Electrolyte disturbances and acute kidney injury in patients with cancer

Electrolyte disorders induced by six multikinase inhibitors therapy for renal cell carcinoma: a large-scale pharmacovigilance analysis

To provide evidence for optimization of multi-kinase inhibitors (MKIs) use in the clinic, we use the public database to describe and evaluate electrolyte disorders (EDs) related to various MKIs treated for renal cell carcinoma. We analyzed spontaneous reports submitted to the Food and Drug Administration Adverse Events Reporting System (FAERS) in an observational and retrospective manner. Selecting electrolyte disorders' adverse events to multikinase inhibitors (axitinib, cabozantinib, lenvatinib, pazopanib, sunitinib, and sorafenib). We used Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and multi-item gamma Poisson shrinker (MGPS) algorithms to analyze suspected adverse reactions of electrolyte disorders induced by MKIs (which were treated for renal cell carcinoma) between January 2004 and December 2022. As of December 2022, 2772 MKIs (which were treated for renal cell carcinoma) ICSRs were related to electrolyte disorders AEs. In general, there were more AEs cases in males, except lenvatinib and 71.8% of the cases were submitted from North America. ICSRs in this study, the age group most frequently affected by electrolyte disorders AEs was individuals aged 45-64 years for axitinib, cabozantinib, pazopanib, and sunitinib, whereas electrolyte disorders AEs were more common in older patients (65-74 years) for sorafenib and lenvatinib. For all EDs documented in ICSRs (excluding missing data), the most common adverse outcome was hospitalization(1429/2674, 53.4%), and the most serious outcome was death/life-threat(281/2674, 10.5%). The prevalence of mortality was highest for sunitinib-related EDs (145/616, 23.5%), excluding missing data (n = 68), followed by cabozantinib-related EDs (20/237, 8.4%), excluding missing data (n = 1). The distribution of time-to-onset of Each drug-related ICSRs was not all the same, and the difference was statistically significant (P = 0.001). With the criteria of ROR, the six MKIs were all significantly associated with electrolyte disorders AEs, the strongest association was the association between cabozantinib and hypermagnesaemia. MKIs have been reported to have significant electrolyte disorders AEs. Patients and physicians need to recognize and monitor these potentially fatal adverse events.

Characteristics, Outcomes, and Clinical Indicators of Bloodstream Infections in Neutropenic Patients with Hematological Malignancies: A 7-Year Retrospective Study

Purpose

The aim of this study was to investigate the current epidemiology, its changes during the study years, and inflammatory biomarkers of bacterial bloodstream infections (BSIs) in neutropenic patients with hematological malignancies. We assessed mortality risk factors and multidrug-resistant (MDR) gram-negative BSI predictors.

Patients and Methods

We conducted a retrospective study from January 2015 to December 2021, which included adult neutropenic oncohematological patients with confirmed BSIs. We used univariable and multivariable analyses to analyze the risk factors. Each index's reliability for bacterial BSI diagnosis was assessed using the receiver-operating characteristic curve and area under the curve.

Results

A total of 514 isolates were obtained from the 452 patients. The average mortality was 17.71%. Gram-negative organisms were the predominant causes of BSI. Escherichia coli was the most common microorganism (49.90%). The overall variation trend of the isolation rate of MDR and carbapenem-resistant gram-negative bacteria increased. Multivariate analysis indicated that: 1) neutropenia that lasted for more than 7 days, patients ≥ 60 years of age, septic shock, hospitalization for >20 days, BSI with a carbapenem-resistant strain, and treatment with linezolid or vancomycin in infections lasting less than 30 days were independent mortality risk factors; 2) severe neutropenia exceeding 7 days, unreasonable empirical therapy, and receipt of aminoglycosides or 3rd or 4th generation cephalosporins in infections lasting less than 30 days were independent risk factors of MDR gram-negative bacteria. Procalcitonin, absolute neutrophil count, and white blood cell indicate higher diagnostic accuracy for BSIs. Moreover, bacteria time to detection was better at differentiating Gram-negative and Gram-positive bacterial infections.

Conclusion

We analyzed the risk factors for BSI neutropenic patients with hematological malignancies, the distribution of bacteria, antibiotic resistance, and the changes in clinical parameters. This single-center retrospective study may provide clinicians with novel insights into the diagnosis and treatment of BSI to improve future clinical outcomes.

Nomogram Prediction Model of Serum Chloride and Sodium Ions on the Risk of Acute Kidney Injury in Critically Ill Patients

Purpose

This study aims to investigate the effect of serum chloride and sodium ions on AKI occurrence in ICU patients, and further constructs a prediction model containing these factors to explore the predictive value of these ions in AKI.

