Acute kidney injury predicts all-cause mortality in patients with cancer

Global burden of anticancer drug-induced acute kidney injury and tubulointerstitial nephritis from 1967 to 2023

This study aims to figure out the worldwide prevalence of anticancer therapy-associated acute kidney injury (AKI) and tubulointerstitial nephritis (TIN) and the relative risk of each cancer drug. We conducted an analysis of VigiBase, the World Health Organization pharmacovigilance database, 1967-2023 via disproportionate Bayesian reporting method. We further categorized the anticancer drugs into four groups: cytotoxic therapy, hormone therapy, immunotherapy, and targeted therapy. Reporting odds ratio (ROR) and information component (IC) compares observed and expected values to investigate the associations of each category of anticancer drugs with AKI and TIN. We identified 32,722 and 2056 reports (male, n = 17,829 and 1,293) of anticancer therapy-associated AKI and TIN, respectively, among 4,592,036 reports of all-drug caused AKI and TIN. There has been a significant increase in reports since 2010, primarily due to increased reports of targeted therapy and immunotherapy. Immunotherapy exhibited a significant association with both AKI (ROR: 8.92; IC0.25: 3.06) and TIN (21.74; 4.24), followed by cytotoxic therapy (7.14; 2.68), targeted therapy (5.83; 2.40), and hormone therapy (2.59; 1.24) for AKI, and by cytotoxic therapy (2.60; 1.21) and targeted therapy (1.54; 0.61) for TIN. AKI and TIN were more prevalent among individuals under 45 years of age, with a female preponderance for AKI and males for TIN. These events were reported in close temporal relationship after initiation of the respective drug (16.53 days for AKI and 27.97 days for TIN), and exhibited a high fatality rate, with 23.6% for AKI and 16.3% for TIN. These findings underscore that kidney-related adverse drug reactions are of prognostic significance and strategies to mitigate such side effects are required to optimize anticancer therapy.

Incidence and risk factors of acute kidney injury in patients with malignant tumors: a systematic review and meta-analysis

BACKGROUND

There are significant differences in the incidence and risk factors of tumor patients, and there is no relevant statistical data. Therefore, this study aims to clarify the incidence and risk factors of acute kidney injury (AKI) in malignant tumor patients and compare critically ill patients with non-critically ill patients.

METHODS

Relevant literature on the occurrence of AKI in malignant tumors was retrieved from databases. Two authors independently screened and evaluated the eligibility and quality of the literature and extracted the data. The Stata 12.0 software was used for meta-analysis.

RESULTS

A total of 3922 articles were initially retrieved, and 24 articles were finally included, 8 of which were about critically ill malignant tumor patients, and 16 were about malignant tumor patients. Among the 4107 patients included in the 8 studies on critically ill malignant tumors, 1932 developed AKI, with an incidence rate of 52% (95%CI 34-70%, I2 = 99%). The risk factors for AKI in critically ill malignant tumor patients were sepsis and hypovolemia, which were different from those in non-critically ill patients. Among the 292,874 patients included in the 16 studies on malignant tumors, 51,211 developed AKI, and the combined incidence rate was 24% (95%CI 17-30%, I2 = 100%). The risk factors for AKI in critical malignant tumor patients were sepsis and hypovolemia.

CONCLUSION

This meta-analysis shows that the incidence of AKI in critically ill malignant tumor patients is consistent with that in other critically ill patients, and independent risk factors are sepsis and hypovolemia. The incidence of AKI in malignant tumor patients is higher than that in other patients, and tumor is a risk factor for AKI. This study has been registered in INPLASY (INPLASY202320079),Registered February 18,2023.

Chapter 1: Evaluation of kidney function in patients undergoing anticancer drug therapy, from clinical practice guidelines for the management of kidney injury during anticancer drug therapy 2022

