Management of anticancer treatment in patients under chronic dialysis: results of the multicentric CANDY (CANcer and DialYsis) study

Management of cancer treatments in hemodialysis patients

INTRODUCTION

The number of cancer patients receiving long-term hemodialysis (HD) is increasing, and HD could jeopardize treatments' safety and efficacy. Therefore, managing anticancer drugs is critical in this frail population. In addition, evidence of HD safety or risk is regularly released both for cytotoxic chemotherapy (CT) or hormone therapy (HT) as well as new therapies with molecularly targeted therapies (MTT), immune checkpoint inhibitors (ICI), and a summary of current knowledge is needed.

METHODS

We aimed to synthesize available data on cancer treatments in HD patients using PubMed database, FDA labels, summary of product characteristics (SmPC), FDA and EMA approval documents, guidelines and finally case reports for which relevant pharmacokinetic (PK) data is available.

RESULTS

For CT, recently proposed guidelines were balanced by the publication of particular toxic reports following them. SmPC was helpful in some cases, but no data was found for most CTs. MTT, both oral and monoclonal antibodies, were rarely modified by HD. However, HD patients have particular frailty that could require dose adaptation despite no substantial PK modification. Similarly, exposure to ICIs is unlikely to be modified by HD since immunoglobulins are not dialyzable. For HT, PK characteristics and HD impact were more heterogeneous and were reviewed molecule by molecule.

CONCLUSIONS

We summarized current knowledge on HD and cancer treatments. Data remains scarce, and the latest guidelines rely on few clinical data. There is a need to collect both retrospective and prospective data to better characterize the safety and relevant dose and schedule adaptations whenever needed in this situation to reinforce future guidelines.

PD-L1-negative Non-small-cell Lung Cancer Treated with Nivolumab Plus Ipilimumab during Maintenance Hemodialysis Results in Rapid Initial Progression Followed by a Long-lasting Response

Nivolumab plus ipilimumab is one of the first-line treatments for advanced non-small-cell lung cancer (NSCLC), but the safety and efficacy in patients on hemodialysis (HD) is unclear. We herein report a patient with NSCLC on HD in whom nivolumab and ipilimumab were initiated. We observed general deterioration and enlarged lesions, followed by a long-term response. The patient developed secondary hypoadrenocorticism, an immune-related adverse event that was easily controlled. Nivolumab plus ipilimumab can be used safely for patients with NSCLC on HD. Long-term effectiveness can be observed after initial progression, so we should carefully assess the response.

Maintenance avelumab therapy for urothelial carcinoma in a hemodialysis patient: a case report

In recent years, immune checkpoint inhibitors have attracted attention in treatment for urothelial carcinoma. However, many clinical trials included only patients who had adequate renal function. The efficacy of immune checkpoint inhibitors for hemodialysis patients had not been well-documented. Herein, we report a case of a 73-years-old male with metastatic urothelial carcinoma. He was on maintenance hemodialysis, because he underwent total urinary tract resection for treatment of the urothelial carcinoma in his sixties. He was introduced to our hospital with metastases of lung and pubic bone, and was treated with chemotherapy including gemcitabine and paclitaxel. After two cycles, although his metastases decreased in size, he experienced severe anemia, diarrhea, and duodenitis. Therefore, he transitioned to maintenance therapy with avelumab earlier than initially planned. The treatment achieved 10 months disease control, without significant adverse events. To our best knowledge, this is the first case in which avelumab maintenance therapy achieved disease control of metastatic urothelial carcinoma in a hemodialysis patient.

Chapter 2:indications and dosing of anticancer drug therapy in patients with impaired kidney function, from clinical practice guidelines for the management of kidney injury during anticancer drug therapy 2022

This comprehensive review discusses the dosing strategies of cancer treatment drugs for patients with impaired kidney function, specifically those with chronic kidney disease (CKD), undergoing hemodialysis, and kidney transplant recipients. CKD patients often necessitate dose adjustments of chemotherapeutic agents, e.g., platinum preparations, pyrimidine fluoride antimetabolites, antifolate agents, molecularly targeted agents, and bone-modifying agents, to prevent drug accumulation and toxicity due to diminished renal clearance of the administered drugs and their metabolites. In hemodialysis patients, factors such as drug removal from hemodialysis and altered pharmacokinetics demand careful optimization of anticancer drug therapy, including dose adjustment and timing of administration. While free cisplatin is removed by hemodialysis, most of the tissue- and protein-bound cisplatin remains in the body and rebound cisplatin elevations are observed after hemodialysis. It is not recommended hemodialysis for drug removal, regardless of timing. Kidney transplant patients encounter unique challenges in cancer treatment, as maintaining the balance between reduction of immunosuppression, switching to mTOR inhibitors, and considering potential drug interactions with chemotherapeutic agents and immunosuppressants are crucial for preventing graft rejection and achieving optimal oncologic outcomes. The review underscores the importance of personalized, patient-centric approaches to anticancer drug therapy in patients with impaired kidney function.