Methods

The clinical information of patients admitted to ICU of Beijing Friendship Hospital Affiliated to Capital Medical University was collected for retrospective analysis. Logistic regression analysis was used to analyzing the influencing factors. A nomogram for predicting AKI risk was constructed with R software and validated by repeated sampling. Afterwards, the effectiveness and accuracy of the model were tested and evaluated.

Results

A total of 446 cases met the requirements of this study, of which 178 developed AKI during their stay in ICU, with an incidence rate of 39.9%. Hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine value and BE value at ICU admission before the diagnosis of AKI were identified as independent risk factors for developing AKI during ICU stay. These predictors were incorporated into the nomogram of AKI risk in critically ill patients, which was constructed by using R software. Receiver operating characteristic curve analysis was further used and showed that the area under the curve of the model was 0.7934 (95% CI 0.742–0.8447), indicating that the model had an ideal value. Finally, further evaluated its clinical effectiveness. The clinical effect curve and decision curve showed that most areas of the decision curve of this model were greater than 0, indicating that this model owned a certain clinical effectiveness.

Conclusion

The nomogram based on hypernatremia, heart failure, sepsis, APACHE II score, and initial creatinine and BE value in ICU can predict the individualized risk of AKI with satisfactory distinguishability and accuracy.

Serum Potassium Disorders Predict Subsequent Kidney Injury: A Retrospective Observational Cohort Study of Hospitalized Patients

INTRODUCTION

Electrolyte disorders are common findings in kidney diseases and might represent a useful biomarker preceding kidney injury. Serum potassium [K+] imbalance is still poorly investigated for association with acute kidney injury (AKI), and most evidence came from intensive care units. The aim of our study was to comprehensively investigate this association in a large, unselected cohort of hospitalized patients.

METHODS

We performed a retrospective observational cohort study on the inpatient population admitted to Fondazione Policlinico Universitario A. Gemelli IRCCS between January 1, 2010 and December 31, 2014, with inclusion of adult patients with at least 2 [K+] and 3 serum creatinine measurements who did not develop AKI during an initial 10-day window. The outcome of interest was in-hospital AKI. The exposures of interest were [K+] fluctuations and hypo (HoK) and hyperkalemia (HerK). [K+] variability was evaluated using the coefficient of variation. Cox proportional hazards regression models were used to obtain hazard ratios and 95% confidence intervals of the association between the exposures of interest and development of AKI.

RESULTS

About 21,830 hospital admissions from 18,836 patients were included in our study. During a median follow-up of 5 (interquartile range [IQR] 7) days, AKI was observed in 555 hospital admissions (2.9%); median time for AKI development was 5 (IQR 7) days. Higher [K+] variability was independently associated with increased risk of AKI with a statistically significant linear trend across groups (p value = 0.012). A significantly higher incidence of AKI was documented in patients with HerK compared with normokalemia. No statistically significant difference was observed between HoK and HerK (p value = 0.92).

CONCLUSION

[K+] abnormalities including fluctuations even within the normal range are associated with development of AKI.

Acute Kidney Injury in Patients With Cancer: A Review of Onconephrology

Over the past 2 decades, significant research and advancements have been made in oncology and its therapeutics. Thanks to novel diagnostic methods, treatments, and supportive measures, patients with cancer live longer and have a better quality of life. However, an unforeseen consequence of this progress has been increasing medical complications, including acute kidney injury. The purpose of this review is to provide an overview of the epidemiology and most common causes of acute kidney injury in patients with cancer unrelated to oncological treatment.

Disorders of Divalent Ions (Magnesium, Calcium, and Phosphorous) in Patients With Cancer

Disorders of the divalent ions (magnesium, calcium, and phosphorous) are frequently encountered in patients with cancer. Of these, hypomagnesemia, hypocalcemia, hypercalcemia, and hypophosphatemia are seen most commonly. These electrolyte disturbances may be related to the underlying malignancy or due to side effects of anticancer therapy. When caused by a paraneoplastic process, these abnormalities may portend a poor prognosis. Importantly, the development of severe electrolyte derangements may be associated with symptoms that negatively impact quality of life, preclude the administration of critical chemotherapeutic agents, or lead to life-threatening complications that require hospitalization and emergent treatment. In accordance, prompt recognition and treatment of these disorders is key to improving outcomes in patients living with cancer. This review will discuss selected derangements of the divalent ions seen in this population, with a focus on paraneoplastic and therapy-associated etiologies.