The prevalence of CKD may be higher in patients with cancer than in those without due to the addition of cancer-specific risk factors to those already present for CKD. In this review, we describe the evaluation of kidney function in patients undergoing anticancer drug therapy. When anticancer drug therapy is administered, kidney function is evaluated to (1) set the dose of renally excretable drugs, (2) detect kidney disease associated with the cancer and its treatment, and (3) obtain baseline values for long-term monitoring. Owing to some requirements for use in clinical practice, a GFR estimation method such as the Cockcroft-Gault, MDRD, CKD-EPI, and the Japanese Society of Nephrology's GFR estimation formula has been developed that is simple, inexpensive, and provides rapid results. However, an important clinical question is whether they can be used as a method of GFR evaluation in patients with cancer. When designing a drug dosing regimen in consideration of kidney function, it is important to make a comprehensive judgment, recognizing that there are limitations regardless of which estimation formula is used or if GFR is directly measured. Although CTCAEs are commonly used as criteria for evaluating kidney disease-related adverse events that occur during anticancer drug therapy, a specialized approach using KDIGO criteria or other criteria is required when nephrologists intervene in treatment. Each drug is associated with the different disorders related to the kidney. And various risk factors for kidney disease associated with each anticancer drug therapy.

Do outcomes for patients with hospital-acquired Acute Kidney Injury (H-AKI) vary across specialties in England?

BACKGROUND

Acute Kidney Injury (AKI) is a common and serious clinical syndrome. There is increasing recognition of heterogeneity in observed AKI across different clinical settings. In this analysis we have utilised a large national dataset to outline, for the first time, differences in burden of hospital acquired AKI (H-AKI) and mortality risk across different treatment specialities in the English National Health Service (NHS).

METHODS

A retrospective observational study was conducted using a large national dataset of patients who triggered a biochemical AKI alert in England during 2019. This dataset was enriched through linkage with NHS hospitals administrative and mortality data. Episodes of H-AKI were identified and attributed to the speciality of the supervising consultant during the hospitalisation episode in which the H-AKI alert was generated. Associations between speciality and death in hospital or within 30 days of discharge (30-day mortality) was modelled using logistic regression, adjusting for patient age, sex, ethnicity, socioeconomic status, AKI severity, season and method of admission.

RESULTS

In total, 93,196 episodes of H-AKI were studied. The largest number of patients with H-AKI were observed under general medicine (21.9%), care of the elderly (18.9%) and general surgery (11.2%). Despite adjusting for differences in patient case-mix, 30-day mortality risk was consistently lower for patients in surgical specialities compared to general medicine, including general surgery (OR 0.65, 95% CI 0.61 to 0.7) and trauma and orthopaedics (OR 0.52, 95% CI 0.48 to 0.56). Mortality risk was highest in critical care (OR 1.78, 95% CI 1.56 to 2.03) and oncology (OR 1.74, CI 1.54 to 1.96).

CONCLUSIONS

Significant differences were identified in the burden of H-AKI and associated mortality risk for patients across different specialities in the English NHS. This work can help inform future service delivery and quality improvement activity for patients with AKI across the NHS.

Acute Kidney Injury after Multiple Cycles of Cisplatin Chemotherapy: A Nomogram for Risk Assessment

INTRODUCTION

Acute kidney injury (AKI) caused by cisplatin is common and has a higher incidence of multiple use, resulting in a poor short- and long-term prognosis for patients. There is currently no good premedication AKI risk assessment tool. The aim of this study was to establish an AKI risk assessment nomogram for patients with multiple cisplatin applications.

METHODS

This study was a retrospective analysis of patients who were treated with non-first-time cisplatin chemotherapy regimen at Changzhou Second People's Hospital affiliated to Nanjing Medical University from January 2016 to January 2022. All data from the development group were used to screen the impact factors of AKI via univariate and multivariate analyses. A nomogram was developed based on these impact factors and verified with verification group. The area under the curve (AUC) of receiver operating characteristic (ROC) curve, calibration curves, and decision curve analyses (DCAs) were used to evaluate the nomogram.

RESULTS

Among the 256 patients enrolled in 450 cycles of chemotherapy, 282 were in the development cohort (97 AKI), and 168 were in the validation cohort (61 AKI). Multivariate logistic regression revealed that age, hypertension, diabetes, serum cystatin C (sCysC), urinary kidney injury molecule-1 (uKim1), and a single dose of cisplatin were independently associated with AKI. The results showed that our model yielded satisfied diagnostic performance with an AUC value of 0.887 and 0.906 using the development group and on verification group. The calibration plots and DCA showed the superior clinical applicability of the nomogram. These results were verified in the validation cohort.

CONCLUSION

A nomogram combining functional (sCysC) and tubular (uKim1) injury biomarkers with conventional clinical factors might assess the risk of AKI after multiple cycles of cisplatin chemotherapy.

