Ifosfamide-induced Fanconi syndrome and desmopressin-responsive nephrogenic diabetes insipidus

A case of ifosfamide-induced acute kidney injury, Fanconi syndrome, and nephrogenic diabetes insipidus

Ifosfamide, a cytotoxic antineoplastic drug, can induce rare complications of Fanconi syndrome and nephrogenic diabetes insipidus (DI). Ifosfamide-induced Fanconi syndrome tends to occur in patients with certain risk factors including young age, high cumulative ifosfamide dose, and coadministration of cisplatin. Nephrogenic DI causes polyuria from impaired urinary concentrating ability due to resistance to arginine vasopressin (AVP) at the collecting duct. These complications are serious and potentially fatal. Here, we describe a case of a middle-aged man without risk factors who was admitted for the management of acute kidney injury and electrolyte derangements after his fourth cycle of chemotherapy including ifosfamide for synovial sarcoma. He was found to have hypokalemia, hypophosphatemia, renal glycosuria, and aminoaciduria, likely from Fanconi syndrome, which were managed by electrolyte replacement therapy. In addition, polyuria and hypernatremia were considered due to nephrogenic DI, which partially responded to desmopressin treatment. This case highlights the importance of the routine electrolytes monitoring after ifosfamide treatment.

Ifosfamide-induced nephrotoxicity in oncological patients

INTRODUCTION

Ifosfamide is an alkylating chemotherapeutic agent used in the treatment of various neoplasms. Its main adverse effects include renal damage.

AREAS COVERED

A comprehensive review was conducted, including 100 articles from the Scielo, Scopus, and EMBASE databases. Ifosfamide-induced nephrotoxicity is attributed to its toxic metabolites, such as acrolein and chloroacetaldehyde, which cause mitochondrial damage and oxidative stress in renal tubular cells. Literature review found a 29-year average age with no gender predominance and a mortality of 13%. Currently, no fully effective strategy exists for preventing ifosfamide-induced nephrotoxicity; however, hydration, forced diuresis, and other interventions are employed to limit renal damage. Long-term renal function monitoring is essential for patients treated with ifosfamide.

EXPERT OPINION

Ifosfamide remains essential in neoplasm treatment, but nephrotoxicity, often compounded by coadministered drugs, poses diagnostic challenges. Preventive strategies are lacking, necessitating further research. Identifying timely risk factors can mitigate renal damage, and a multidisciplinary approach manages established nephrotoxicity. Emerging therapies may reduce ifosfamide induced nephrotoxicity.

Ifosfamide‐induced acute kidney injury in a patient with leiomyosarcoma: A case report

Background

Leiomyosarcoma (LMS) is an aggressive soft tissue sarcoma that is derived from smooth muscles. Ifosfamide is in use for advanced metastatic LMS.

Case

A‐44‐years old woman with a chief complaint of pain in the epigastric area, itching, coughing, nausea, and vomiting was referred to the emergency department. Her medical history was LMS. She had taken Ifosfamide and mesna in her last chemotherapy. Seventy percent of her liver and her left kidney were removed 4 years ago to prevent the progress of the disease. Because of the increase in the level of creatinine and urea in the initial laboratory report, a Shaldon catheter was inserted for the patient, and she was under emergency dialysis for 3 h. In addition, during the six‐day hospitalization period, dialysis was done two times. Finally, the patient was discharged with improved clinical tests accompanied by a twice‐weekly dialysis order.

Conclusion

Ifosfamide is metabolized into chloroacetaldehyde, which can cause acute kidney injury. Recovery from acute kidney injury may not always be perfect and can lead to some degree of chronic kidney disease. Opposite to hemorrhagic cystitis, mesna is not effective in preventing ifosfamide's nephrotoxicity and N‐acetylcysteine may be effective in the prevention of this nephrotoxicity.

Ifosfamide-induced nephrogenic diabetes insipidus responsive to supraphysiologic doses of intravenous desmopressin

Nephrogenic diabetes insipidus (DI) refers to the reduction in the ability of the kidney to concentrate urine, which can be caused by partial or complete resistance at the site of action of anti-diuretic hormone (ADH) in the collecting tubules. Ifosfamide-induced nephrogenic DI typically occurs concomitantly in patients who have other signs of tubular toxicity consistent with Fanconi syndrome including glucosuria, aminoaciduria, and hypophosphatemia. We present a case of a 36-year-old female with recurrent synovial cell sarcoma of the pleural membranes, treated with ifosfamide-based chemotherapy, who was admitted to the hospital for the management of polyuria, hypotension, as well as electrolyte derangements including hypokalemia, hypophosphatemia and non-anion gap metabolic acidosis, 1 week after receiving a cumulative ifosfamide dose of 7.5 g/m². Nephrogenic DI was indicated by polyuria as well as a urine osmolality to plasma osmolality ratio of less than 1.5 following a trial of intravenous desmopressin, but the patient’s acute kidney injury on presentation precluded the early employment of thiazides and non-steroidal anti-inflammatory drugs (NSAIDs). Instead, the patient’s polyuria and urine osmolality improved only after the administration of repetitive supraphysiologic doses of intravenous desmopressin. Our case reiterates that patients with non-hereditary nephrogenic DI may have partial rather than complete resistance to ADH and highlights that desmopressin may be considered in patients with ifosfamide-induced nephrogenic DI to prevent severe volume depletion, especially in patients who have persistent symptomatic polyuria despite maintaining a careful fluid balance and pharmacological therapy with NSAIDs and diuretics, or if the patient’s clinical condition precludes the use of these strategies.

Bendamustine-induced nephrogenic diabetes insipidus - A case report

INTRODUCTION

In patients with relapsed or refractory lymphoma, high-dose chemoimmunotherapy with subsequent autologous hematopoietic cell transplantation (HCT) is a standard of care. Bendamustine, an alkylating agent, is used in the BeEAM (bendamustine, etoposide, cytarabine, melphalan) protocol for conditioning therapy before autologous HCT in patients with relapsed or refractory lymphoma who are eligible for transplant. There is no consensus regarding an optimal salvage regimen and the approach varies according to toxicity.

CASE REPORT

We present a case of partial nephrogenic diabetes insipidus after receiving bendamustine, as part of the BeEAM protocol.Management and outcome: The patient was managed with parenteral fluid administration and intranasal desmopressin before the condition resolved on its own.

DISCUSSION

We summarize published reports of bendamustine-induced diabetes insipidus.