Hemodialysis of chronic kidney failure patients requiring ablative radioiodine therapy

Use of approved Lu-177 radiopharmaceuticals in patients with end-stage renal disease: A review of the literature and proposed treatment algorithm

Peptide receptor radionuclide therapy (PRRT) can be a very useful treatment for patients with neuroendocrine neoplasms and metastatic castration-resistant prostate cancer but it is routinely avoided in those with advanced kidney disease because it can adversely affect the renal function. Accordingly, no clear guidelines exist on the use of PRRT for patients on hemodialysis (HD). We performed a literature review to identify publications on HD patients who received PRRT with Lutetium-177 (Lu177) Dotatate and Y-90 and obtained information on Lu177 pharmacokinetics and early testing data from the manufacturer. We also perused the most recent North American Neuroendocrine Tumor Society (NANETS)/European Neuroendocrine Tumor Society (ENETS) recommendations. Seven relevant publications with a total of 15 patients were included. Patients received dose-adjusted fractions of PRRT with HD occurring usually within 24 h. There were no immediate or long-term serious adverse events attributed to the radioligand, although data was limited. Using available evidence and input from a multidisciplinary group, we have created an institutional workflow. Dose-adjusted PRRT can be offered to patients undergoing HD under careful, multidisciplinary supervision.

Dosing lutetium Lu 177-dotatate for a hemodialysis patient

Lu177-dotatate (Lutathera™) is a radioactive drug approved for the treatment of adults with gastro-entero-pancreatic neuroendocrine tumors and is predominantly renally excreted. Currently all patients receive 7400 MBq (200 mCi), and there are no guidelines for treating hemodialysis patients. We measured radioactivity prior to and post administration of two cycles of Lu177-dotatate in a hemodialysis patient, and radiation exposure to staff. We reduced the standard 7400 MBq by 33% for the first cycle and patient radioactivity fell by 40% following postdilution hemodiafiltration started 6 h post dosing, and by 45% for the second cycle and radioactivity fell by 47% with postdilution hemodiafiltration started 5 h post administration. By reducing the initial administered radioactivity, coupled with early dialysis, and choosing postdilution hemodiafiltration we were able to achieve radioactivity retention curves similar to those from patients with normal renal function receiving the standard administration of 7400 MBq.

Clinical Management of End-Stage Renal Disease Patients on Dialysis Receiving Radioactive Iodine Treatment

PURPOSE

Radioactive iodine (RAI) is used to treat thyroid cancer patients with a clear paradigm for most patients. End-stage renal disease (ESRD) patients pose several challenges when undergoing RAI treatment, primarily due to the lack of renal clearance. We retrospectively report our experience with RAI treatment in a cohort of patients with ESRD and provide a set of recommendations on aspects such as the need for adjusted dose activity, balancing scheduling between RAI therapy and dialysis, and radiation safety precautions.

PATIENTS AND METHODS

In this study, we report on 5 patients (6 cases), with ESRD on dialysis, treated with RAI for thyroid cancer. Retention measurements to determine individual biological clearance of RAI from the patient's body before and after dialysis sessions were assessed using external exposure dose rates measured at 1 m.

RESULTS

Delayed biological clearance of RAI, after the first hemodialysis session, resulted in a longer RAI effective half-life as a consequence of longer retention periods, consistent with observations reported in scientific literature. To achieve a much closer radiation exposure compared with a nondialysis patient, one would recommend administering ~20%-30% of the dose activity normally administered to a thyroid cancer patient based on their medical history, histopathology, and uptake with the appropriate dialysis schedule.

CONCLUSIONS

Special precautions should be taken with the administration of RAI in ESRD patients by adjusting the prescribed dose activity, dialysis sessions, and paying special attention to wastes. Pooling data from multiple centers may be useful to build a consensus and substantiated recommendations.

Management of Challenging Radioiodine Treatment Protocols: A Case Series and Review of the Literature

Radioactive iodine (RAI) therapy with ¹³¹I is the standard of care for treatment in many patients with differentiated thyroid cancer. Because ¹³¹I is typically administered as a pill, and much of its radioactivity is excreted via the urine, there can be challenges in patients who cannot swallow pills, absorb iodine via the gastrointestinal tract, or eliminate RAI via the urine (i.e., dialysis patients and patients with renal failure). In this article, we present 3 cases in which the standard ¹³¹I treatment protocol for thyroid cancer could not be used because of these challenges, and we discuss the strategies used to overcome them. Provider collaboration and treatment customization are critical in overcoming patient-specific challenges.

