Nephrotic syndrome as a complication of intravesical BCG treatment of transitional cell carcinoma of urinary bladder

The prognosis and safety of continuous saline bladder irrigation in patients after transurethral resection of bladder tumors: a systematic review and meta-analysis of comparative study

The prognosis and safety of continuous saline bladder irrigation (CSBI) after transurethral resection of bladder tumor (TURB) as an alternative method needs to be explored. A literature review and meta-analysis were performed by searching PubMed, EMBASE, Cochrane Library databases and original references of the included articles. PRISMA checklists were followed. We used the GRADEpro GDT to assess the certainty of evidence from the results of our meta-analysis. A total of eight articles including 1600 patients were studied. The results indicated that patients received CSBI after TURB had no statistical differences compared to the control group in the recurrence-free survival and progression-free survival. However, the CSBI group showed significant improvements compared to the control group in terms of the number of recurrences during follow-up and the period to first recurrence except for the number of tumor progression during follow-up. Furthermore, patients treated with CSBI did not show an inferior effect than those treated with immediate intravesical chemotherapy (IC) in respects of recurrence-free survival, progression-free survival, the number of recurrences during follow-up, the number of tumor progression during follow-up and the period to first recurrence. But the immediate IC group had a higher incidence than the CSBI group in terms of macrohematuria, micturition pain, frequency of urination, dysuria, retention and local toxicities. Patients treated with CSBI after TURB showed a significant improvement compared to the control group in terms of the number of recurrences during follow-up and the period to first recurrence. However, compared to immediate IC, CSBI did not show an inferior effect except for lower incidence of adverse reactions.PROSPERO registration number CRD42021247088.

Autoimmune disorders caused by intravesical bacillus Calmette-Guerine treatment: A systemic review

Intravesical bacillus Calmette-Guérin (BCG) is a common and highly effective treatment for non-muscle invasive urothelial carcinoma of the urinary bladder. BCG may cause an autoimmune reaction in some patients. One hundred and fifty-eight papers were analyzed, for a total of hundred and thirty patients with reactive arthritis, sixty patients with ocular manifestations and eighteen patients with other rheumatologic diseases. Among 130 subjects with reactive arthritis, an autoimmune symptom occurred after 5 instillations of intravesical BCG (IQR 4-6), which represents 5 weeks in most cases. Fifty-one patients had concurrent ocular involvement. The resolution of symptoms was achieved in a median of 32.5 days (IQR 14-90). Forty-two men and twenty women had ocular manifestations, most commonly conjunctivitis. Patients with HLA-B27 typing had earlier presentation of ocular symptoms related to the number of instillations (4.5 vs 6 [p < 0.05]. Resolution of symptoms was achieved at a median of 128 days (IQR 21-150). Among patients treated with NSAIDs (either with or without steroids), the duration of the disease was significantly shorter in both the articular and the ocular groups (28 vs. 120 [p < 0.05] and 30 vs.105 [p < 0.05], respectively). Other autoimmune manifestations included general autoimmune diseases, such as vasculitis, psoriasis and myasthenia gravis.

Acute Kidney Injury in Cancer Immunotherapy Recipients

Cancer immunotherapy has now entered clinical practice and has reshaped the standard of care for many cancer patients. With these new strategies, specific toxicities have emerged, and renal side effects have been described. In this review, we will describe the causes of acute kidney injury in CAR T cell, immune checkpoint inhibitors and other cancer immuno-therapy recipients. CAR T cell therapy and bispecific T cell engaging antibodies can lead to acute kidney injury as a consequence of cytokine release syndrome, tumor lysis syndrome, sepsis or specific CAR T cell infiltration. Immune checkpoint blockade most often results in acute tubular interstitial nephritis, but glomerular diseases have also been described. Although the pathophysiology remains mostly elusive, we will describe the mechanisms of renal damage in these contexts, its prognosis and treatment. As the place of immunotherapy in the anti-cancer armamentarium is exponentially increasing, close collaboration between nephrologists and oncologists is of utmost importance to provide the best standard of care for these patients.

Adverse Renal Effects of Anticancer Immunotherapy: A Review

Modern oncological therapy utilizes various types of immunotherapy. Immune checkpoint inhibitors (ICIs), chimeric antigen receptor T cells (CAR-T) therapy, cancer vaccines, tumor-targeting monoclonal antibodies (TT-mAbs), bispecific antibodies and cytokine therapy improve patients' outcomes. However, stimulation of the immune system, beneficial in terms of fighting against cancer, generates the risk of harm to other cells in a patient's body. Kidney damage belongs to the relatively rare adverse events (AEs). Best described, but still, superficially, are renal AEs in patients treated with ICIs. International guidelines issued by the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) cover the management of immune-related adverse events (irAEs) during ICI therapy. There are fewer data concerning real occurrence and possible presentations of renal adverse drug reactions of other immunotherapeutic methods. This implies the need for the collection of safety data during ongoing clinical trials and in the real-life world to characterize the hazard related to the use of new immunotherapies and management of irAEs.

