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Kitchlu A, Silva VTCE, Anand S, Kala J, Abudayyeh A, Inker LA, Rosner MH, Karam S, Gudsoorkar P, Gupta S, Chen S, Klomjit N, Leung N, Milanez T, Motwani SS, Khalid SB, Srinivasan V, Wanchoo R, Beumer JH, Liu G, Tannir NM, Orchanian-Cheff A, Geng Y, Herrmann SM. Assessment of GFR in Patients with Cancer: A Statement from the American Society of Onco-Nephrology. Clin J Am Soc Nephrol 2024; 19:1061-1072. [PMID: 38848131 PMCID: PMC11321742 DOI: 10.2215/cjn.0000000000000508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Accurate assessment of GFR is crucial to guiding drug eligibility, dosing of systemic therapy, and minimizing the risks of both undertreatment and toxicity in patients with cancer. Up to 32% of patients with cancer have baseline CKD, and both malignancy and treatment may cause kidney injury and subsequent CKD. To date, there has been lack of guidance to standardize approaches to GFR estimation in the cancer population. In this two-part statement from the American Society of Onco-Nephrology, we present key messages for estimation of GFR in patients with cancer, including the choice of GFR estimating equation, use of race and body surface area adjustment, and anticancer drug dose-adjustment in the setting of CKD. These key messages are based on a systematic review of studies assessing GFR estimating equations using serum creatinine and cystatin C in patients with cancer, against a measured GFR comparator. The preponderance of current data involving validated GFR estimating equations involves the CKD Epidemiology Collaboration (CKD-EPI) equations, with 2508 patients in whom CKD-EPI using serum creatinine and cystatin C was assessed (eight studies) and 15,349 in whom CKD-EPI with serum creatinine was assessed (22 studies). The former may have improved performance metrics and be less susceptible to shortfalls of eGFR using serum creatinine alone. Since included studies were moderate quality or lower, the American Society of Onco-Nephrology Position Committee rated the certainty of evidence as low. Additional studies are needed to assess the accuracy of other validated eGFR equations in patients with cancer. Given the importance of accurate and timely eGFR assessment, we advocate for the use of validated GFR estimating equations incorporating both serum creatinine and cystatin C in patients with cancer. Measurement of GFR via exogenous filtration markers should be considered in patients with cancer for whom eGFR results in borderline eligibility for therapies or clinical trials.
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Affiliation(s)
- Abhijat Kitchlu
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Verônica T. Costa E. Silva
- Serviço de Nefrologia, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica (LIM) 16, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Shuchi Anand
- Department of Medicine (Nephrology), Stanford University, Stanford, California
| | - Jaya Kala
- Division of Renal Diseases and Hypertension, University of Texas Health Science Center at Houston-McGovern Medical School, Houston, Texas
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health, Charlottesville, Virginia
| | - Sabine Karam
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Prakash Gudsoorkar
- Division of Nephrology, Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, Ohio
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sheldon Chen
- Section of Nephrology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Nattawat Klomjit
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Tomaz Milanez
- Institute of Oncology Ljubljana and Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenija
| | - Shveta S. Motwani
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Sheikh B. Khalid
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Vinay Srinivasan
- Division of Nephrology, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, New Jersey
| | - Rimda Wanchoo
- Division of Kidney Diseases and Hypertension, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
| | - Jan H. Beumer
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Geoffrey Liu
- Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nizar M. Tannir
- Division of Cancer Medicine, Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Yimin Geng
- Section of Nephrology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sandra M. Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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Yanagita M, Muto S, Nishiyama H, Ando Y, Hirata S, Doi K, Fujiwara Y, Hanafusa N, Hatta T, Hoshino J, Ichioka S, Inoue T, Ishikura K, Kato T, Kitamura H, Kobayashi Y, Koizumi Y, Kondoh C, Matsubara T, Matsubara K, Matsumoto K, Okuda Y, Okumura Y, Sakaida E, Shibagaki Y, Shimodaira H, Takano N, Uchida A, Yakushijin K, Yamamoto T, Yamamoto K, Yasuda Y, Oya M, Okada H, Nangaku M, Kashihara N. Clinical questions and good practice statements of clinical practice guidelines for management of kidney injury during anticancer drug therapy 2022. Clin Exp Nephrol 2024; 28:85-122. [PMID: 37878114 PMCID: PMC10808569 DOI: 10.1007/s10157-023-02415-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/26/2023]
Affiliation(s)
- Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
- Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Kyoto, Japan.