Management of Patients with Renal Failure Undergoing Dialysis During 131I Therapy for Thyroid Cancer

Radioactive iodine (¹³¹I) therapy may be used to treat thyroid cancer in end-stage renal disease patients who undergo hemodialysis. Because iodine uses predominantly renal clearance, treatment management in hemodialysis patients may be problematic, and no formal recommendations on hemodialysis currently exist. This work details our experience with treating thyroid cancer with iodine in chronic renal failure patients who require hemodialysis and details the dosimetry results obtained during treatment to ensure that the dose to the bone marrow (BM) was acceptable. Methods: We treated 6 patients in the metabolic radiotherapy unit after thyroid stimulation. Two hemodialysis sessions in the metabolic radiotherapy unit were performed at 42 and 90 h after radiopharmaceutical administration. BM toxicity was estimated with activity measurements from blood samples and with whole-body measurements that were regularly repeated during hospitalization and measured with a γ-counter. The patients underwent thyroid and hematologic monitoring to assess treatment efficacy and therapeutic toxicity in the short, medium, and long term. Results: Whole-body activity was reduced on average by 66.7% (range, 60.1%-71.5%) after the first dialysis session and by 53.3% (range, 30.4%-67.8%) after the second. The mean estimated total absorbed dose to the BM was 0.992 Gy for all patients (range, 0.431-2.323 Gy). We did not observe any significant hematologic toxicity, and the clinical, biologic, and ultrasound test results confirmed the success of ablative treatment for most patients. Conclusion: In hemodialysis patients with thyroid cancer, an ¹³¹I activity approximately 30% lower than the nominal dose appears to strike an appropriate balance between absence of BM toxicity and therapeutic efficacy. To avoid overirradiation, we recommend pretherapeutic dosimetry studies for metastatic patients to calculate the amount of activity to be administered. We also recommend dosimetry monitoring during the hemodialysis sessions performed after therapeutic dose administration and under the same conditions.

Dosing of radioactive iodine in end-stage renal disease patient with thyroid cancer

We describe detailed administration of thyroidal and extrathyroidal doses of radioiodine to a patient with end-stage renal disease on hemodialysis. A thorough description of area under curve measurements in a patient with compromised renal function has rarely been described in the literature. Few publications have described thyroid cancer management of patients on hemodialysis, and we believe our management will aid in patient treatment in the future.

131I-MIBG Therapy in a Metastatic Small Bowel Neuroendocrine Tumor Patient Undergoing Hemodialysis

Systemic radioisotope therapy with I-metaiodobenzylguanidine (I-MIBG) is an effective form of targeted therapy for neuroendocrine tumors. One of the absolute contraindications to administering I-MIBG therapy listed in the 2008 European Association of Nuclear Medicine guidelines is renal insufficiency requiring dialysis, although this contraindication is not evidence based. We describe a 68-year-old woman with a metastatic small bowel neuroendocrine tumor who developed renal insufficiency requiring hemodialysis. Imaging and dosimetry with I-MIBG were performed and showed that the radiation doses to the whole body and lungs were within safe limits. She was treated with 1820 MBq of I-MIBG with no short-term adverse reactions.

[Management of iodine-131 ablation therapy for thyroid carcinoma in a patient on chronic hemodialysis]

Iodine-131 ablation therapy for thyroid cancer in the patient on chronic hemodialysis represents a real problem since the main route of elimination of radioiodine is urinary. There is no recommendation on the management of this treatment in the patient on hemodialysis. We report our experience of management of this treatment in a patient aged 38 years, undergoing hemodialysis for chronic renal failure, and who have been indicated the treatment with iodine-131 for papillary thyroid carcinoma high risk. After multidisciplinary discussions (nephrologists and specialists in nuclear medicine and radiation safety), it has been decided to treat the patient with continuous ambulatory peritoneal dialysis therapy (CAPD). Because of the low but continuous elimination of iodine in the case of CAPD, the patient received a reduced ablative (131)I dose of 1850 MBq, which is 30% of the usual dose delivered in subjects with normal renal function. The patient was hospitalized for four days in nuclear medicine unit and the (131)I radioactivity emitted from him was 2.5 μSv/h at one meter at his hospital discharge. In conclusion, CAPD in relay of hemodialysis is a technique of renal replacement therapy that can be suggested to minimize exposure to radioactivity to the patient, his family and the medical staff.

Can radioiodine be administered effectively and safely to a patient with severe chronic kidney disease?

Chronic kidney disease is an increasingly widespread problem. The progression of renal failure is associated with the development of various hormonal disorders, including those affecting the thyroid gland. The prevalence of multinodular goitre and differentiated thyroid cancer increases significantly in patients with renal failure. However, radioiodine treatment in patients with severe chronic kidney disease gives rise to a number of difficulties. The only conclusions regarding this treatment thus far have been derived from single case studies. It seems that prospective controlled studies can contribute to the creation of standards for radioiodine treatment in patients with various stages of chronic kidney disease, while maintaining the safety of such treatment for both patients and medical staff. This review gives the response to the question how nowadays to treat the patients with severe chronic kidney disease with radioiodine.