Contemporary Monoclonal Antibody Utilization in Glomerular Diseases

Therapeutic monoclonal antibodies (MAbs) have been one of the fastest growing drug classes in the past 2 decades and are indicated in the treatment of cancer, autoimmune disorders, solid organ transplantation, and glomerular diseases. The Food and Drug Administration has approved 100 MAbs between 1986 and 2021, and MAbs account for 20% of Food and Drug Administration's new drug approval every year. MAbs are preferred over traditional immunosuppressive agents because of their high specificity, reduced number of drug-drug interactions, and low toxicity, which make them a prime example of personalized medicine. In this review article, we provide an overview of the taxonomy, pharmacology, and therapeutic applications of MAbs in glomerular diseases. We searched the literature through PubMed using the following search terms: monoclonal antibodies, glomerular diseases, pharmacokinetics, pharmacodynamics, immunoglobulin, murine, chimeric,humanized, and fully human, and limited our search to years 2018-2023. We selected peer-reviewed journal articles with an evidence-based approach, prioritizing randomized control trials in specific glomerular diseases, if available. Advances in the MAb field have resulted in a significant paradigm shift in targeted treatment of immune-mediated glomerular diseases, and multiple randomized control trials are currently being conducted. Increased recognition is critical to expand their use in experimental research and personalized medicine.

Screening for dihydropyrimidine dehydrogenase deficiency by measuring uracilemia in chronic kidney disease patients is associated with a high rate of false positives

BACKGROUND

Pretherapeutic screening for dihydropyrimidine dehydrogenase (DPD) deficiency based on the measurement of plasma uracil ([U]) is recommended prior to the administration of fluoropyrimidine-based chemotherapy. Cancer patients frequently have impaired kidney function, but the extent to which kidney function decline impacts [U] levels has not been comprehensively investigated.

METHODS

We assessed the relationship between DPD phenotypes and estimated glomerular filtration rate (eGFR) in 1751 patients who benefited on the same day from a screening for DPD deficiency by measuring [U] and [UH₂]:[U], and an evaluation of eGFR. The impact of a kidney function decline on [U] levels and [UH₂]:[U] ratio was evaluated.

RESULTS

We observed that [U] was negatively correlated with eGFR, indicating that [U] levels increase as eGFR declines. For each ml/min of eGFR decrease, [U] value increased in average by 0.035 ng/ml. Using the KDIGO classification of chronic kidney disease (CKD), we observed that [U] values >16 ng/ml (DPD deficiency) were measured in 3.6 % and 4.4 % of stage 1 and 2 CKD (normal-high eGFR, >60 ml/min/1.73m²) patients, but in 6.7 % of stage 3A CKD patients (45 to 59 ml/min/1.73m²), 25% of stage 3B CKD patients (30 to 44 ml/min/1.73m²), 22.7% of stage 4 CKD patients (15 to 29 ml/min/1.73m² and 26.7% of stage 5 CKD patients (<15 ml/min/1.73m²). [UH2]:[U] ratios were not impacted by kidney function.

CONCLUSION

DPD phenotyping based on the measurement of plasma [U] in patients with decreased eGFR is associated with an exceedingly high rate of false positives when kidney function decline reaches 45 ml/minute/1.73m² of eGFR or lower. In this population, an alternative strategy that remain to be evaluated would be to measure the [UH₂]:[U] ratio in addition to [U].

Long-Term Response of Pembrolizumab in a Patient with Metastatic Squamous Non-Small Cell Lung Cancer on Hemodialysis: Case Report and Review of the Literature

In patients with renal failure and hemodialysis, there are difficulties in drug selection and dose adjustment for cancer treatment. The use of immune checkpoint inhibitors (ICIs), including pembrolizumab, approved by the U.S. Food and Drug Administration (FDA) for patients with metastatic non-small cell lung cancer (NSCLC) in 2015, has become an important option for the treatment of metastatic NSCLC. However, data regarding the dosage and schedule for long-term use of ICIs, especially pembrolizumab, in hemodialysis patients are limited. We present the case of a patient with metastatic squamous NSCLC who demonstrated a long-term partial response to pembrolizumab monotherapy for 45 months during hemodialysis and showed no immune-related adverse events (irAEs). To our knowledge, this is the longest remission to be reported without irAEs after discontinuation of pembrolizumab in a NSCLC patient undergoing HD. In addition, we reviewed previously reported lung cancer patients who used ICI during dialysis, comparing them with our case in clinical aspect. We believe that this report will provide clinical insights into the long-term efficacy and safety of pembrolizumab in lung cancer patients undergoing hemodialysis.