| | - Satoru Muto
- Department of Urology, Graduate School of Medicine, Juntendo University, Bunkyo City, Tokyo, Japan
| | - Hiroyuki Nishiyama
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuichi Ando
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan
| | - Sumio Hirata
- Department of Academic Education, I and H Co., Ltd, Ashiya, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Bunkyo City, Tokyo, Japan
| | - Yutaka Fujiwara
- Department of Thoracic Oncology, Aichi Cancer Center, Nagoya, Japan
| | - Norio Hanafusa
- Department of Blood Purification, Tokyo Women's Medical University, Shinjuku City, Tokyo, Japan
| | - Takahiro Hatta
- Department of Respiratory Medicine, Anjo Kosei Hospital, Anjo, Japan
| | - Junichi Hoshino
- Department of Nephrology, Tokyo Women's Medical University, Shinjuku City, Tokyo, Japan
| | - Satoko Ichioka
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Takamitsu Inoue
- Department of Renal and Urologic Surgery, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Minato, Kanagawa, Japan
| | - Taigo Kato
- Department of Urology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Kitamura
- Department of Urology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yusuke Kobayashi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Minato, Tokyo, Japan
| | - Yuichi Koizumi
- Department of Pharmacy, Seichokai Fuchu Hospital, Izumi, Japan
| | - Chihiro Kondoh
- Departments of Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazuo Matsubara
- Department of Pharmacy, Wakayama Medical University Hospital, Wakayama, Japan
| | | | - Yusuke Okuda
- Department of Pediatrics, Kitasato University School of Medicine, Minato, Kanagawa, Japan
| | - Yuta Okumura
- Department of Gastrointestinal and Medical Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, Saint Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Hideki Shimodaira
- Division of Medical Oncology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Nao Takano
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akiko Uchida
- Department of Nursing, Seirei Sakura Citizen Hospital, Chiba, Japan
| | - Kimikazu Yakushijin
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Takehito Yamamoto
- Department of Pharmacy, The University of Tokyo Hospital, Bunkyo City, Tokyo, Japan
| | | | - Yoshinari Yasuda
- Department of Nephrology, Internal Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Minato, Tokyo, Japan
| | - Hirokazu Okada
- Department of Nephrology, Saitama Medical University, Saitama, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, Bunkyo City, Tokyo, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
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Berton M, Bettonte S, Stader F, Battegay M, Marzolini C. Repository Describing the Anatomical, Physiological, and Biological Changes in an Obese Population to Inform Physiologically Based Pharmacokinetic Models. Clin Pharmacokinet 2022; 61:1251-1270. [PMID: 35699913 PMCID: PMC9439993 DOI: 10.1007/s40262-022-01132-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/24/2022]
Abstract
Background Obesity is associated with physiological changes that can affect drug pharmacokinetics. Obese individuals are underrepresented in clinical trials, leading to a lack of evidence-based dosing recommendations for many drugs. Physiologically based pharmacokinetic (PBPK) modelling can overcome this limitation but necessitates a detailed description of the population characteristics under investigation. Objective The purpose of this study was to develop and verify a repository of the current anatomical, physiological, and biological data of obese individuals, including population variability, to inform a PBPK framework. Methods A systematic literature search was performed to collate anatomical, physiological, and biological parameters for obese individuals. Multiple regression analyses were used to derive mathematical equations describing the continuous effect of body mass index (BMI) within the range 18.5–60 kg/m2 on system parameters. Results In total, 209 studies were included in the database. The literature reported mostly BMI-related changes in organ weight, whereas data on blood flow and biological parameters (i.e. enzyme abundance) were sparse, and hence physiologically plausible assumptions were made when needed. The developed obese population was implemented in Matlab® and the predicted system parameters obtained from 1000 virtual individuals were in agreement with observed data from an independent validation obese population. Our analysis indicates that a threefold increase in BMI, from 20 to 60 kg/m2, leads to an increase in cardiac output (50%), liver weight (100%), kidney weight (60%), both the kidney and liver absolute blood flows (50%), and in total adipose blood flow (160%). Conclusion The developed repository provides an updated description of a population with a BMI from 18.5 to 60 kg/m2 using continuous physiological changes and their variability for each system parameter. It is a tool that can be implemented in PBPK models to simulate drug pharmacokinetics in obese individuals.