Hemodialysis in patients requiring 131I treatment for thyroid carcinoma

PURPOSE

Thyroid malignancies can be treated by surgery followed by ablation of the remnant tissue with 131I. As iodide removal from the body occurs by renal extraction, in patients suffering from end-stage renal disease it is necessary to properly evaluate both timing and method of the extracorporeal treatment.


METHODS

We present two patients on regular hemodialysis, admitted in isolation to the Nuclear Medicine Department and treated with 131I for thyroid carcinoma diagnosed during the check-up for transplantation. Both patients underwent two hemodialysis sessions with a portable machine for CRRT (continuous renal replacement therapy), 24 and 48 hours after the administration of 50 mCi of 131I. The nursing staff were monitored with a dosimeter. Radioactivity of the patients, dialysate and urines were measured during hemodialysis. 


RESULTS

The greater reduction was obtained with the first dialysis, but in both patients a further, though shorter, hemodialysis at 48 hours was necessary for reaching a patient's radioactivity compatible with discharge. Radioactivity measured in the dialysate demonstrated the almost total removal of radioiodine by dialysis alone. In both patients, follow-up exams revealed a complete ablation of thyroid tissue, without signs of local recurrence. The dose of radioactivity of the dialysis staff was below allowable limits. 


CONCLUSIONS

We conclude that a successful reduction of radioactivity, without dispersing its therapeutic efficacy, can be obtained with daily hemodialysis with a CRRT machine in patients in isolation treated with 131I. A therapeutic model is proposed.

Impact of the Fukushima Daiichi Nuclear Power Plant accident on hemodialysis facilities: an evaluation of radioactive contaminants in water used for hemodialysis

Following the crisis at the Fukushima Daiichi Nuclear Power Plant caused by the 2011 Tohoku earthquake and tsunami, radioactive substances ((131) I, (134) Cs, (137) Cs) were detected in tap water throughout eastern Japan. There is now concern that internal exposure to radioactive substances in the dialysate could pose a danger to hemodialysis patients. Radioactive substances were measured in three hemodialysis facilities before and after purification of tap water for use in hemodialysis. Radioactive iodine was detected at levels between 13 and 15 Bq/kg in tap water from the three facilities, but was not detected by reverse osmosis membrane at any of the facilities. We confirmed that the amount of radioactive substances in dialysate fell below the limit of detection (7-8 Bq/kg) by reverse osmosis membrane. It is now necessary to clarify the maximum safe level of radiation in dialysate for chronic hemodialysis patients.

Trace minerals in patients with end-stage renal disease

The kidneys are famously responsible for maintaining external balance of prevalent minerals, such as sodium, chloride, and potassium. The kidney's role in handling trace minerals is more obscure to most nephrologists. Similarly, the impact of kidney failure on trace mineral metabolism is difficult to anticipate. The associated dietary modifications and dialysis create the potential for trace mineral deficiencies and intoxications. Indeed, there are numerous reports of dialysis-associated mishaps causing mineral intoxication, notable for the challenge of assigning causation. Equally challenging has been the recognition of mineral deficiency syndromes, amid what is often a cacophony of multiple comorbidities that vie for the attention of clinicians who care for patients with chronic kidney disease. In this paper, I review a variety of minerals, some of which are required for maintenance of normal human physiology (the U.S. Food and Drug Administration's list of essential minerals), and some that have attracted attention in the care of dialysis patients. For each mineral, I will discuss its role in normal physiology and will review reported deficiency and toxicity states. I will point out the interesting inter-relationships between several of the elements. Finally, I will address the special concerns of aluminum and magnesium as they pertain to the dialysis population.

Guidelines for radioiodine therapy of differentiated thyroid cancer

INTRODUCTION

The purpose of the present guidelines on the radioiodine therapy (RAIT) of differentiated thyroid cancer (DTC) formulated by the European Association of Nuclear Medicine (EANM) Therapy Committee is to provide advice to nuclear medicine clinicians and other members of the DTC-treating community on how to ablate thyroid remnant or treat inoperable advanced DTC or both employing large 131-iodine ((131)I) activities.

DISCUSSION

For this purpose, recommendations have been formulated based on recent literature and expert opinion regarding the rationale, indications and contraindications for these procedures, as well as the radioiodine activities and the administration and patient preparation techniques to be used. Recommendations also are provided on pre-RAIT history and examinations, patient counselling and precautions that should be associated with (131)I iodine ablation and treatment. Furthermore, potential side effects of radioiodine therapy and alternate or additional treatments to this modality are reviewed. Appendices furnish information on dosimetry and post-therapy scintigraphy.