Urinary T cells are detected in patients with immune checkpoint inhibitor-associated immune nephritis that are clonotypically identical to kidney T cell infiltrates

Acute kidney injury (AKI) occurs in ~20% of patients receiving immune checkpoint inhibitor (ICI) therapy; however, only 2-5% will develop ICI-mediated immune nephritis. Conventional tests are nonspecific in diagnosing disease pathology and invasive procedures (i.e. kidney biopsy) may not be feasible. In other autoimmune renal diseases, urinary immune cells correlated with the pathology or were predictive of disease activity. Corresponding evidence and analysis are absent for ICI-mediated immune nephritis. We report the first investigation analyzing immune cell profiles of matched kidney biopsies and urine of patients with ICI-AKI. We demonstrated the presence of urinary T cells in patients with immune nephritis by flow cytometry analysis. Clonotype analysis of T cell receptor (TCR) sequences confirmed enrichment of kidney TCRs in urine. As ICI therapies become standard of care for more cancers, noninvasively assessing urinary immune cells of ICI therapy recipients can facilitate clinical management and an opportunity to tailor ICI-nephritis treatment.

Immune checkpoint inhibitors and kidney disease

PURPOSE OF REVIEW

Immune checkpoint inhibitors (ICIs) have changed the landscape of cancer treatment. However, use of ICIs can be limited by inflammatory toxicities referred to as immune-related adverse events (irAEs). ICI-associated acute kidney injury (ICI-associated AKI) affects 3-5% of ICI users.

RECENT FINDINGS

With the rapidly growing indication of ICI, knowledge of ICI-associated kidney toxicity has also expanded from case series to large multicentre cohort studies. In this review, we discuss the clinical features, risk factors, clinicopathological correlations and prognosis of ICI-associated AKI from the most recent rigorously conducted retrospective cohort studies. We also discuss recent advances in diagnostic biomarker investigation, treatment and the unique challenge faced in the kidney transplant population.

SUMMARY

With more comprehensive understanding of the clinical features and risk factors, ICI-associated AKI is commonly diagnosed clinically, especially given the inherent challenges performing a kidney biopsy in the cancer population; however, this highlights the urgent need for improved noninvasive diagnostic biomarkers to aid diagnosis and prognosis. Prospective studies are needed to better define the optimal treatment of ICI-associated AKI and to minimize the risk of graft loss in patients with kidney transplant who require ICIs.

Acute Kidney Injury in Critically Ill Patients with Cancer

Advances in cancer therapy have significantly improved overall patient survival; however, AKI remains a common complication in patients with cancer, occurring in anywhere from 11% to 22% of patients, depending on patient-related or cancer-specific factors. Critically ill patients with cancer as well as patients with certain malignancies (e.g., leukemias, lymphomas, multiple myeloma, and renal cell carcinoma) are at highest risk of developing AKI. AKI may be a consequence of the underlying malignancy itself or from the wide array of therapies used to treat it. Cancer-associated AKI can affect virtually every compartment of the nephron and can present as subclinical AKI or as overt acute tubular injury, tubulointerstitial nephritis, or thrombotic microangiopathy, among others. AKI can have major repercussions for patients with cancer, potentially jeopardizing further eligibility for therapy and leading to greater morbidity and mortality. This review highlights the epidemiology of AKI in critically ill patients with cancer, risk factors for AKI, and common pathologies associated with certain cancer therapies, as well as the management of AKI in different clinical scenarios. It highlights gaps in our knowledge of AKI in patients with cancer, including the lack of validated biomarkers, as well as evidence-based therapies to prevent AKI and its deleterious consequences.

Prediction model of acute kidney injury induced by cisplatin in older adults using a machine learning algorithm

Background

Early detection and prediction of cisplatin-induced acute kidney injury (Cis-AKI) are essential for the management of patients on chemotherapy with cisplatin. This study aimed to evaluate the performance of a prediction model for Cis-AKI.

Methods

Japanese patients, who received cisplatin as the first-line chemotherapy at Fujita Health University Hospital, were enrolled in the study. The main metrics for evaluating the machine learning model were the area under the curve (AUC), accuracy, precision, recall, and F-measure. In addition, the rank of contribution as a predictive factor of Cis-AKI was determined by machine learning.