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Affiliation(s)
- Mattia Berton
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Sara Bettonte
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Imoto Y, Naito T, Miyadera Y, Ono T, Kawakami J. Associations between plasma hydroxylated metabolite of itraconazole and serum creatinine in patients with a hematopoietic or immune-related disorder. Eur J Clin Pharmacol 2020; 77:369-379. [PMID: 33033881 DOI: 10.1007/s00228-020-03010-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Serum markers of renal function have not been characterized in patients treated with itraconazole (ITZ). This study aimed to evaluate the associations between plasma ITZ and its hydroxylated metabolite (OH-ITZ) concentrations and serum markers of renal function in patients with hematopoietic or immune-related disorder. METHODS This study enrolled 40 patients with hematopoietic or immune-related disorder who are receiving oral ITZ solution. Plasma concentrations of ITZ and OH-ITZ at 12 h after dosing were determined at steady state. Their relationships with serum levels of creatinine and cystatin C and their estimated glomerular filtration rate (eGFR) were evaluated. RESULTS The free plasma concentration of ITZ had no correlation with serum creatinine and serum creatinine-based estimated glomerular filtration rate (eGFR-cre). The free plasma concentration of OH-ITZ was positively and negatively correlated with serum creatinine and eGFR-cre, respectively. The free plasma concentrations of ITZ and OH-ITZ had no association with serum cystatin C and serum cystatin C-based eGFR. Serum creatinine was higher by 16% after than before starting ITZ treatment, while eGFR-cre was lower by 9.3%. The serum creatinine ratio after/before ITZ treatment was positively correlated with the free plasma concentration of OH-ITZ. The patients co-treated with trimethoprim-sulfamethoxazole had higher serum creatinine. Concomitant glucocorticoid administration did not significantly alter serum cystatin C. CONCLUSIONS Patients with hematopoietic or immune-related disorder treated with oral ITZ had a higher level of serum creatinine. Although serum creatinine potentially increases in conjunction with the free plasma concentration of OH-ITZ, concomitant ITZ administration has a slight impact on the eGFR-cre level in clinical settings.
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Affiliation(s)
- Yumi Imoto
- Department of Hospital Pharmacy, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Takafumi Naito
- Department of Hospital Pharmacy, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
| | - Yukari Miyadera
- Department of Hospital Pharmacy, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Takaaki Ono
- Division of Hematology, Internal Medicine 3, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Junichi Kawakami
- Department of Hospital Pharmacy, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Influence of muscle mass on the estimation of glomerular filtration rate in Japanese terminal cancer patients. Clin Exp Nephrol 2020; 24:876-884. [PMID: 32621075 DOI: 10.1007/s10157-020-01906-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/16/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Estimated glomerular filtration rate (eGFR) based on serum cystatin C (Scys) is useful for patients with decreased muscle mass, but has been also reported to be affected by cancer. The usefulness of Scys in eGFR in terminal cancer patients with decreased muscle mass is unknown. Therefore, we analyzed appropriate eGFR formulae for terminal cancer patients. METHODS Study design was a retrospective observational study. Based on creatinine height index (CHI), 184 terminal cancer patients were stratified into CHI ≥ 90% (normal muscle mass, 59 patients); CHI 60-89% (mildly to moderately decreased muscle mass, 64 patients); and CHI < 60% (severely decreased muscle mass, 61 patients) groups. Twenty-four-hour creatinine clearance was measured and converted to the glomerular filtration rate (GFR) as a renal function measure. To estimate GFR, various eGFR formulae for Japanese were used: eGFRScys, eGFRScr5 and eGFRScr3, eGFRaverage and eGFRScys-Scr, and eGFRCG, based on Scys, serum creatinine (Scr), Scys and Scr combined, and Cockcroft-Gault formula (CG), respectively. Errors between measured and estimated values of renal function were verified using mean prediction errors (ME). When a 95% confidence interval (CI) of ME included 0, the accuracy of the eGFR formula was graded as good. RESULTS eGFRScys ME was 0.2 (95% CI lower limit - 3.7, upper limit 4.0) mL/min/1.73 m2 in CHI 60-89% group and 9.2 (6.1, 12.9) mL/min/1.73 m2 in CHI < 60% group. eGFRScys was most accurate among the eGFR formulae. CONCLUSIONS eGFR based on Scys was demonstrated as useful in terminal cancer patients with decreased muscle mass.
