Pharmacokinetic analysis of carboplatin in patients with cancer who are undergoing hemodialysis

Durvalumab plus carboplatin-etoposide treatment in a patient with small-cell lung cancer on hemodialysis: a case report and literature review

Little is known about the efficacy and safety of durvalumab plus carboplatin-etoposide treatment in patients with extensive-disease (ED) small-cell lung cancer (SCLC) on hemodialysis. Here, we present a case of a 67-year-old man with pleuroperitoneal communication on continuous ambulatory peritoneal dialysis who was diagnosed with ED-SCLC based on a cytological analysis of the peritoneal fluid. He was switched from peritoneal dialysis to hemodialysis and received durvalumab (1500 mg/body on day 1) plus carboplatin (area under the concentration-time curve = 5, 125 mg on day 1) and etoposide (50 mg/m2 on days 1 and 3) as first-line therapy. During the first cycle, grade 2 anemia, grade 3 neutropenia, and grade 3 upper gastrointestinal bleeding occurred; therefore, durvalumab and reduced doses of carboplatin and etoposide were administered. No other severe adverse events occurred, and a partial response was observed after four cycles. Our findings indicate that durvalumab plus carboplatin-etoposide treatment is safe and effective even in patients on hemodialysis.

Treatment of advanced ovarian cancer with carboplatin and paclitaxel in a patient undergoing hemodialysis: Case report and literature review

A 69-year-old woman under maintenance hemodialysis was diagnosed with advanced ovarian cancer. We treated the patient with combination chemotherapy using paclitaxel and carboplatin. She experienced grade 4 thrombopenia on day 8 of the third course. The area under the concentration versus time curve (AUC) of platinum was 3.5 mg/ml·min. The interval between chemotherapy and hemodialysis was shortened starting with the fourth course. The AUC of platinum was then found to be 1.8 mg/ml·min. After seven courses of chemotherapy, the patient's CA 125 serum level dropped from 1317 to 42.6 U/ml. Nevertheless, the patient presented with long periods of severe myelosuppression. In patients on hemodialysis receiving such chemotherapy, the AUC of each cycle should be closely monitored and the dialysis schedule should be adjusted as need to reduce the risk of bone marrow suppression.

Investigation of tolerability and quality of life for carboplatin-based chemotherapy in an elderly urothelial carcinoma patient undergoing hemodialysis: a case report

BACKGROUND

To our knowledge, no studies have evaluated the safety of carboplatin (CBDCA)-based chemotherapy in hemodialysis patients > 80 years-old. In addition, the impact of CBDCA-based chemotherapy on such elderly patients' quality of life (QOL) is unknown. We report a case of gemcitabine plus CBDCA chemotherapy treatment in an 81-year-old man with metastatic urothelial carcinoma undergoing hemodialysis.

CASE PRESENTATION

The optimal CBDCA dose and hemodialysis timing were determined by monitoring the measured area under the concentration-time curve (AUC) of CBDCA. This was used because the AUC of CBDCA is correlated with hematologic toxicities, especially nadir thrombocytopenia, and CBDCA is easily dialyzed during hemodialysis. In the first cycle, a 160 mg CBDCA dose, calculated using Calvert's formula (target-AUC: 5), was administered on day 1. Hemodialysis was performed for 3 h, starting 2 h after the end of the CBDCA infusion. The measured-AUC was 5.96 mg/mL min in the first cycle, after which the patient developed grade 3/4 hematologic toxicities. Thus, in the second cycle, the CBDCA dose was reduced to 135 mg and the time interval between CBDCA infusion and hemodialysis was shortened to 1 h, according to the results of a pharmacokinetic study performed using parameters from the first cycle. The measured-AUC in the second cycle was 4.97 mg/mL min, and hematologic toxic effects decreased to grade 2. Stable disease according to the Response Evaluation Criteria in Solid Tumors was demonstrated after the second and third cycles. QOL scores determined using a short-form questionnaire (SF-36) after 2 cycles were not significantly lower than pretreatment values.

CONCLUSIONS

CBDCA-based chemotherapy is clinically acceptable in hemodialysis patients aged > 80 years, and this systemic chemotherapy can be a treatment option in such elderly patients undergoing hemodialysis. However, the measured-AUC should be monitored, as the actual AUC is unpredictable in hemodialysis patients. This is due to the influence of various factors that may be different for each patient, such as the patient's residual renal function and hemodialysis duration and conditions, especially in elderly patients, who have a higher risk of chemotherapy-induced neutropenia.

Clinical Pharmacodynamics: Principles of Drug Response and Alterations in Kidney Disease

Pharmacokinetics and pharmacodynamics follow the logic of cause and consequence. Receptor-mediated and reversible effects can be distinguished from direct and irreversible effects. Reversible effects are capacity-limited and saturable whereas irreversible effects are limited only by the number of viable targets. In the case of receptor-mediated and reversible effects a threshold and a ceiling concentration can be defined. Antimicrobial drugs with concentration-dependent action are distinguished from drugs with time-dependent action. Concentration-dependent effects are associated with a high ceiling concentration and the target is the high peak. Time-dependent effects are associated with a high threshold concentration and the target is the high trough. During kidney dysfunction, alterations of drug response are usually attributed to pharmacokinetic but rarely to pharmacodynamic changes. Dose adjustment calculations, therefore, tacitly presume that pharmacodynamic parameters remain unchanged while only pharmacokinetic parameters are altered in kidney failure. Kidney dysfunction influences the pharmacokinetic parameters of at least 50% of all essential drugs. Clinicians usually consider pharmacokinetics when kidney disease is found, but pharmacodynamics is as important. Alterations of pharmacodynamic parameters are conceivable but only rarely reported in kidney failure. Sometimes surprising dosing adjustments are needed when pharmacodynamic concepts are brought into the decision process of which dose to choose. Pharmacokinetics and pharmacodynamics should both be considered when any dosing regimen is determined.