Pediatric onco-nephrology: time to spread the word : Part I: early kidney involvement in children with malignancy

Onco-nephrology has been a growing field within the adult nephrology scope of practice. Even though pediatric nephrologists have been increasingly involved in the care of children with different forms of malignancy, there has not been an emphasis on developing special expertise in this area. The fast pace of discovery in this field, including the development of new therapy protocols with their own kidney side effects and the introduction of the CD19-targeted chimeric antigen receptor T cell (CAR-T) therapy, has introduced new challenges for general pediatric nephrologists because of the unique effects of these treatments on the kidney. Moreover, with the improved outcomes in children receiving cancer therapy come an increased number of survivors at risk for chronic kidney disease related to both their cancer diagnosis and therapy. Therefore, it is time for pediatric onco-nephrology to take its spot on the expanding subspecialties map in pediatric nephrology.

Comparison of Prediction Models for Acute Kidney Injury Among Patients with Hepatobiliary Malignancies Based on XGBoost and LASSO-Logistic Algorithms

Background

Based on the admission data, we applied the XGBoost algorithm to create a prediction model to estimate the AKI risk in patients with hepatobiliary malignancies and then compare its prediction capacity with the logistic model.

Methods

We reviewed clinical data of 7968 and 589 liver/gallbladder cancer patients admitted to Zhongshan Hospital during 2014 and 2015. They were randomly divided into the training set and test set. Data were collected from the electronic medical record system. XGBoost and LASSO-logistic were used to develop prediction models, respectively. The performance measures included the classification matrix, the area under the receiver operating characteristic curve (AUC), lift chart and learning curve.

Results

Of 6846 participants in the training set, 792 (11.6%) cases developed AKI. In XGBoost model, the top 3 most important variables for AKI were serum creatinine (SCr), glomerular filtration rate (eGFR) and antitumor treatment in liver cancer patients. Similarly, SCr and eGFR also ranked second and third most important variables in the gallbladder cancer-related AKI model just after phosphorus. In the classification matrix, XGBoost model possessed a comparably better agreement between the actual observations and the predictions than LASSO-logistic model. The Youden’s index of XGBoost model was 47.5% and 59.3%, respectively, which was significantly higher than that of LASSO-logistic model (41.6% and 32.7%). The AUCs of XGBoost model were 0.822 in liver cancer and 0.850 in gallbladder cancer. By comparison, the AUC values of Logistic models were significantly lower as 0.793 and 0.740 (p=0.024 and 0.018). With the accumulation of training samples, XGBoost model maintained greater robustness in the learning curve.

Conclusion

XGBoost model based on admission data has higher accuracy and stronger robustness in predicting AKI. It will benefit AKI risk classification management in clinical practice and take an advanced intervention among patients with hepatobiliary malignancies.

Serum sodium variability and acute kidney injury: a retrospective observational cohort study on a hospitalized population

Aim of our study was to analyze the association between serum sodium (Na) variability and acute kidney injury (AKI) development. We performed a retrospective observational cohort study on the inpatient population admitted to Fondazione Policlinico Universitario A. Gemelli IRCCS between January 1, 2010 and December 31, 2014 with inclusion of adult patients with ≥ 2 Na and ≥ 2 serum creatinine measurements. We included only patients with ≥ 2 Na measurements before AKI development. The outcome of interest was AKI. The exposures of interest were hyponatremia, hypernatremia and Na fluctuations before AKI development. Na variability was evaluated using the coefficient of variation (CV). Multivariable Cox proportional hazards and logistic regression models were fitted to obtain hazard ratios (HRs), odds ratios (ORs) and 95% confidence intervals (CIs) for the association between the exposures of interest and AKI. Overall, 56,961 patients met our inclusion criteria. During 1541 person-years of follow-up AKI occurred in 1450 patients. In multivariable hazard models, patients with pre-existent dysnatremia and those who developed dysnatremia had a higher risk of AKI compared with patients with normonatremia. Logistic models suggested a higher risk for AKI in the 3rd (OR 1.41, 95% CI 1.18, 1.70, p < 0.001) and 4th (OR 1.53, 95% CI 1.24, 1.91, p < 0.001) highest quartiles of Na CV with a significant linear trend across quartiles (p trend < 0.001). This association was also independent from Na highest and lowest peak value. Dysnatremia is a common condition and is positive associated with AKI development. Furthermore, high Na variability might be considered an independent early indicator for kidney injury development.