Results

A total of 1,014 and 226 patients were assigned to the development and validation data groups, respectively. The current prediction model showed the highest performance in patients 65 years old and above (AUC: 0.78, accuracy: 0.77, precision: 0.38, recall: 0.70, F-measure: 0.49). The maximum daily cisplatin dose and serum albumin levels contributed the most to the prediction of Cis-AKI.

Conclusion

Our prediction model for Cis-AKI performed effectively in older patients.

Management of acute kidney injury in gastrointestinal tumor: An overview

Gastrointestinal tumors remain a global health problem. Acute kidney injury (AKI) is a common complication during the treatment of gastrointestinal tumors. AKI can cause a decrease in the remission rate and an increase in mortality. In this review, we analyzed the causes and risk factors for AKI in gastrointestinal tumor patients. The possible mechanisms of AKI were divided into three groups: pretreatment, intrafraction and post-treatment causes. Treatment and prevention measures were proposed according to various factors to provide guidance to clinicians and oncologists that can reduce the incidence of AKI and improve the quality of life and survival rate of gastrointestinal tumor patients.

Prognostic Implications of a Cumulative Renal Score Based on Both Serum Creatinine and Urine Output Criteria for Staging of Acute Kidney Injury: A Cohort Study

Purpose

Traditionally, the Kidney Disease: Improving Global Outcomes (KDIGO) stages acute kidney injury (AKI) into three stages based on the highest severity of increase in serum creatinine (SC) or urine output (UO) criteria. Clinically, however, the two criteria do not provide equivalent information. Thus, we aimed to develop a cumulative renal score (the sum of the highest KDIGO SC and UO severity stages) for staging of AKI, expanding the original three KDIGO stages to six stages. We hypothesized that the cumulative renal score would more accurately describe AKI severity and outcomes.

Patients and Methods

Critically ill adult patients were identified from the Multi-parameter Intelligent Monitoring in Intensive Care III Database. The primary outcome was hospital mortality. Logistic regression was used to explore the association between cumulative renal score and hospital mortality.

Results

A total of 17,404 critically ill adult patients were enrolled. Patients with higher cumulative renal scores had greater hospital mortality than patients with lower cumulative renal scores (score 0, 7.6%; score 1, 9.3%; score 2, 12.5%; score 3, 18.9%; score 4, 27.1%; score 5, 34.7%; score 6, 46.8%, p < 0.001). After adjustment for significant covariates, relative to cumulative renal score 0, cumulative renal scores 2–6 were associated with increased hospital mortality. Within the traditional KDIGO stage 2 AKI, when compared with cumulative renal score 2, cumulative renal score 4 had increased hospital mortality. Within the traditional KDIGO stage 3 AKI, when compared with cumulative renal score 3, cumulative renal score 6 had increased hospital mortality.

Conclusion

Our study demonstrates that the KDIGO SC and UO criteria have a cumulative effect on AKI severity staging. The cumulative renal score improves the traditional KDIGO AKI staging by applying the two sets of criteria sequentially and provides more insight into the relationship between AKI and outcomes.

Clinical Significance of Acute Kidney Injury in Lung Cancer Patients

Purpose

Acute kidney injury (AKI) in cancer patients is associated with increased morbidity and mortality. The incidence of AKI in lung cancer seems to be relatively higher compared with other solid organ malignancies, although its impact on patient outcomes remains unclear.

Materials and Methods

The patients newly diagnosed with lung cancer from 2004 to 2013 were enrolled in this retrospective cohort study. The patients were categorized according to the presence and severity of AKI. We compared all-cause mortality and long-term renal outcome according to AKI stage.

Results

A total of 3,202 patients were included in the final analysis. AKI occurred in 1,783 (55.7%) patients during the follow-up period, with the majority having mild AKI stage 1 (75.8%). During the follow-up of 2.6±2.2 years, total 1,251 patients (53.7%) were died and 5-year survival rate was 46.9%. We found that both AKI development and severity were independent risk factors for all-cause mortality in lung cancer patients, even after adjustment for lung cancer-specific variables including the stage or pathological type. In addition, patients suffered from more severe AKI tend to encounter de novo chronic kidney disease development, worsening kidney function, and end-stage kidney disease progression.

Conclusion

In this study, more than half of the lung cancer patients experienced AKI during their diagnosis and treatment period. Moreover, AKI occurrence and more advanced AKI were associated with a higher mortality risk and adverse kidney outcomes.