Extension of the Calvert formula to patients with severe renal insufficiency

PURPOSE

The Calvert formula was derived from the study among patients with glomerular filtration rates (GFRs) of 33-135 ml/min, and it remains unclear whether the formula can be used to calculate optimal and safe dosages of carboplatin in patients with severe renal insufficiency. We evaluated the utility of this formula in patients with severe renal insufficiency.

METHODS

For pharmacokinetic analysis, we studied nine adult Japanese patients with advanced cancer who had an estimated GFR of lower than 30 ml/min/1.73 m(2), as calculated by the Japanese equation for estimating GFR, or who were receiving hemodialysis. The dose of carboplatin was calculated with the Calvert formula, in which GFR was measured by inulin clearance or was assumed to be 0 in patients requiring hemodialysis. Hemodialysis was started 23 h after the end of carboplatin infusion.

RESULTS

Although there was a significant correlation between the estimated and measured carboplatin clearance, the estimated clearance was consistently higher than the measured clearance [mean prediction error ± standard deviation = 41.0 ± 26.3 %] in all seven patients with renal insufficiency (GFR, median 21.4, range 7.8-31.4 ml/min) and in the two hemodialysis patients. Actual areas under the concentration-time curve (AUC) (mg/ml min) were 5.4, 5.7, 6.2, and 9.0 for the four patients with a target AUC (mg/ml min) of 5; 5.7, 6.2, and 7.1 for the three patients with a target AUC (mg/ml min) of 4; and 5.1 and 8.7 for the two hemodialysis patients with a target AUC (mg/ml min) of 5. The measured clearance of carboplatin ranged from 23.0 to 51.3 ml/min in the seven patients not receiving hemodialysis. The pre-hemodialysis carboplatin clearance in the hemodialysis patients was 20.5 and 11.1 ml/min, respectively.

CONCLUSION

For adult patients with severe renal insufficiency, the Calvert formula causes carboplatin overdosing by overestimating the carboplatin clearance.

Pharmacokinetics of Carboplatin in a One-Year-Old Anuric Boy Undergoing Hemodialysis and a Review of the Literature

There have been few reports of carboplatin-based chemotherapy for anuric infants. As we had a chance to treat a one-year-old anuric hepatoblastoma patient with carboplatin, we performed a pharmacokinetic analysis and examined the optimal treatment strategy. A one-year-old anuric boy under peritoneal dialysis was diagnosed with hepatoblastoma. Surgical resection was performed, and administration of carboplatin was scheduled postoperatively aiming at 5 mg·min/mL of the area under the curve from the time of dosing to the time of the last observation (AUC(0-t)). We set the initial dose at 50 mg, higher than that calculated by the Calvert formula (34 mg); the time from the end of carboplatin infusion to the initiation of hemodialysis at 2 h; and the hemodialysis duration at 24 h. The actual AUC0-t was 3.05 mg·min/mL because the elimination half-lives before and during hemodialysis were shorter than expected. The AUC(0-t) after the second dose (100 mg) and the third dose (80 mg) were 7.00 and 4.68 mg·min/mL, respectively. The Calvert formula is not suitable for hemodialysis patients because removal of platinum by hemodialysis is not taken into account. It appears that extrarenal clearance in anuric infants is different from that in adults. We obtained an optimal AUC(0-t) using a dose of 80 mg (200 mg/m(2)), setting the time from the end of carboplatin infusion to the initiation of hemodialysis at 2 h, and performing 8-h hemodialysis. Further accumulation of the pharmacokinetic data of carboplatin is necessary for anuric children.

Advanced thymic cancer treated with carboplatin and paclitaxel in a patient undergoing hemodialysis

A 53-year-old man with an asymptomatic anterior mediastinal tumor undergoing hemodialysis was referred to our institution. He was diagnosed with thymic basaloid carcinoma based on the findings of a chest tomography-guided biopsy and successfully treated with carboplatin (300 mg/m(2)/day) and paclitaxel (200 mg/m(2)/day) on day 1 for six three-week cycles. To our knowledge, this is the first report regarding the efficiency of a carboplatin dose-definition method based on the body surface area with paclitaxel in a hemodialysis patient. This report may therefore be useful for treating hemodialysis patients who are candidates for carboplatin and paclitaxel therapy.

Tumor lysis syndrome in a patient with merkel cell carcinoma and provoked pathologic sequence of acute kidney injury, reduced clearance of carboplatin and fatal pancytopenia

BACKGROUND

Merkel cell carcinoma (MCC) is a rare, highly malignant cancer of the skin primarily affecting the elderly, with a tendency for local recurrence and regional lymph node metastasis. It is very unusual for this kind of tumor to induce clinically apparent tumor lysis syndrome (TLS) which is a consequence of spontaneous cytolysis or massive tumor cell lysis, beginning a few hours after the initiation of treatment.

CASE REPORT

We report here on a patient with metastatic MCC, who developed TLS following combination chemotherapy with carboplatin and etoposide.

CONCLUSION

The evolving acute kidney injury (AKI) provoked a pathologic sequence of reduced renal clearance leading to protracted clearance of carboplatin and subsequent fatal pancytopenia. When AKI occurs in close association with the administration of carboplatin, the institution of rescue hemodialysis is recommended to decrease plasma carboplatin levels and avoid this lethal complication.