Electrolyte and acid-base disorders in cancer patients and its impact on clinical outcomes: evidence from a real-world study in China

Background: This study aims to delineate the incidence of electrolyte and acid-base disorders (EAD) in cancer patients, to figure out the risk factors of EAD, then to assess the impact of EAD on patients' in-hospital clinical outcomes.Methods: Patients with the diagnosis of malignancies hospitalized during 1 October 2014 and 30 September 2015 were recruited in Zhongshan Hospital, Fudan University in Shanghai of China. Demographic characteristics, comorbidities, and clinical data, including survival, length of stay and hospital cost, were extracted from the electronic medical record system. Electrolyte and acid-base data were acquired from the hospital laboratory database.Results: Of 25,881 cancer patients with electrolyte data, 15,000 (58.0%) cases had at least one electrolyte and acid-base abnormity. Hypocalcemia (27.8%) was the most common electrolyte disorder, followed by hypophosphatemia (26.7%), hypochloremia (24.5%) and hyponatremia (22.5%). The incidence of simple metabolic acidosis (MAC) and metabolic alkalosis (MAL) was 12.8% and 22.1% respectively. Patients with mixed metabolic acid-base disorders (MAC + MAL) accounted for 30.2%. Lower BMI score, preexisting hypertension and diabetes, renal dysfunction, receiving surgery/chemotherapy, anemia and hypoalbuminemia were screened out as the major risk factors of EAD. In-hospital mortality in patients with EAD was 2.1% as compared to those with normal electrolytes (0.3%). The risk of death significantly increased among patients with severe EAD. Similarly, the length of stay and hospital cost also tripled as the number and grade of EAD increased.Conclusion: EAD is commonly encountered in cancer patients and associated with an ominous prognosis. Patients with comorbidities, renal/liver dysfunction, and anti-tumor therapy have a higher risk of EAD. Regular monitoring of electrolytes, optimum regimen for intravenous infusion, timely correction of modifiable factors and appropriate management of EAD should not be neglected during anti-tumor treatment.

The Effect of Admission Serum Magnesium on the Acute Kidney Injury Among Patients with Malignancy

Purpose

This study aimed to explore the relationship between serum magnesium (Mg) levels and incidence of acute kidney injury (AKI) in patients with malignancy.

Patients and Methods

Hospitalized patients with malignancy between October 1, 2014 and September 30, 2015 in Zhongshan Hospital were recruited. All relevant data were extracted from the electronic database.

Results

All 99,845 patients were enrolled and 16,082 eligible patients were divided into three groups according to admission serum Mg levels in this study. Among them, 2383 (14.8%) cases were diagnosed as AKI. The incidence of AKI showed a V trend with the increase of serum Mg level. The effect of low serum Mg level on the onset of AKI seems to be greater than high serum Mg level. Patients with low serum Mg level spent a longer time in the hospital than those with normal serum Mg level and high serum Mg level. Further, multivariate logistic regression model was used to assess the importance of serum Mg level to influence AKI incidence. There was a higher AKI incidence in patients with magnesium level 0.66mmol/L or less (aOR=2.438, 95% CI=1.696, 3.505).

Conclusion

Low serum Mg level might be a independent risk factor for AKI in patients with malignancy. Appropriate clinical intervention for serum Mg disorder may contribute to decreasing the incidence of AKI and the possibility of poor outcomes in cancer patients.

Intensive care unit-acquired hyponatremia in critically ill medical patients

Background

Previous research has focused on intensive care unit (ICU)-acquired hypernatremia; however, ICU-acquired hyponatremia has frequently been overlooked and has rarely been studied in surgical or mixed ICUs. The aim of this study is to investigate the incidence of ICU-acquired hyponatremia, the risk factors associated with its development, and its impact on outcomes in critically ill medical patients.

Methods

We conducted a retrospective cohort study based on the prospective registry of all critically ill patients admitted to the medical ICU from January 2015 to December 2018. Baseline characteristics and management variables were compared between ICU-acquired hyponatremia and normonatremia patients.

Results

Of 1342 patients with initial normonatremia, ICU-acquired hyponatremia developed in 217 (16.2%) patients and ICU-acquired hypernatremia developed in 117 (8.7%) patients. The Sequential Organ Failure Assessment (8.0 vs 7.0, P = 0.009) and Simplified Acute Physiology Score 3 scores (55.0 vs 51.0, P = 0.005) were higher in ICU-acquired hyponatremia patients compared with normonatremia patients. Baseline sodium (137.0 mmol/L vs 139.0 mmol/L, P < 0.001), potassium (4.2 mmol/L vs 4.0 mmol/L, P = 0.001), and creatinine (0.98 mg/dL vs 0.88 mg/dL, P = 0.034) levels were different between the two groups. Net volume balance over first 3 days was higher in ICU-acquired hyponatremia patients (19.4 mL/kg vs 11.5 mL/kg, P = 0.004) and was associated with the development of ICU-acquired hyponatremia (adjusted odds ratio, 1.004; 95% confidence interval, 1.002–1.007; P = 0.001). ICU mortality was similar in both groups (15.2% vs. 14.4%, P = 0.751), but renal replacement therapy was more commonly required in ICU-acquired hyponatremia patients (13.4% vs 7.4%, P = 0.007).