Differences in the performance of adjuvant chemotherapy between hemodialysis and nonhemodialysis patients

BACKGROUND

The survival of hemodialysis (HD) patients with cancer is poor, which may be caused by undertreatment due to renal dysfunction. Particularly, adjuvant chemotherapy after surgery may be considered optional because of its preventive nature. This study investigated the current frequency of administration of adjuvant chemotherapy to HD patients compared with non-HD patients in Japan.

METHODS

We used data from the Hospital-Based Cancer Registries national database linked to health services utilization data to analyze cases of newly diagnosed colon cancer, gastric cancer, breast cancer, and non-small cell lung cancer (NSCLC) at the stages where adjuvant chemotherapy is generally required. We compared the performance rate of adjuvant chemotherapy and the adjuvant chemotherapy regimens between HD and non-HD patients from October 2011 to December 2017.

RESULTS

Of the 99,761 patients who underwent curative surgery, 1207 (1%) were HD patients. HD patients received adjuvant chemotherapy less frequently than non-HD patients (24% vs. 63%, p < 0.001). After adjusting for potential confounders, HD remained negatively related to adjuvant chemotherapy administration for all four cancer types. Among all patients who received adjuvant chemotherapy 0(N = 61,873), HD patients were less likely to receive standard regimens and chemotherapy requiring dose adjustment than non-HD patients (88% vs. 95%, p < 0.001 and 92% vs. 98%, p < 0.001, respectively). This trend was particularly pronounced among patients with gastric cancer.

CONCLUSIONS

HD patients were less likely to receive adjuvant chemotherapy with standard regimens than non-HD patients.

Improving Cancer Care for Patients With CKD: The Need for Changes in Clinical Trials

Chemotherapeutic agents used to treat cancer generally have narrow therapeutic indices along with potentially serious adverse toxicities. Many cancer drugs are at least partially excreted through the kidney and, thus, the availability of accurate data on safe and effective dosing of these drugs in patients with chronic kidney disease (CKD) is essential to guide treatment decisions. Typically, during drug development, initial clinical studies only include patients with normal or only mildly impaired kidney function. In subsequent preregistration studies, a limited number of patients with more severe kidney dysfunction are included. Data obtained from patients with either severe kidney dysfunction (here defined as an estimated glomerular filtration rate [eGFR] < 30 ml/min or stage 4G CKD) or end-stage kidney disease (ESKD) requiring kidney replacement treatment are particularly limited before drug registration and only a minority of new drug applications to the US Food and Drug Administration (FDA) include data from this population. Unfortunately, limited data and/or other safety concerns may result in a manufacturer statement that the drug is contraindicated in patients with advanced kidney disease, which hinders access to potentially beneficial drugs for these patients. This systemic exclusion of patients with CKD from cancer drug trials remains an unsolved problem, which prevents provision of optimal clinical care for these patients, raises questions of inclusion, diversity, and equity. In addition, with the aging of the population, there are increasing numbers of patients with CKD and cancer who face these issues. In this review, we evaluate the scientific basis to exclude patients with CKD from cancer trials and propose a comprehensive strategy to address this problem.

Gestational trophoblastic neoplasm in a patient with end-stage renal failure (ESRF): the challenges and lessons learnt

Gestational trophoblastic neoplasm (GTN) in end-stage renal failure (ESRF) has not been reported. We reported an unprecedented case of GTN in ESRF from an antecedent partial mole. She had total abdominal hysterectomy and bilateral salpingectomy following the diagnosis as the disease was confined to the uterus. A histopathological examination confirmed an invasive mole. Consequently, she received a total of four cycles of single-agent intravenous actinomycin D as she was at low risk. Despite initial response, her disease metastasised to her right kidney for which radiotherapy was given, followed by a total of 33 doses of weekly paclitaxel. She responded to the chemotherapy and currently remains in remission. The choice of chemotherapy and their side effects due to ESRF remain the main challenges in her management. Total hysterectomy should be considered as the first-line treatment for a hydatidiform mole to prevent GTN. A multidisciplinary approach is important to optimise the efficacy of the treatment with minimal compromise of her safety.