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Teaford HR, Barreto JN, Vollmer KJ, Rule AD, Barreto EF. Cystatin C: A Primer for Pharmacists. PHARMACY 2020; 8:E35. [PMID: 32182861 PMCID: PMC7151673 DOI: 10.3390/pharmacy8010035] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/22/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Pharmacists are at the forefront of dosing and monitoring medications eliminated by or toxic to the kidney. To evaluate the effectiveness and safety of these medications, accurate measurement of kidney function is paramount. The mainstay of kidney assessment for drug dosing and monitoring is serum creatinine (SCr)-based estimation equations. Yet, SCr has known limitations including its insensitivity to underlying changes in kidney function and the numerous non-kidney factors that are incompletely accounted for in equations to estimate glomerular filtration rate (eGFR). Serum cystatin C (cysC) is a biomarker that can serve as an adjunct or alternative to SCr to evaluate kidney function for drug dosing. Pharmacists must be educated about the strengths and limitations of cysC prior to applying it to medication management. Not all patient populations have been studied and some evaluations demonstrated large variations in the relationship between cysC and GFR. Use of eGFR equations incorporating cysC should be reserved for drug management in scenarios with demonstrated outcomes, including to improve pharmacodynamic target attainment for antibiotics or reduce drug toxicity. This article provides an overview of cysC, discusses evidence around its use in medication dosing and in special populations, and describes practical considerations for application and implementation.
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Affiliation(s)
- Hilary R. Teaford
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
| | - Jason N. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
| | - Kathryn J. Vollmer
- College of Pharmacy and Health Sciences, Drake University, Des Moines, IA 50311, USA;
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA;
- Division of Epidemiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
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The value of serum cystatin C in early evaluation of renal insufficiency in patients undergoing chemotherapy: a systematic review and meta-analysis. Cancer Chemother Pharmacol 2019; 83:561-571. [PMID: 30610366 DOI: 10.1007/s00280-018-3762-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 12/18/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Several studies have shown that cystatin C levels can be used to detect decline in renal function in cancer patients receiving chemotherapy, and can serve as a supplement to creatinine level measurement for early detection of renal insufficiency. Nevertheless, use of the parameter remains controversial. This study aimed to assess the value of serum cystatin C levels in evaluation of early renal insufficiency due to chemotherapy. METHODS Studies were retrieved from PubMed, Ovid Embase, the Web of Science, the Cochrane Library, Ovid, and the CNKI databases up to May 15, 2018. Serum levels of cystatin C before and after chemotherapy were evaluated for its ability to assess renal function. RESULTS A total of 12 studies, including 1775 participants, met our inclusion and exclusion criteria. Pooled analysis revealed that the levels of serum cystatin C in cancer patients after chemotherapy were significantly higher than those of patients prior to treatment [standard mean difference (SMD) = 0.54, 95% CI 0.34-0.74, P = 0.0000]. Compared to creatinine, serum cystatin C increased significantly in the early phases of glomerular filtration rate (GFR) change before and after chemotherapy (GFR ≥ 90 ml/min/1.73 m2, P < 0.05 vs. P > 0.05, 5.83%; 60 < GFR < 90 ml/min/1.73 m2, P < 0.01 vs. P > 0.01, 38.83%) and increased more substantially in the later phases (GFR < 60 ml/min/1.73 m2, P < 0.01 vs. P < 0.01, 70.87% vs. 23.09%). However, creatinine decreased even in the early phases and did not increase in an obvious manner until the later phases (GFR < 60 ml/min/1.73 m2, P < 0.01, 23.09%). The GFR values were derived from measured methods. CONCLUSIONS Cystatin C may be superior to creatinine for the detection of minor changes in GFR in early stages of renal insufficiency secondary to chemotherapy. More studies are needed to further verify this result.