Acute Tubulointerstitial Nephritis in Clinical Oncology: A Comprehensive Review

Acute kidney injury in patients who suffer a malignancy is a common complication. Due to its high prevalence and effective treatment, one of the most frequent causes that both oncologists and nephrologists must be aware of is acute tubulointerstitial nephritis (ATIN). ATIN is an immunomediated condition and the hallmark of the disease, with the presence of a tubulointerstitial inflammatory infiltrate in the renal parenchyma. This infiltrate is composed mainly of T lymphocytes that can be accompanied by macrophages, neutrophils, or eosinophils among other cells. One of the major causes is drug-related ATIN, and some antineoplastic treatments have been related to this condition. Worthy of note are the novel immunotherapy treatments aimed at enhancing natural immunity in order to defeat cancer cells. In the context of the immunosuppression status affecting ATIN patients, some pathogen antigens can trigger the development of the disease. Finally, hematological malignancies can also manifest in the kidney leading to ATIN, even at the debut of the disease. In this review, we aim to comprehensively examine differential diagnosis of ATIN in the setting of a neoplastic patient.

Overnight continuous saline irrigation after transurethral resection for non-muscle-invasive bladder cancer is helpful in prevention of early recurrence

INTRODUCTION

It has been reported that many methods prevent recurrence after transurethral resection of bladder tumour (TURBT) for non-muscle-invasive bladder cancer (NMIBC), but it has rarely been reported that overnight continuous saline irrigation is effective in preventing recurrence. The purpose of this study was to evaluate the efficacy of overnight continuous saline irrigation in preventing recurrence after TURBT.

METHODS

We retrospectively studied patients with NMIBC who underwent TURBT from January 2010 to May 2015 at our institution. Patients who underwent cystoscopy every 12 weeks during the first year after surgery were included. Patients with cancer stage ≥pT2, lymph node metastasis, or distant metastasis were excluded. The overnight continuous saline irrigation (OCSI) group and the no irrigation group were compared and analyzed.

RESULTS

A total of 332 patients were included in the study. There were no differences in the basic characteristics of the patients between the two groups. In the OCSI group, the recurrence-free survival rate was higher than that in the no irrigation group, indicating that there was a significant difference between the two groups (p=0.032).

CONCLUSIONS

After TURBT surgery, OCSI may help prevent early recurrence of NMIBC.

Emerging concepts and spectrum of renal injury following Intravesical BCG for non-muscle invasive bladder cancer

Background

Intravesical Bacilli Calmette-Guerin (IVBCG) therapy for non-muscle invasive bladder cancer (NMIBC) has long been in use successfully. Albeit rarely, we still face with its safety concerns more than 25 years on since its approval by US Food and Drug Agency in 1990. Local and systemic infection following intravesical BCG is widely reported as compared to immune mediated local or systemic hypersensitivity reactions involving kidneys; acute kidney injury (AKI) and other renal manifestations are well reported but not of chronic kidney disease (CKD).

Case

An interesting case of a female was referred to nephrologists in advanced stages of CKD at an eGFR of 10 ml/min/1.73² following IVBCG for NMIBC. Our patient’s renal function plateaued when IVBCG was held; and worsened again when reinstilled. It introduces the concept of ‘repetitive’ immune mediated renal injury presenting as progressive CKD rather than AKI, as is generally reported. Although response was poor, corticosteroids stopped CKD progression to end stage renal disease.

Conclusions

We highlight the need for increased awareness and early recognition of IVBCG renal complications by both urologists and nephrologists in order to prevent progressive and irreversible renal damage. Low incidence of IVBCG renal complications may also be due to under recognition in the era prior to CKD Staging and AKI Network (and AKI e-alerts) that defined AKI as a rise in serum creatinine of ≥26umol/L; hence an unmet need for urgent prospective studies. Major literature review focuses on emerging spectrum of histopathological IVBCG related renal complications and their outcomes.

Complications of intravesical bacillus calmette-guérin

Intravesical Bacillus Calmette-Guérin (BCG) is an important treatment for the management of non-muscle invasive bladder cancer because of its proven efficacy and favourable safety profile. The most common complications associated with BCG treatment are relatively minor. They include urinary frequency, cystitis, fever, and hematuria. Although serious complications are rare, patients can develop severe, life-threatening sepsis with disseminated mycobacterial infection. We report a rare case of periurethral diverticulum formation after intravesical BCG and review the literature on the potential complications of this treatment modality.