Triage and Prognostication of Cancer Patients Admitted to the Intensive Care Unit

Cancer remains a leading cause of morbidity and mortality. Advances in cancer screening, early detection, targeted therapies, and supportive care have led to improvements in outcomes and quality of life. The rapid increase in novel cancer therapies can cause life-threatening adverse events. The need for intensive care unit (ICU) care is projected to increase. Until 2 decades ago, cancer diagnosis often precluded ICU admission. Recently, substantial cancer survival has been achieved; therefore, ICU denial is not recommended. ICU resources are limited and expensive; hence, appropriate utilization is needed. This review focuses on triage and prognosis in critically ill cancer patients requiring ICU admission.

Acute kidney injury after nephron sparing surgery and microwave ablation: focus on incidence, survival impact and prediction

Purpose: To compare acute kidney injury (AKI) incidence between nephron sparing surgery (NSS) and microwave ablation (MWA) for T1a RCC patients, reveal the effect of AKI on survival prognosis, construct AKI nomogram and use Law of Total Probability for survival probability (SP) prediction.Materials and methods: Patients were studied retrospectively after NSS (n = 1267) or MWA (n = 210) from January 1, 2011 to June 30, 2017. Using one to one Propensity Score Matching (PSM), 158 pairs of patients were identified for the cohort study. AKI incidence, risk factors and impact on survival outcomes were analyzed using Chi-square test, logistic and cox regression analysis. AKI risk and SP were predicted by nomogram and Law of Total Probability. The performance of the nomogram was assessed with respect to its discrimination, calibration, and clinical usefulness.Results: AKI occurred more commonly in NSS (27.85%) cohort, when compared to MWA (17.72%) cohort (p = 0.032), but treatment modality was not independently predictive of AKI occurrence (odds ratio [OR]: 0.598; 95% confidence interval [CI]: 0.282-1.265; p = 0.178). The 5-yr overall survival (OS) was lower in AKI patients (73.5%) compared with non-AKI patients (94.8%; p < 0.001). AKI was an independent risk factor for all-cause mortality in RCC patients (hazard ratio [HR]: 2.820; 95% confidence interval [CI]: 1.110-7.165; p = 0.029). Predictors for both NSS- and MWA-related AKI included tumor diameter, baseline eGFR and CCI score. RENAL score and tumor blood supply can predict AKI after NSS and MWA, respectively. The AKI normograms demonstrated good discrimination, with AUCs >0.86, excellent calibration and net benefits at the decision curve analysis with probabilities ≥5%. SP predicted by Law of Total Probability was comparable to actual OS.Conclusion: AKI was an early indicator for poor overall survival in RCC patients. It can be predicted by several oncological parameters. Nomogram and Law of Total Probability can accurately predict AKI risk and SP.

Acute kidney injury predicts all-cause mortality in patients with cancer

Background

Acute kidney injury (AKI) is a critical issue in cancer patients because it is not only a morbid complication but also able to interrupt timely diagnostic evaluation or planned optimal treatment. However, the impact of AKI on overall mortality in cancer patients remains unclear.

Methods

We conducted a retrospective cohort study of 67 986 cancer patients, from 2004 to 2013 to evaluate the relationship between AKI and all‐cause mortality. We used KDIGO AKI definition and grading system.

Results

During 3.9 ± 3.1 years of follow‐up, 33.8% of the patients experienced AKI at least once. Among AKI events, stage 1, 2, and 3 was 71.0%, 13.8%, and 15.1%, respectively. AKI incidence was highest in hematologic malignancies, followed by urinary tract cancer, and hepatocellular carcinoma. Male sex, older age, underlying diabetes and hypertension, lower serum albumin and plasma hemoglobin, more frequent radio‐contrast exposure, entrance of clinical trials, and receiving chemotherapy were associated with AKI occurrence. AKI development was an independent risk factor for elevated mortality in cancer patients with dose‐responsive manner (Stage 1, hazard ratio [HR] 1.183, 95% confidence interval [CI] 1.145‐1.221, P < 0.001; Stage 2, HR 1.710, 95% CI 1.629‐1.796; Stage 3, HR 2.000, 95% CI 1.910‐2.095; No AKI, reference group) even after adjustment. This tendency was reproduced in various cancer types except thyroid cancer and in various treatment modalities, however, not shown in patients with baseline renal dysfunction.

Conclusion

AKI was an independent risk factor for all‐cause mortality in overall cancer patients with dose‐responsive manner.