Cemiplimab for Locally Advanced Cutaneous Squamous Cell Carcinoma: A Case Series of 3 Unique Scenarios

Cemiplimab, a monoclonal antibody directed against programmed death receptor 1 (PD-1), has shown promising results in cutaneous squamous cell carcinoma (cSCC). In a nonrandomized trial where cemiplimab 3 mg/kg was given every 2 weeks for up to 96 weeks, a 44% response rate was noted. This case series discusses 3 unique scenarios of patients with advanced cSCC treated with cemiplimab. The first case is of an end stage kidney disease (ESKD) patient with failed living donor kidney transplant who had developed recurrent cSCC despite several excisions and topical 5-flurouracil and acitretin therapy. He received 8 cycles of cemiplimab leading to resolution. This case serves as an example of the safety and efficacy of cemiplimab in a complex patient who is a kidney transplant recipient on hemodialysis. The second case describes an elderly gentleman with inoperable cSCC initially treated with radiotherapy who later received 9 cycles of cemiplimab for recurrent metastatic disease with excellent response. This case supports the safe and effective use of cemiplimab in an elderly patient. In the third case, cSCC presented itself as a large fungating mass that would have otherwise necessitated limb amputation and was successfully treated with 18 cycles of cemiplimab. This case highlights the dramatic response to cemiplimab obviating the need for surgical intervention and resulting in limb salvage.

Pretherapeutic screening for Dihydropyrimidine deshydrogenase deficiency in measuring uracilemia in dialysis patients leads to a high rate of falsely positive results

BACKGROUND

Pretherapeutic screening for dihydropyrimidine dehydrogenase (DPD) deficiency is recommended prior to the administration of fluoropyrimidine-based chemotherapy. However, the best strategy to identify DPD deficiency in End Stage Renal Disease (ESRD) patients is unknown.

METHODS

We assessed the characteristics of both DPD phenotypes and DPYD genotypes in 20 dialyzed patients before and after dialysis session. The extent to which the concentrations of uracil [U] and dihydrouracil [UH₂] were affected by dialysis was evaluated.

RESULTS

Mean [U] was 14 ± 3.3 ng/ml before the dialysis session, and 7.9 ± 2.7 ng/ml after. Notably, mean [U] in 119 non-ESRD patients during the same timeline was 8.7 ± 3.9 ng/ml, which is similar to [U] values after dialysis session (p = 0.38). [U] values > 16 ng/ml were measured in 4 ESRD patients (20%), whereas the rate was 3.3% in the non-ESRD cohort. Whole gene sequencing did not reveal DPYD deleterious allelic variants in the 4 ESRD patients with [U] values > 16 ng/ml. The profile of [UH2] values during dialysis was similar to that of [U]: 385 ± 86 ng/ml before, and 185 ± 62 ng/ml after (mean reduction rate 42.5%). Thus, [UH2]:[U] ratio remained unaffected by dialysis, and was similar to the values in non-ESRD patients (22.4 ± 7.1).

CONCLUSION

Phenotyping based on measuring plasma [U] before a dialysis sessions in ESRD patients is associated with an unacceptable high rate of false positives. The optimal strategy for the identification of patients with DPD deficiency in this population would be the monitor the [UH₂]:[U] ratio, which remains unaffected.

Short-term Outcomes of Liver Resection in Patients With Hemodialysis

BACKGROUND

The number of patients with hemodialysis is increasing increased yearly. Few reports are available on hepatobiliary and gastrointestinal surgery in these patients.

PATIENTS AND METHODS

A total of 222 patients who underwent partial liver resection or segmentectomy in our hospital between January 2015 and September 2019 were included in this study. Patients were divided into the hemodialysis group (n=9) and non-hemodialysis group (n=213).

RESULTS

No significant difference was observed in postoperative complications between the hemodialysis and non-hemodialysis group. The hemodialysis group had a significantly higher infectious complication rates than the non-hemodialysis group (33.3% vs. 8.0%, p=0.009). In logistic regression analysis, hemodialysis was only a significant risk factor for postoperative infectious complications (OR=5.61, 95% CI=1.12-28.20, p=0.036).

CONCLUSION

Liver resections, at least segmentectomy or smaller, is acceptable in patients on hemodialysis. However, these patients may have a higher risk of postoperative infectious complications than other patients.

Prognosis of hemodialysis patients undergoing surgery for gastric cancer: Results of a multicenter retrospective study

BACKGROUND

Little is known about the survival outcomes of and predictive factors for survival in hemodialysis patients undergoing surgery for gastric cancer.

METHODS

We performed a multicenter retrospective study from 9 institutions to investigate the survival outcomes of 75 hemodialysis patients with gastric cancer. Patient characteristics included demographic data, hemodialysis- and gastric cancer-related variables. Multivariate Cox hazards models were applied to determine independent predictors of poor overall survival and non-gastric cancer related death.