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Kwon WS, Kim TS, Nahm CH, Moon Y, Kim JJ. Aberrant cystatin-C expression in blood from patients with breast cancer is a suitable marker for monitoring tumor burden. Oncol Lett 2018; 16:5583-5590. [PMID: 30344712 PMCID: PMC6176264 DOI: 10.3892/ol.2018.9380] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 03/30/2017] [Indexed: 01/05/2023] Open
Abstract
The present study was performed to evaluate the efficacy of circulating cystatin-C as a tumor monitoring biomarker at different clinical time points in patients with breast cancer over a long-term follow-up period. In addition, the secretory rate of circulating cystatin-C from cancer tissue was investigated by comparing the blood and tissue expression levels of cystatin-C. Blood samples from healthy volunteers (40 males and 40 females) were obtained at yearly health examinations if laboratory and imaging abnormalities were not detected. Blood samples from 34 patients with breast cancer were obtained at 205 different time points of clinical progression. Blood levels of cystatin-C were measured using ELISA and the tissue levels were measured using immunohistochemistry. No age-associated effect was observed in male and female blood cystatin-C levels. The positivity rate was 46% in patients (38/83) and 40% in samples collected at different time points (82/205). Blood cystatin-C levels were lowest following surgery compared with patients with systemic metastasis (P<0.001). The sensitivity, specificity and accuracy rates of ELISA were 53.6, 63.6 and 53.9%, respectively. The concordance rate between blood and tissue expression was 38%. The main reason for discordance between tissue and serum expression of cytostatin-C came from low serum positivity in samples showing tissue cytostatin-C (3/11, 27%). The specificity between cytostatin-C and CA-125 was highest in tumor absence state. In conclusion, elevated blood levels of cystatin-C were observed in 40% of breast cancer cases and were tumor-volume dependent. However, the concordance rate between tissue and blood was quite low, suggesting tumor heterogeneity of cystatin-C expression or co-acting pathway activation, such as cathepsin D. As one-third of breast cancer tissues express cystatin-C without cancer antigen 15-3 elevation, cystatin-C may represent a good tumor-monitoring marker in breast cancer.
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Affiliation(s)
- Woo Sun Kwon
- Song-Dang Institute for Cancer Research, Cancer Metastasis Research Center, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Tae Soo Kim
- Song-Dang Institute for Cancer Research, Cancer Metastasis Research Center, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chung Hyun Nahm
- Department of Laboratory Medicine, Inha University College of Medicine, Incheon 22332, Republic of Korea
| | - Yeonsook Moon
- Department of Laboratory Medicine, Inha University College of Medicine, Incheon 22332, Republic of Korea
| | - Jin Ju Kim
- Department of Laboratory Medicine, Inha University College of Medicine, Incheon 22332, Republic of Korea
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Delanaye P, Guerber F, Scheen A, Ellam T, Bouquegneau A, Guergour D, Mariat C, Pottel H. Discrepancies between the Cockcroft-Gault and Chronic Kidney Disease Epidemiology (CKD-EPI) Equations: Implications for Refining Drug Dosage Adjustment Strategies. Clin Pharmacokinet 2017; 56:193-205. [PMID: 27417226 DOI: 10.1007/s40262-016-0434-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The dosages of many medications require adjustment for renal function. There is debate regarding which equation, the Chronic Kidney Disease Epidemiology (CKD-EPI) equation vs. the Cockcroft-Gault (CG) equation, should be recommended to estimate glomerular filtration rate. METHODS We used a mathematical simulation to determine how patient characteristics influence discrepancies between equations and analyzed clinical data to demonstrate the frequency of such discrepancies in clinical practice. In the simulation, the modifiable variables were sex, age, serum creatinine, and weight. We considered estimated glomerular filtration rate results in mL/min, deindexed for body surface area, because absolute excretory function (rather than per 1.73 m2 body surface area) determines the rate of filtration of a drug at a given plasma concentration. An absolute and relative difference of maximum (±) 10 mL/min and 10 %, respectively, were considered concordant. Clinical data for patients aged over 60 years (n = 9091) were available from one hospital and 25 private laboratories. RESULTS In the simulation, differences between the two equations were found to be influenced by each variable but age and weight had the biggest effect. Clinical sample data demonstrated concordance between CKD-EPI and CG results in 4080 patients (45 %). The majority of discordant results reflected a CG result lower than the CKD-EPI equation. With aging, the CG result became progressively lower than the CKD-EPI result. When weight increased, the opposite occurred. DISCUSSION The choice of equation for excretory function adjustment of drug dosage will have different implications for patients of different ages and body habitus. CONCLUSIONS The optimum equation for drug dosage adjustment should be defined with consideration of individual patient characteristics.