Conclusions

ICU-acquired hyponatremia is not uncommon in critically ill medical patients. Increased volume balance is associated with its development. ICU-acquired hyponatremia is related to increased use of renal replacement therapy but not to mortality.

Refeeding syndrome in hematological cancer patients - current approach

Introduction: According to estimates based on the GLOBOCAN database of the International Agency for Research on Cancer, in 2018 alone, 18 100 000 cancers were globally diagnosed. Importantly, the majority of cancer patients experience unintended weight loss that leads to many adverse clinical consequences, including malnutrition and cancer cachexia. At the same time, each nutritional intervention must be carried out individually, as it can lead to critical complications, resulting in a threat to the health and life of the cachectic patient. An example of this type of risk is refeeding syndrome.Areas covered: Three factors seem to be crucial in this case: early identification of patients at risk of malnutrition, the introduction of an individualized diet regimen and constant monitoring of nutritional intervention. It seems equally important to spread awareness about the possibility of refeeding syndrome and knowledge about its patomechanisms and consequences among medical staff. This should lead to minimizing the risk of refeeding syndrome.Expert opinion: It should be noted that current guidelines on the pathogenesis, risk factors and methods of prevention and treatment of refeeding syndrome require further modifications, that would harmonize the management regimen in both prevention and therapy of refeeding syndrome.

Clinical Approach to Sodium Homeostasis Disorders in Children with Pituitary-Suprasellar Tumors

Children with pituitary-suprasellar tumors are at high risk of developing sodium metabolism disorders since the tumoral mass itself or surgical and medical treatment can damage AVP release circuits. Additional risk factors are represented by the use of hypotonic fluids, the young age, total parenteral nutrition, and obstructive hydrocephalus secondary to tumor pathology. The most frequent hyponatremic disorders related to AVP in these patients are the syndrome of inappropriate ADH secretion and the cerebral/renal salt wasting syndrome, while hypernatremic conditions include central diabetes insipidus (CDI) and adipsic CDI. The main challenge in the management of these patients is to promptly distinguish the AVP release disorder at the base of the sodium imbalance and treat it correctly by avoiding rapid sodium fluctuations. These disorders can coexist or follow each other in a few hours or days; therefore, careful clinical and biochemical monitoring is necessary, especially during surgery, the use of chemotherapeutic agents, or radiotherapy. This monitoring should be performed by experienced healthcare professionals and should be multidisciplinary, including pediatric endocrinologists, neurosurgeons, and oncologists since maintaining sodium homeostasis also plays a prognostic role in terms of disease survival, therapeutic response, hospitalization rate, and mortality. In this review, we analyze the management of sodium homeostasis disorders in children with pituitary-suprasellar tumors and discuss the main challenges in the diagnosis and treatment of these conditions based on literature data and over 30 years of clinical experience at our Department of Pediatric Endocrinology.

Epidemiology of acute kidney injury and associated factors among patients with malignancy: Analysis of hospital inpatient database in Shanghai, China

Objective:

This study aimed to understand the incidence of acute kidney injury in cancer patients, to figure out which clinical factors could increase the risks of acute kidney injury, and then to assess the effect of acute kidney injury on in-hospital mortality, length of stay, and hospital cost.

Methods:

This study was designed as a retrospective cohort study based on the hospital inpatient database in Zhongshan Hospital, Shanghai, China. Patients with malignancy and admitted to the hospital between 1 October 2014 and 30 September 2015 were recruited. Data on demographics, comorbidities, and clinical records were exported for analysis. Acute kidney injury was diagnosed using KDIGO (Kidney Disease: Improving Global Outcomes) criteria and stratified into community-acquired and hospital-acquired acute kidney injury. Multivariate model and survival analysis were applied to discover the influencing factors of acute kidney injury among cancer patients.