RESULTS

Stage I disease was predominant (58.7%) in our series. The overall morbidity and the 30-day mortality rates were 25.3% and 1.3%, respectively. The 5-year overall survival rates of patients with pStages I, II, III, and IV disease were 59.2%, 42.9%, 32.3%, and 0%, respectively. Eleven (14.7%) patients died of gastric cancer, whereas many more (40.0%) died owing to causes other than gastric cancer. Non-gastric cancer-related death was especially prevalent in patients with pStages I (95.2%) and II (75.0%) disease. Multivariable analysis revealed advanced age, long duration of hemodialysis (> 5 years), total gastrectomy, and pStage IV disease to be independently associated with poor overall survival. Notably, advanced age, long duration of hemodialysis, and the presence of cardiovascular disease were all independent predictors of non-gastric cancer-related death. Patients with all 3 factors had very poor survival outcomes (3-year overall survival; 14.3%).

CONCLUSION

The survival outcomes of hemodialysis patients with gastric cancer, especially those with early-stage gastric cancer, were clearly poor, largely owing to the increased risk of non-gastric cancer-related death. Preoperative comorbidities and hemodialytic features were useful for predicting long-term outcomes of this vulnerable population.

Evaluation of Checkpoint Inhibitors in Cancer Patients With End-stage Renal Disease on Hemodialysis: Case Series and Review of the Literature

Checkpoint inhibitors (CPIs) have become standard of care for multiple types of malignancies and while end-stage renal disease is not a contraindication, these patients are frequently excluded from clinical trials. As a result, there is limited data regarding the safety and efficacy of CPI use in this patient population. In this case series, we report outcomes and adverse events in 8 patients on hemodialysis treated with CPIs. Treatment was overall well-tolerated with adverse events in 3 of 8 (37.5%) patients, with 1 (12.5%) having a grade 4 adverse event, which is comparable to the rate reported in literature for the overall population receiving CPI. No treatment related deaths were seen. Because of small sample size, efficacy data is limited. Further studies are needed in this patient population to elucidate the true incidence of adverse events and antitumor activity.

Treatment of Gastric and Gastroesophageal Cancer Patients with Hemodialysis by CapeOX

Two patients underwent hemodialysis. Case 1 with stage IV gastric cancer was treated with reduced doses of capecitabine (1,000 mg/m²/day, days 1 to 14) and oxaliplatin (65 mg/m², day 1). Although grade 1 thrombocytopenia occurred in the first cycle, grade 3 thrombocytopenia developed in the second cycle because of increasing dosage. After the dosage was reduced, chemotherapy was continued safely. Case 2 with stage IA gastroesophageal cancer was treated with radiotherapy followed by chemotherapy. Treatment with the same dose of CapeOX therapy as in case 1 resulted in no severe toxicity. We conclude that a half-dose of the CapeOX regimen is safe for gastric cancer patients undergoing hemodialysis.

Dialysis physicians' referral behaviors for hemodialysis patients suspected of having cancer: A vignette-based questionnaire study

BACKGROUND

Although cancer management in dialysis patients has become a commonly encountered issue, known as "onco-nephrology", few evidence-based clinical recommendations have been proposed. Here, we examined the variation in referral behaviors adopted by dialysis physicians on encountering dialysis patients with signs/symptoms suggestive of cancer.

METHODS

We conducted a vignette-based study in August 2015. We sent a 14-page questionnaire to 191 dialysis physicians, including the representative dialysis facilities participating in a Japanese dialysis cohort (the Japan Dialysis Outcomes and Practice Patterns Study). Using vignette scenarios for respiratory, digestive, and urological areas, we assessed the referral behaviors (expert referral or not) adopted by dialysis physicians on encountering dialysis patients with symptoms suggestive of cancer. Each scenario contained three patient functional factors: age (60 or 75 years), performance status (PS 0 or 1), and cognitive dysfunction (absence or presence). We examined the association between physician factors, patient factors, and referral behaviors.

RESULTS

We obtained 94 replies (response rate: 49.2%). For the respiratory scenarios, 38.3% and 51.9% of physicians reported watchful waiting when encountering bilateral and unilateral pleural effusion, respectively. In digestive and urologic scenarios, most physicians (>85%) selected expert referral. We detected differences in referral behaviors between scenarios with different cancer biological factors. However, we found consistency in referral behaviors within the same scenario, even with different patient functional factors (intra-class correlation coefficients within each scenario all >0.7).

