he- modialysis (CHD) with lower blood flow rates (<250 mi/mm) and cuprophan or cellulose acetate mem- branes is ineffective in removing significant amounts of porphyrins in this condition. Changes in plasma porphyrin levels and porphyrin clearances during hemodlalysis with higher blood flow rates and more- permeable, high-efficiency cellulose acetate and high-flux polysulfone dialyzers were evaluated in a chronic hemodialysis patient with PCT and markedly elevated plasma porphyrins. The polysulfone mem- brane achieved significantly better fractional por- phyrin removal (P = 0.02) and porphyrin clearances (P< 0.0I)than did the high-efficiency cellulose ace- tate membrane. After conversion from maintenance CHD with a standard cellulose acetate dialyzer to a 4-wk period of high-flux hemodialysis (HFHD) with a polysulfone dialyzer, predialysis plasma porphyrins fell by 37%. After returning to CHD, plasma porphyrins returned to the higher prestudy levels. These obser- vatlons suggest that HFHD with more permeable I ReceIved July 9. 1991. Accepted October 21, 1991. 2 Correspondence to Dr. R. Carson, University of Texas Medical Branch. Division of Nephrology, Room 4.200 OJS, E-62, Galveston, TX 77550. 1046-6673/0209-1445$03.00/0 Journal of the AmerIcan Society of Nephrology CopyrIght C 1992 by the AmerIcan Society of Nephrology membranes and higher blood flow rates removes porphyrins more effectively than does CHD. HFHD may be a useful adjunct to other measures used in treating dialysis patients with PCT. Key Words: High-flux hemodialysis, porphyrins, porphyria cu- tanea tarda P orphynia cutanea tanda (PCT) occurs in some patients with end-stage renal disease and is as- sociated with increased levels of plasma porphyrins and cutaneous photosensitivity (1 .2). Recent reviews have described in detail the characteristic blistering. depigmented skin lesions, biochemical abnormali- ties, and pathogenesis of PCT. as well as other bul- bus dermatoses with little or no increase in plasma porphynins that are observed in dialysis patients (1- 5). Photosensitivity in PCT results from an accumu- lation of light-reactive porphyrins in plasma and skin. The excess porphyrins originate from the liver because of a deficiency of unoporphyrinogen decar- boxybase, an enzyme of the heme biosynthetic path- way that is subject to inactivation by iron. Reducing hepatic iron content by phlebotomy on other methods lowers plasma porphyrins and is associated with clinical improvement (6-8). Unfortunately, repeated phlebotomies may not be a realistic option for some hemodiabysis patients with PCT because of the ane- mia associated with chronic renal failure. Although erythropoietmn administration can mobilize hepatic iron stores and support phlebotomies in such pa- tients (9), a complete remission may require several months. Therefore, adjunctive therapies to remove porphynins from dialysis patients with PCT would be useful. Efforts to lower plasma porphyrin levels with he- modialysis with conventional cuprophan and ceblu- lose acetate membranes have been unsuccessful. The few published reports that examine porphyrin removal have shown no significant differences in prediabysis and postdialysis plasma porphyrin con- centrations. Although porphyrins have occasionally been detected in diabysate. the amounts removed are small and of little clinical significance (1 ,2, 1 0, 1 1). Dialysis with more-permeable membranes has somewhat greaten potential for removing porphyrins.