Results:

Of the 26,914 eligible cancer admissions, 3326 acute kidney injury cases were identified with an incidence of 12.4%. Of them, 2961 patients located in acute kidney injury stage 1 and another 365 cases developed to stage 2–3. The highest rates were localized to renal cancer (27.3%), multiple myeloma (24.1%), and leukemia (23.9%). Patients with older age and hematologic cancer shared a higher acute kidney injury incidence. Pre-existing chronic kidney disease (adjusted odds ratio = 7.14), heart failure (adjusted odds ratio = 4.20), surgery/chemotherapy (adjusted odds ratio = 0.99/2.28), hyponatremia (adjusted odds ratio = 2.84), hypokalemia (adjusted odds ratio = 2.42), and hyperuricemia (adjusted odds ratio = 2.62) were the major factors associated with acute kidney injury. In-hospital mortality for acute kidney injury patients was 5.1% as compared with those without acute kidney injury (0.8%). Survival analysis reveals that the risk of death was higher among patients with hospital-acquired acute kidney injury (adjusted hazard ratio = 4.50) and severe acute kidney injury stage (adjusted hazard ratio = 2.68/3.91). Furthermore, the length of stay (13.5 days) and hospital cost (45,066 CNY) were significantly greater in patients with community-acquired acute kidney injury.

Conclusion:

Acute kidney injury was common in cancer patients and associated with an ominous outcome. Pre-existing comorbidities, electrolyte disturbances, and abnormal biochemical were the predicting factors for acute kidney injury incidence. Better monitoring of electrolytes, identification of high-risk patients, and early acute kidney injury diagnosis should be considered as a priority during anti-cancer treatment.

Acute kidney injury and electrolyte disorders in the critically ill patient with cancer

PURPOSE OF REVIEW

Patients with cancer increasingly make up a significant proportion of patients receiving care in the intensive care unit (ICU). Acute kidney injury and cancer-associated electrolyte disorders are encountered in many of these patients and can significantly impact both short-term and long-term outcomes.

RECENT FINDINGS

Advances in chemotherapeutic regimens as well as in our understanding of cancer-associated kidney disease highlight the need for specialized knowledge of the unique causes and therapies required in this subset of critically ill patients. This is especially the case as targeted cancer therapies may have off-target effects that need to be recognized in a timely manner.

SUMMARY

This review outlines key knowledge areas for critical care physicians and nephrologists caring for patients with cancer and associated kidney issues such as acute kidney injury and electrolyte disorders. Specifically, understanding kidney-specific effects of new chemotherapeutic approaches is outlined, and provides an up-to-date compendium of these effects.

Prevention of Chemotherapy-Induced Nephrotoxicity in Children with Cancer

Children with cancer treated with cytotoxic drugs are frequently at risk of developing renal dysfunction. The cytotoxic drugs that are widely used for cancer treatment in children are cisplatin (CPL), ifosfamide (IFO), carboplatin, and methotrexate (MTX). Mechanisms of anticancer drug-induced renal disorders are different and include acute kidney injury (AKI), tubulointerstitial disease, vascular damage, hemolytic uremic syndrome (HUS), and intrarenal obstruction. CPL nephrotoxicity is dose-related and is often demonstrated with hypomagnesemia, hypokalemia, and impaired renal function with rising serum creatinine and blood urea nitrogen levels. CPL, mitomycin C, and gemcitabine treatment cause vascular injury and HUS. High-dose IFO, streptozocin, and azacitidine cause renal tubular dysfunction manifested by Fanconi syndrome, rickets, and osteomalacia. AKI is a common adverse effect of MTX, interferon-alpha, and nitrosourea compound treatment. These strategies to reduce the cytotoxic drug-induced nephrotoxicity should include adequate hydration, forced diuresis, and urinary alkalization. Amifostine, sodium thiosulfate, and diethyldithiocarbamate provide protection against CPL-induced renal toxicity.

Electrolyte Disorders Associated with Cancer

Cancer patients frequently suffer electrolyte abnormalities that complicate the management of their condition. The most commonly occurring derangement is hyponatremia, while hypercalcemia, hypokalemia, and hypophosphatemia are also encountered. The etiology of these abnormalities is often identifiable, and early diagnosis and management can prevent delays in necessary anti-cancer therapies.

Cancer and the kidney: dangereoux liasons or price paid for the progress in medicine?

A long time ago, the links between renal disease and malignancy were observed, however, quite recently, their importance was recognized and 'new' subspecialty in nephrology, namely 'onconephrology' was established. In the XXI century, patients with malignancy make up the most growing number of the subjects seen for nephrology consult and/or critical care nephrology services. A plethora of renal problems may be found in patients with malignancy. They may influence not only their short-term outcomes but also the adequate therapy of the underlying oncological problem. Thus, all these kidney-related issues pose an important challenge for both specialities: oncology and nephrology. In the review a spectrum of acute and chronic renal injury caused by the malignancy is presented as well as the associations between renal disease and cancer. Assessment of kidney function and its importance in patients with malignancy is also discussed as medical oncologists should check the appropriate dose of chemotherapeutic drugs in relation to the actual renal function before prescribing them to the patients. Moreover, effects of kidney function on outcomes in oncology is presented. In addition, nephrology services should better understand both the biology of malignancy with its treatment to become a valuable part treating team to yield the best possible outcome. It is important for nephrology services to be acknowledged and to take an active participation in care of oncology patients.