CONCLUSIONS

Physicians' referral behaviors for dialysis patients suspected of having cancer vary for different cancer biological factors (probability of having cancer). However, the referral behaviors are similar for different patient functional factors (age, PS, and cognitive dysfunction).

Dialysis-related practice patterns among hemodialysis patients with cancer

RATIONALE AIMS AND OBJECTIVES

With the achievement of longevity in hemodialysis patients, the risk of comorbid cancer has begun to draw attention. In the present study, we examined dialysis-related practice patterns and compared those patterns by cancer status.

METHODS

Using data from the Japan Dialysis Outcomes and Practice Patterns Study phase 4, we evaluated 2153 hemodialysis patients. Baseline cancer status for patients was separated into 3 categories: no cancer, cancer with recent treatment, and cancer without recent treatment. We then assessed variations among hemodialysis patients in dialysis-related practice patterns, including anemia management, management of mineral and bone metabolism disorder, nutritional management, and dialysis treatment, by cancer status.

RESULTS

We observed both similarities and differences in dialysis-related practice patterns among hemodialysis patients, by cancer status. Hemoglobin levels were largely similar for all cancer statuses, although erythropoiesis stimulating agents dose tended to be higher in hemodialysis patients with recent cancer treatment (multivariable adjusted mean difference of erythropoiesis stimulating agents dose: 5.4 × 103 IU/L/month) than in those without cancer. Phosphorus and calcium levels were also similar. Nutrition statuses were similar among cancer statuses, as were dialysis therapies. These results suggested that physicians do not modulate their dialysis-related practices based on whether or not a hemodialysis patient has cancer.

CONCLUSION

Among long-term facility-based hemodialysis patients with cancer, we detected no statistically significant differences to suggest that cancer status affects hemodialysis practice regarding mineral and bone disorder management, nutritional management, and dialysis treatment. Facility-based hemodialysis patients with recent cancer treatment, however, receive a higher dose of erythropoietin-stimulating agent than those without cancer.

Metastatic castration-resistant prostate cancer and the challenge of a patient with chronic kidney disease in hemodialysis

At a time when the population shows increasing longevity, entities such as cancer and chronic kidney disease (CKD) are more frequently connected. In the United States, approximately 6% of the patients on hemodialysis have cancer. The challenge to manage oncologic patients with CKD in a hemodialytic program represents a great shortage of available information on the choice of the best drug, timing, dosage adjustments, dialysis method, and treatment safety. We present the case of a patient with prostate cancer and terminal CKD in hemodialysis, and the treatment sequence after the development of resistance to hormonal blockade therapy, which included docetaxel, enzalutamide, and radium-223.

Chemotherapy in cancer patients undergoing haemodialysis: a nationwide study in Japan

Background

Cancer is a major cause of death in patients undergoing haemodialysis. However, information about the actual clinical practice of chemotherapy for patients with cancer undergoing haemodialysis is lacking. We conducted a nationwide survey using questionnaires on the clinical practice of chemotherapy for such patients.

Patients and methods

The nationwide survey included patients undergoing haemodialysis who were subsequently diagnosed with cancer in 20 hospitals in Japan from January 2010 to December 2012. We reviewed their clinical data, including cancer at the following primary sites: kidney, colorectum, stomach, lung, liver, bladder, pancreas and breast. The questionnaires consisted of the following subjects: (1) patient characteristics; (2) regimen, dosage and timing of chemotherapy; and (3) clinical outcome.

Results

Overall, 675 patients were registered and assessed for main primary cancer site involvement. Of 507 patients with primary site involvement, 74 patients (15%) received chemotherapy (44 as palliative chemotherapy and 30 as perioperative chemotherapy). The most commonly used cytotoxic drugs were fluoropyrimidine (15 patients), platinum (8 patients) and taxane (8 patients), and the dosage and timing of these drugs differed between institutions; however, the dosage of molecular targeted drugs (24 patients) and hormone therapy drugs (15 patients) was consistent. The median survival time of patients receiving palliative chemotherapy was 13.0 months (0.1-60.3 months). Three patients (6.8%) died from treatment-related causes and nine patients (20%) died of causes other than cancer. Of the 30 patients who received perioperative chemotherapy, 6 (20%) died of causes other than cancer within 3 years after the initiation of chemotherapy.

Conclusion

Among the haemodialysis patients with cancer who received chemotherapy, the rates of mortality from causes other than cancer might be high for both palliative and perioperative chemotherapy. Indications for the use of chemotherapy in patients undergoing haemodialysis should be considered carefully.

