Drug dosing in cancer patients with decreased kidney function: A practical approach

Severe Acute Kidney Injury in Hospitalized Cancer Patients: Epidemiology and Predictive Model of Renal Replacement Therapy and In-Hospital Mortality

BACKGROUND

Acute kidney injury (AKI) is a common complication among cancer patients, often leading to longer hospital stays, discontinuation of cancer treatment, and a poor prognosis. This study aims to provide insight into the incidence of severe AKI in this population and identify the risk factors associated with renal replacement therapy (RRT) and in-hospital mortality.

METHODS

This retrospective cohort study included 3201 patients with cancer and severe AKI admitted to a Comprehensive Cancer Center between January 1995 and July 2023. Severe AKI was defined according to the KDIGO guidelines as grade ≥ 2 AKI with nephrological in-hospital follow-up. Data were analyzed in two timelines: Period A (1995-2010) and Period B (2011-2023).

RESULTS

A total of 3201 patients (1% of all hospitalized cases) were included, with a mean age of 62.5 ± 17.2 years. Solid tumors represented 75% of all neoplasms, showing an increasing tendency, while hematological cancer decreased. Obstructive AKI declined, whereas the incidence of sepsis-associated, prerenal, and drug-induced AKI increased. Overall, 20% of patients required RRT, and 26.4% died during hospitalization. A predictive model for RRT (AUC 0.833 [95% CI 0.817-0.848]) identified sepsis and hematological cancer as risk factors and prerenal and obstructive AKI as protective factors. A similar model for overall in-hospital mortality (AUC 0.731 [95% CI 0.71-0.752]) revealed invasive mechanical ventilation (IMV), sepsis, and RRT as risk factors and obstructive AKI as a protective factor. The model for hemato-oncological patients' mortality (AUC 0.832 [95% CI 0.803-0.861]) included IMV, sepsis, hematopoietic stem cell transplantation, and drug-induced AKI. Mortality risk point score models were derived from these analyses.

CONCLUSIONS

This study addresses the demographic and clinical features of cancer patients with severe AKI. The development of predictive models for RRT and in-hospital mortality, along with risk point scores, may play a role in the management of this population.

Prior cancer history and suitability for kidney transplantation

Kidney transplantation is the optimal treatment for most patients with kidney failure. For patients with a prior history of treated cancers, listing and transplant eligibility decisions are complex. Patients and health professionals are obliged to consider the time-periods between cancer cure and transplantation, the risk of cancer recurrence under the influence of immunosuppression and anti-cancer treatment options if the disease recurs. Cancer recurrence is associated with a high mortality rate, thus potentially reduces the projected survival benefit of transplantation, and dampens the utility of scarce organs. In view of the uncertain risk of harms, clinicians may consider transplantation for candidates with prior cancer history only after an extended period of cancer-free interval, as the fear of disease recurrence and shortened life expectancy may outweigh the benefits of receiving a kidney transplant compared with dialysis. Over the past decade, the evolution of novel anti-cancer therapies coupled with improved understanding of cancer genomics have led to considerable improvement in cancer-free survival. It is therefore justifiable to make individualized transplant suitability decisions based the joint effects of cancer biology, available therapeutic options and prognostic covariates on clinical outcomes. In this review, we first summarized the cancer epidemiology in kidney transplant recipients. We then explored how the probability of cancer cure, risk of recurrence and outcomes in candidates with a prior cancer history may influence the decisions to transplant. Finally, the role of shared decision-making between health professionals and patients regarding the optimal management options, and considerations of patients' preferences and values are discussed.

Low-dose apatinib in subjects with renal impairment: A pharmacokinetics study

OBJECTIVE

In patients with renal impairment, we studied apatinib and its major metabolites (M1-1, M1-2, M1-6, and M9-2) for pharmacokinetics.

METHODS

Subjects with different renal functions were given a single oral dose of apatinib mesylate tablets of 250 mg. Pharmacokinetic samples were collected at 1 hour before dosing,0.25, 0.5, 1, 2, 3, 4, 6, 8, 24, 48, 72, and 96 h after dosing. The pharmacokinetic parameters of apatinib and its major metabolites were calculated by noncompartmental analysis.

RESULTS

Comparing PK parameters of the mild or moderate renal impairment group with the healthy group: the geometric mean ratios of maximum observed drug concentration (Cmax), the area under the plasma drug concentration-time curve from time 0 to the final quantifiable time (AUC0-t), and the area under the plasma concentration-time curve from time 0 extrapolated to infinity (AUC0-inf) were all about one. No significant effect of mild and moderate renal impairment on apatinib pharmacokinetics was observed. Mild and moderate renal impairment was also not observed to have a significant effect on the pharmacokinetics of metabolites M1-1, M1-2, and M1-6. However, mild and moderate renal impairment had a certain increase in exposure to the metabolite M9-2. Considering that M9-2 has no inhibitory effect on protein tyrosine kinase, it has no clinical significance. In addition, the proportion of cumulative excretion of apatinib and its major metabolites was small and almost negligible in all three groups of subjects.

CONCLUSION

Patients with mild and moderate renal impairment do not need to adjust the dose of apatinib when using low dose (250 mg) apatinib.

Glomerular Filtration Rate Measurement and Chemotherapy Dosing

Many chemotherapeutic drugs used to treat malignancies undergo renal clearance. Thus, accurate knowledge of kidney function is critical to ensure proper dosing, maximize efficacy, and minimize toxicity of drugs that often have a narrow therapeutic index. Making this issue more salient is the fact that impaired kidney function, as assessed by glomerular filtration rate (GFR), is encountered commonly in patients with cancer. Recent data and expert guidelines recommend the use of the Chronic Kidney Disease-Epidemiology Collaboration equation to guide the assessment of kidney function, except when directly measured GFR is clinically necessary. Controversies regarding the measurement of kidney function include the use of race in this equation, indexing to body surface area, and dosing of medications based on stages of chronic kidney disease versus more discrete values of estimated GFR. The development of accurate, real-time GFR measures may hold great promise in allowing for more accurate dosing of these important drugs.

Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity

All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.