The Effects of Pre-Existing Hyponatremia and Subsequent-Developing Acute Kidney Injury on In-Hospital Mortality: A Retrospective Cohort Study

Background and Objectives

Both hyponatremia and acute kidney injury (AKI) are common and harmful in hospitalized patients. However, their combined effects on patient mortality have been little studied.

Methods

We retrospectively enrolled 19191 adult patients who were admitted for 1 year. Pre-existing hyponatremia was defined as a serum sodium level < 135 mmol/L on the first measurement of their admission. AKI was defined as a rise in serum creatinine by ≥ 26.5 μmol/L or ≥ 1.5 times of the baseline value of creatinine during the hospital stay.

Results

The prevalence of pre-existing hyponatremia was 8.2%. During a median 6.0 days of hospital stay, the incidence rates of AKI and in-hospital patient mortality were 5.1% and 0.9%, respectively. Pre-existing hyponatremia independently predicted AKI development and in-hospital mortality (adjusted hazard ratio [HR] 1.300, P = 0.004; HR 2.481, P = 0.002, respectively). Pre-existing hyponatremia and subsequent development of AKI increased in-hospital mortality by 85 times, compared to the patients with normonatremia and no AKI. In subgroup analysis, the AKI group showed higher rates of de novo hypernatremia than the non-AKI group during the admission. De novo hypernatremia, which might be associated with over-correction of hyponatremia, increased in-hospital mortality (HR 3.297, P <0.001), and patients with AKI showed significantly higher rates of de novo hypernatremia than patients without AKI (16.2% vs. 1.4%, P < 0.001, respectively).

Conclusion

Pre-existing hyponatremia may be associated with the development of AKI in hospitalized patients, and both hyponatremia and hospital-acquired AKI could have a detrimental effect on short term patient mortality, which might be related to the inappropriate correction of hyponatremia in AKI patients.

Prognostic impact of hyponatraemia in patients with colorectal cancer

AIM

Hyponatraemia is a common in surgical practice, but its clinical impact in patients with colorectal cancer has not been evaluated.

METHOD

We retrospectively assessed 2944 patients who had been admitted to Chonnam National University Hwasun Hospital, Korea with a diagnosis of colorectal cancer. In order to determine the relationship between the serum sodium level and 3-year mortality, we categorized the patients as having normonatraemia (135-147 mEq/l), or mild (130-134 mEq/l), moderate (125-129 mEq/l) or severe hyponatraemia (< 125 mEq/l).

RESULTS

Hyponatraemia, defined as a serum sodium level of < 135 mEq/l, was evident in 27.6% of patients during hospitalization. Declining serum sodium levels were associated with increasing age, a higher number of comorbidities, a more advanced TNM stage and worsening biochemical parameters. In a multivariate Cox-proportional regression analysis, the mortality risk was correlated with the severity of hyponatraemia [hazard ratio (HR) 1.65, 95% CI 1.38-1.96; HR 2.24, 95% CI 1.69-2.98; HR 2.20, 95% CI 1.25-3.90, for patients with mild, moderate, and severe hyponatraemia, respectively, compared with patients with normonatraemia]. An independent association between hyponatraemia and long-term mortality was sustained among various subpopulations and patients with persistent hyponatraemia had a worse prognosis than those with hyponatraemia that resolved.

CONCLUSION

A substantial proportion of patients developed hyponatraemia during hospitalization, and the long-term mortality risk increased even in mild cases of hyponatraemia. Hyponatraemia should be considered as an important prognostic factor in colorectal cancer.

FGF23: mediator of poor prognosis in a sizeable subgroup of patients with castration-resistant prostate cancer presenting with severe hypophosphatemia?