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Affiliation(s)
- Pierre Delanaye
- Division of Nephrology, Dialysis and Transplantation, CHU Sart Tilman, University of Liège (ULg-CHU), 4000, Liège, Belgium.
| | | | - André Scheen
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines, University of Liège, Liège, Belgium
| | - Timothy Ellam
- Sheffield Kidney Institute, Northern General Hospital and Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Antoine Bouquegneau
- Division of Nephrology, Dialysis and Transplantation, CHU Sart Tilman, University of Liège (ULg-CHU), 4000, Liège, Belgium
| | - Dorra Guergour
- Biochemistry Laboratory, Grenoble University Hospital, Grenoble, France
| | - Christophe Mariat
- Division of Nephrology, Dialysis, Transplantation and Hypertension, CHU Hôpital Nord, University Jean Monnet, PRES Université de LYON, Saint-Etienne, France
| | - Hans Pottel
- Department of Public Health and Primary Care, KU, Leuven Kulak, Kortrijk, Belgium
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10
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Jones M, Denieffe S, Griffin C, Tinago W, Fitzgibbon MC. Evaluation of cystatin C in malignancy and comparability of estimates of GFR in oncology patients. Pract Lab Med 2017; 8:95-104. [PMID: 28856234 PMCID: PMC5575377 DOI: 10.1016/j.plabm.2017.05.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 03/31/2017] [Accepted: 05/18/2017] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Creatinine is the biomarker of choice for use in estimates of kidney function in oncology patients. However as non-renal factors such as muscle mass can influence creatinine concentrations, we evaluated cystatin C as an alternative biomarker and its incorporation in GFR estimating formulae in an oncology setting. Measured GFR is infrequently undertaken in adult clinical practice with the consequent reliance on calculated GFR for patient assessment. DESIGN AND METHODS Cystatin C and creatinine concentrations were evaluated from 134 oncology patients prior to commencing chemotherapeutic cycles. Estimates of creatinine clearance (Cockroft-Gault) and GFR (using Hoek, Jonsson, MDRD and CKD-EPI) were evaluated. Cystatin C-based GFR estimates (using CKD-EPI CysC and CKD-EPI SCr/CysC) were compared with the creatinine-based GFR estimates (CG, MDRD and CKD-EPI SCr) within the GFR ranges of 60-89, 45-59 and ≤44 mL/min/1.73 m2. RESULTS Cystatin C concentrations were significantly higher in oncology patients both prior to commencing chemotherapy (F: P<0.01 and M: P<0.0001) and during cycles of treatment (F: P<0.0001 and M: P<0.01) when compared with a reference population. Cystatin C concentrations also increased significantly during chemotherapy (P<0.0001) in a subset of female patients evaluated. Poor agreement (average 42%) was demonstrated between CKD-EPI CysC and creatinine-based GFR estimates within the investigated GFR ranges, with improved agreement (average 55%) when using the combined CKD-EPI SCr/CysC formula. CONCLUSIONS This study demonstrated a malignancy and treatment-mediated effect on cystatin C measures, which may confound its clinical utility in estimating GFR in oncology patients.
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Affiliation(s)
- Melissa Jones
- Department of Clinical Chemistry and Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Ciara Griffin
- Department of Clinical Biochemistry, Mater Private Hospital, Dublin, Ireland
| | | | - Maria C. Fitzgibbon
- Department of Clinical Chemistry and Diagnostic Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Ireland
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11
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Tong Y, Liu X, Guan M, Wang M, Zhang L, Dong D, Niu R, Zhang F, Zhou Y. Evaluation of Serological Indicators and Glomerular Filtration Rate Equations in Chinese Cancer Patients. Med Sci Monit 2017. [PMID: 28623247 PMCID: PMC5486681 DOI: 10.12659/msm.902138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background The performance of estimated glomerular filtration rate (eGFR) have been proved to vary according to the races of the target population. The eGFR equations have not been validated in the Chinese cancer population received chemotherapy. Meanwhile, serum cystatin C (CysC), urea, β2 microglobulin (β2-MG), and creatinine (SCr) were also evaluated in a cohort of Chinese cancer patients. Material/Methods A total of 1000 cancer patients undergoing combination chemotherapy and 108 healthy volunteers were included in this study, and their renal function parameters were evaluated. The eGFR values were compared with reference GFR (rGFR) according to correlation, consistency, precision, and accuracy. Receiver operating characteristic (ROC) curves were used to evaluate the discriminating ability of the GFR equations and serological indicators of renal function. Results (1) The equations contained CysC had the same varying tendency as rGFR in relation to the chemotherapeutic cycle. (2) eGFRscr+cysc and eGFRChinese scr+cysc worked better than the other equations, as indicated by a stronger correlation, less bias, improved precision, higher accuracy, and greater AUC. (3) CysC was more sensitive than the other serological indicators for identifying early renal injury. (4) Each parameter showed different characteristics in subgroups of Chinese cancer patients. Conclusions CysC was the most sensitive marker for early renal injury. Among the 8 most commonly used eGFR equations, the combination equation eGFRscr+cysc and eGFRChinese scr+cysc exhibited the best performance in the assessment of the renal function of Chinese cancer patients.