Relationship Between Mortality and Cancer-Bearing Status in Patients With Chronic Kidney Disease Who Attended an Educational Program

Patients with malignancy have a poorer prognosis than others do, which must be taken into consideration when treating them for chronic kidney disease (CKD). However, there are few studies investigating their prognosis. This was an observational study of 515 (394 men and 121 women) stable non-dialysis patients with CKD who attended a CKD educational program. Mean age was 68.8 ± 13.0 years. Median follow-up was 968.5 days. Mean creatinine was 3.4 ± 1.6 mg/dL. Of these, 63 had malignancy and 452 did not; 20.6% of the former and 11.9% of the latter group died by the end of the study period (P = 0.0548). Malignancy was not associated with all-cause mortality (HR: 1.3475, 95% CI: 0.7202-2.5214, P = 0.3507) but with malignancy-associated mortality (HR: 3.9477, 95% CI: 1.6348-9.5331, P = 0.0023). Renal replacement therapy was not associated with mortality. Since malignancy greatly affects the prognosis, it must be taken into consideration when treating these patients.

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.

Urgent Chemotherapy for Life-Threatening Complications Related to Solid Neoplasms

OBJECTIVES

Solid neoplasms can be directly responsible for organ failures at the time of diagnosis or relapse. The management of such specific complications relies on urgent chemotherapy and eventual instrumental or surgical procedures, combined with advanced life support. We conducted a multicenter study to address the prognosis of this condition.

DESIGN

A multicenter retrospective (2001-2015) chart review.

SETTING

Medical and respiratory ICUs.

PATIENTS

Adult patients who received urgent chemotherapy in the ICU for organ failure related to solid neoplasms were included. The modalities of chemotherapy, requirements of adjuvant instrumental or surgical procedures, and organ supports were collected. Endpoints were short- and long-term survival rates.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty-six patients were included. Lung cancer was the most common malignancy distributed into small cell lung cancer (n = 57) and non-small cell lung cancer (n = 33). The main reason for ICU admission was acute respiratory failure in 111 patients (81.6%), of whom 89 required invasive mechanical ventilation. Compression and tissue infiltration by tumor cells were the leading mechanisms resulting in organ involvement in 78 (57.4%) and 47 (34.6%) patients. The overall in-ICU, in-hospital, 6-month, and 1-year mortality rates were 37%, 58%, 74%, and 88%, respectively. Small cell lung cancer was identified as an independent predictor of hospital survival. However, this gain in survival was not sustained since the 1-year survival rates of small cell lung cancer, non-small cell lung cancer, and non-lung cancer patients all dropped below 20%.

CONCLUSIONS

Urgent chemotherapy along with aggressive management of organ failures in the ICU can be lifesaving in very selected cancer patients, most especially with small cell lung cancer, although the long-term survival is hardly sustainable.

Management of patients with end-stage renal disease undergoing chemotherapy: recommendations of the Associazione Italiana di Oncologia Medica (AIOM) and the Società Italiana di Nefrologia (SIN)

Background

The overall risk of some cancers is increased in patients receiving regular dialysis treatment due to chronic oxidative stress, a weakened immune system and enhanced genomic damage. These patients could benefit from the same antineoplastic treatment delivered to patients with normal renal function, but a better risk/benefit ratio could be achieved by establishing specific guidelines. Key considerations are which chemotherapeutic agent to use, adjustment of dosages and timing of dialysis in relation to the administration of chemotherapy.

Methods

We have reviewed available data present in the literature, including recommendations and expert opinions on cancer risk and use of chemotherapeutic agents in patients with end-stage renal disease. Experts selected by the boards of the societies provided additional information which helped greatly in clarifying some issues on which clear-cut information was missing or available data were conflicting.

Results

Data on the optimal use of chemotherapeutic agents or on credible schemes of polychemotherapy in haemodialysed patients are sparse and mainly derive from case reports or small case series. However, recommendations on dosing and timing of dialysis can be proposed for the most prescribed chemotherapeutic agents.

Discussion

The use of chemotherapeutic agents as single agents, or in combination, can be safely given in patients with end-stage renal disease. Appropriate dosage adjustments should be considered based on drug dialysability and pharmacokinetics. Coordinated care between oncologists, nephrologists and pharmacists is of pivotal importance to optimise drug delivery and timing of dialysis.