Castration-resistant prostate cancer (CRPC) is an advanced and incurable stage of the second most frequently diagnosed malignancy in men globally. Current treatment options improve survival modestly but eventually fail due to intrinsic or acquired therapeutic resistance. A hypothesis is presented wherein circulating levels of fibroblast growth factor 23 (FGF23), an endocrine member of the fibroblast growth factor family with phosphaturic properties, are proposed as a prognostic and predictive marker to identify CRPC patients with poor prognosis that are amenable to FGF23 antibody therapy (FGF23i) or treatment with fibroblast growth factor receptor inhibitors (FGFRi). With respect to the latter, FGF23 may also serve as a pharmacodynamic marker enabling individualized FGFRi dosing. We recently discovered that the development of severe and sustained hypophosphatemia in CRPC patients undergoing zoledronic acid therapy for bone metastases was associated with markedly worse prognosis compared to patients without or with only mild and transient hypophosphatemia. Severe hypophosphatemia is a typical manifestation of tumor-induced hypophosphatemic osteomalacia (TIO), a paraneoplastic condition mediated by FGF23 overexpression in most instances. While the postulated tumor-promoting role of FGF23 in CRPC or other malignancies has not yet been studied, several lines of evidence suggest that FGF23 may mediate both severe hypophosphatemia (via its endocrine properties) and aggressive CRPC behavior (via autocrine and paracrine activities): (i) FGF23 and the necessary signalling machinery (i.e. members of the fibroblast growth factor receptor [FGFR] family and the essential co-receptor α-KLOTHO [KL]) are highly expressed in a sizeable subgroup of CRPC patients; (ii) FGF/FGFR signalling plays important roles in prostate cancer; (iii) FGF23 can induce its own expression via a positive autocrine feedback loop involving FGFR1; and (iv) this positive feedback loop may be triggered by bone-targeted therapies frequently used for the treatment of CRPC-associated bone metastases. While there is a lack of personalized treatment strategies in the management of CRPC to date, FGF23 targeted therapy has the potential to fill this unmet clinical need in the not-so-distant future. In fact, FGFRi are currently in advanced clinical testing for a number of malignancies such as kidney and lung cancer, but there is a lack of conclusive data on FGFRi therapy in patients selected for FGF/FGFR pathway activation.

Apelin beyond kidney failure and hyponatremia: a useful biomarker for cancer disease progression evaluation

Apelin regulates angiogenesis, stimulating endothelial cell proliferation and migration. It is upregulated during tumor angiogenesis, and its overexpression was reported to increase tumor growth. Furthermore, apelin controls vasopressin release and body fluid homeostasis. The aim of this study was to examine the correlations between apelin expression and clinical outcomes in oncologic patients, such as cancer disease progression and patient's survival. Apelin levels were evaluated in a cohort of 95 patients affected by different varieties of cancer. Partial remission and stable disease were assigned to the 'no progression' group, comparing it with the progressor group. Patients were followed up for 2 years. Receiver operating characteristics analysis was employed for identifying the progression of the oncologic disease and Kaplan-Meier curves assessed the survival. Adjusted risk estimates for progression endpoint were calculated using Cox proportional hazard regression analysis. Oncologic patients had higher apelin levels compared with healthy subjects, and apelin was closely related to the stages of the disease. In the hyponatremia group, apelin values were significantly higher than patients with eunatremia. After the follow-up of 24 months, 41 patients (43%) reached the endpoint. Progressor subjects presented significantly increased apelin values at baseline compared with non-progressor. Univariate followed by multivariate Cox proportional hazard regression analysis showed that apelin predicted cancer progression independently of other potential confounders. In patients with cancer, apelin closely reflects the stage of the disease and represents a strong and independent risk marker for cancer progression.

Nephrotoxicity of recent anti-cancer agents

Cancer patients may develop a variety of kidney lesions that impair not only their immediate survival but also limit the adequate treatment of the underlying malignant process. This review summarizes the nephrotoxic potential of some of the most recently developed anti-cancer drugs, focusing on those interfering with the vascular endothelial growth factor and epidermal growth factor receptor pathways and mammalian target of rapamycin inhibitors. Thrombotic microangiopathy (haemolytic-uraemic syndrome), proteinuria, hypertension and magnesium depletion are the most common side effects. Also the risk for developing acute kidney injury in patients with advanced prostate cancer undergoing androgen deprivation therapy is discussed.

Magnesium and its transporters in cancer: a novel paradigm in tumour development

The relationship between magnesium and cancer is not as simple as could be assumed from the well-established requirement of magnesium for cell proliferation. Basic and pre-clinical studies indicate that magnesium deficiency can have both anti- and pro-tumour effects. In the present review, we briefly outline the new findings on the role of magnesium in angiogenesis and metastatization, and focus on the relationship between tumour cell proliferation and metabolic reprogramming, discussing how magnesium and its transporters are involved in these processes. The role of magnesium in cancer is also critically examined with regard to mitochondrial function, apoptosis and resistance to treatment. Finally, we bring together the latest experimental evidence indicating that alteration in the expression and/or activity of magnesium channels is a frequent finding in cancer cells and human tumour tissues examined to date, and we discuss the potential implications for developing novel diagnostic and therapeutic strategies.