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Affiliation(s)
- Yingna Tong
- Department of Clinical Laboratory, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China (mainland)
| | - Xiaobin Liu
- Department of Clinical Laboratory, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China (mainland)
| | - Mingxiu Guan
- Department of Clinical Laboratory, Tianjin Baodi Affiliated Hospital of Tianjin Medical University, Tianjin, China (mainland)
| | - Meng Wang
- Department of Clinical Laboratory, Capital Medical University Beijing Obstetrics and Gynecology Hospital, Beijing, China (mainland)
| | - Lufang Zhang
- Department of Clinical Laboratory, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China (mainland)
| | - Dong Dong
- Department of Clinical Laboratory, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China (mainland)
| | - Ruifang Niu
- Public Laboratory, Key Laboratory of Breast Cancer Prevention and Therapy, Ministry of Education, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Medical University, Tianjin, China (mainland)
| | - Fei Zhang
- Public Laboratory, Key Laboratory of Breast Cancer Prevention and Therapy, Ministry of Education, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Medical University, Tianjin, China (mainland)
| | - Yunli Zhou
- Department of Clinical Laboratory, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China (mainland)
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12
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Correlation of Serum Cystatin C with Glomerular Filtration Rate in Patients Receiving Platinum-Based Chemotherapy. Anal Cell Pathol (Amst) 2016; 2016:4918325. [PMID: 28078200 PMCID: PMC5203881 DOI: 10.1155/2016/4918325] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/12/2016] [Indexed: 11/18/2022] Open
Abstract
Objectives. Serum cystatin C seems to be an accurate marker of glomerular filtration rate (GFR) compared to serum creatinine. The aim of this work was to explore the possibility of using serum cystatin C instead of serum creatinine to early predict renal failure in cancer patients who received platinum based chemotherapy. Design and Methods. Serum creatinine, serum cystatin C concentrations, and GFR were determined simultaneously in 52 cancer patients received carboplatin-based or cisplatin-based chemotherapy. Serum creatinine was assayed on Cobas C6000-Roche, serum cystatin C assay was performed on AIA 360-Tosoh, and GFR was determined in all patients, before the first cycle of chemotherapy and before the subsequent administrations. Results. In the overall series, for the prediction of a fall of GFR < 80 mL/min/1.73 m2, the AUC of the ROC curve for cystatin C was 0,667 and the best threshold was 1.135 mg/L (sensitivity 90.5%, specificity 61.1%). For a GFR fall < 60 mL/min/1.73 m2, the AUC of ROC curve for cystatin C was 74.3% and the best threshold was 1.415 mg/L (sensitivity 66.7%, specificity 73.2%). Conclusions. Baseline cystatin C values were not able to predict renal failure during subsequent treatment. In conclusion, serum cystatin C is not a reliable early marker to efficiently predict renal failure in patients receiving chemotherapy.
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13
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Chew-Harris JSC, Chin PKL, Florkowski CM, George P, Endre Z. Removal of body surface area normalisation improves raw-measured glomerular filtration rate estimation by the Chronic Kidney Disease Epidemiology Collaboration equation and drug dosing in the obese. Intern Med J 2016; 45:766-73. [PMID: 25904102 DOI: 10.1111/imj.12791] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/16/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND/AIM We aimed to compared estimated glomerular filtration rate (eGFR) according to the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI), with (mL/min/1.73 m(2) ) and without body surface area (BSA) normalisation (CKD-EPI_noBSA, mL/min) against measured (99m) Technetium - diethylenepentaacetic acid (Tc-DTPA GFR) (mL/min) in 222 individuals, including 80 with malignancy. METHODS BSA was calculated for each individual using the Du Bois equation. The CKD-EPI and CKD-EPI_noBSA equations were compared with measured Tc-DTPA GFR with respect to bias, proportion within 30% of GFR (P30) and root mean square error for predicting levels of GFR, and concordance in relation to carboplatin dosing. RESULTS The mean (SD) for BSA and measured GFR for the entire group was 1.99 (0.25) m(2) and 127 (41) mL/min respectively. The P30 for Tc-DTPA GFR was significantly higher with the CKD-EPI_noBSA (80%) than with the CKD-EPI equation (63%, P = 0.0001). In those with body mass index (BMI) > 30 kg/m(2) , the P30 values for the CKD-EPI_noBSA and CKD-EPI were 74% and 42% respectively (P < 0.0001). Carboplatin dosing concordance for the cancer patients using the CKD-EPI and CKD-EPI_noBSA equation was 71% and 56% respectively (P = 0.07). In 78 individuals with BMI > 30 kg/m(2) , concordance in relation to carboplatin dosing using CKD-EPI_noBSA was 65% compared with 26% with the CKD-EPI (P < 0.0001). CONCLUSION The CKD-EPI without normalisation (CKD-EPI_noBSA) equation was superior to the CKD-EPI equation in estimating raw-measured Tc-DTPA GFR (mL/min).