Relationship Between Mortality and Cancer-Bearing Status at Time of Dialysis Initiation

Patients with malignancy are reported to have poorer prognosis than those without malignancy. When patients with malignancy develop end-stage kidney disease, clinicians must determine treatment with consideration of prognosis. Furthermore, malignancy is sometimes found at time of dialysis initiation. However, prognosis of patients with malignancy at time of dialysis initiation has not been investigated. A total of 1524 patients with chronic kidney disease who initiated dialysis at 17 centers participating in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis were included. Patients initiated dialysis between October 2011 and September 2013. Mortality rates were compared between patients with and without malignancy. Types of malignancy and respective prognoses also were assessed. The study included 1030 men and 492 women with a mean age of 67.5 ± 13.1 years. Of these, 92 had malignancy and 1430 did not; 45.7% of the former group and 16.0% of the latter group died by March 2015 (P < 0.01). Even after adjusting for various factors, presence of malignancy remained an independent risk factor for mortality (P < 0.01). Patients with performance status (PS) of 0 had significantly lower mortality (P < 0.01). Patients with malignancy at time of dialysis initiation had poor prognosis. Therefore, presence of malignancy should be taken into consideration when patients initiate dialysis. In patients with malignancy, better PS was associated with better prognosis.

Pharmacokinetic/pharmacodynamic considerations for cancer patients undergoing hemodialysis

INTRODUCTION

The increased incidence of cancer in hemodialysis patients has been discussed since the mid-70s. Today, physicians regularly encounter situations where they must manage the prescription of anticancer drugs in hemodialysis patients. Areas covered: Hemodialysis patients are at risk of dose-related toxicities due to pharmacokinetic modifications. Hemodialysis patients are at risk of therapeutic drug removal during their hemodialysis session, which may result in a loss of efficacy. In the advent of novel immunotherapies, particularly tumor vaccines, there is an increased theoretical risk of pharmacodynamic modification. Indeed, pharmacodynamic modifications have already been reported for viral vaccines. Expert opinion: It is important to consider all of the potential pharmacokinetic/pharmacodynamic modifications before prescribing anticancer drugs in hemodialysis patients. However, pharmacokinetic/pharmacodynamic modification should not be considered a contraindication for anticancer drug use in hemodialysis patients, rather, clinicians should be aware of the need individualize treatment according to available recommendations.

Safety and efficacy of pembrolizumab in a patient with advanced melanoma on haemodialysis

Patients with end-stage renal disease present with a distinct challenge in oncology. Many anticancer drugs and their metabolites are excreted by the kidney, but data to guide dose and schedule adjustments in renal dialysis are scant. Pembrolizumab is an anti-programmed cell death protein 1 monoclonal antibody proven to be effective in patients with metastatic melanoma. It has demonstrated promising results and was granted US Food and Drug Administration (FDA) approval in September, 2014 for metastatic melanoma. It was additionally approved for patients with metastatic non-small cell lung cancer by the FDA in October, 2015. We present the first case, to the best of our knowledge, of a patient with metastatic melanoma successfully treated with pembrolizumab while on haemodialysis.

Anticancer Drugs in End-Stage Kidney Disease Patients

The increased incidence of malignancies in patients with chronic kidney patients and especially in end-stage kidney disease (ESKD) patients has been discussed since the mid-1970s. Consequently, oncologists, nephrologists, and pharmacists are increasingly facing challenging situations of cytotoxic drug handling in dialysis patients because of pharmacokinetic modifications. In these patients, two main issues must be considered. First, the absence of renal function in hemodialysis (HD) patients may necessitate drug dosage reduction. Therefore, drug prescription must be cautiously checked before administration with appropriate dosage adjustment whenever necessary to ensure efficacy while avoiding overdosage and related side effects. Second, drug clearance by dialysis session must be taken into account for appropriate chemotherapy timing administration to avoid drug removal, which may result in a loss of efficacy. These two main considerations must not be considered as a contra-indication to chemotherapy in ESKD patients, but more as a need for an individualized prescription according to available recommendations.

Renal effects of targeted anticancer therapies

The use of novel targeted anticancer agents has led to overall improvement in the prognosis of many patients affected by various malignancies, but has also been associated with an increased risk of poorly characterized toxic effects to different organs, including the kidneys. The high prevalence of kidney impairment in the general population complicates the issue further. Nephrologists most frequently work with patients with cancer when they are asked to investigate kidney function to assess the need for dose adjustments in anticancer therapy. A thorough knowledge of the renal safety profile of novel life-prolonging anticancer therapies, specific features of their metabolism, and pharmacokinetic and pharmacodynamic properties (under normal circumstances as well as in the setting of renal replacement therapy) is, therefore, necessary to preserve kidney function as far as possible and to ensure optimum treatment. In this Review we summarize the present knowledge of renal toxic effects from novel targeted anticancer agents and discuss whether the management of patients' treatment needs to be modified. We also advocate the development of a new onconephrology subspeciality.