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Affiliation(s)
- J S C Chew-Harris
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.,Pathology, University of Otago, Christchurch, New Zealand
| | - P K L Chin
- Medicine, University of Otago, Christchurch, New Zealand.,Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - C M Florkowski
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.,Pathology, University of Otago, Christchurch, New Zealand
| | - P George
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.,Pathology, University of Otago, Christchurch, New Zealand
| | - Z Endre
- Medicine, University of Otago, Christchurch, New Zealand.,Prince of Wales Hospital, Sydney, Australia
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14
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Delanaye P, Flamant M, Cavalier É, Guerber F, Vallotton T, Moranne O, Pottel H, Boffa JJ, Mariat C. [Dosing adjustment and renal function: Which equation(s)?]. Nephrol Ther 2015; 12:18-31. [PMID: 26602880 DOI: 10.1016/j.nephro.2015.07.472] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022]
Abstract
While the CKD-EPI (for Chronic Kidney Disease Epidemiology) equation is now implemented worldwide, utilization of the Cockcroft formula is still advocated by some physicians for drug dosage adjustment. Justifications for this recommendation are that the Cockcroft formula was preferentially used to determine dose adjustments according to renal function during the development of many drugs, better predicts drugs-related adverse events and decreases the risk of drug overexposure in the elderly. In this opinion paper, we discuss the weaknesses of the rationale supporting the Cockcroft formula and endorse the French HAS (Haute Autorité de santé) recommendation regarding the preferential use of the CKD-EPI equation. When glomerular filtration rate (GFR) is estimated in order to adjust drug dosage, the CKD-EPI value should be re-expressed for the individual body surface area (BSA). Given the difficulty to accurately estimate GFR in the elderly and in individuals with extra-normal BSA, we recommend to prescribe in priority monitorable drugs in those populations or to determine their "true" GFR using a direct measurement method.
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Affiliation(s)
- Pierre Delanaye
- Service de néphrologie, dialyse et transplantation, CHU Sart-Tilman, université de Liège, 4000 Liège, Belgique
| | - Martin Flamant
- Service d'explorations fonctionnelles, hôpital Bichat, AP-HP, université Paris Diderot, Paris, France
| | - Étienne Cavalier
- Service de chimie clinique, CHU Sart-Tilman, université de Liège, 4000 Liège, Belgique
| | - Fabrice Guerber
- Laboratoire Oriade-Vizille, 75, chemin de la Terrasse, 38220 Vizille, France
| | - Thomas Vallotton
- Laboratoire Vialle, Bastia et Syndicat des jeunes biologistes médicaux, 20600 BastiaFrance
| | - Olivier Moranne
- EA 2415, biostatistique, épidémiologie et santé publique, institut universitaire de recherche clinique, université de Montpellier, 34093 Montpellier, France
| | - Hans Pottel
- Department of Primary Care and Public Health at Kulak, KU Leuven Kulak, 8500 Kortrijk, Belgique
| | - Jean-Jacques Boffa
- Inserm 1155, service de néphrologie et dialyse, hôpital Tenon, AP-HP, université Pierre-et-Marie-Curie, 75020 Paris, France
| | - Christophe Mariat
- Service de néphrologie, dialyse et transplantation, hôpital Nord, CHU de Saint-Étienne, université Jean-Monnet, 42055 Saint-Étienne, France.
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15
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Renal function evaluation in patients with cancer who were scheduled to receive carboplatin or S-1. Clin Exp Nephrol 2015; 19:1107-13. [PMID: 25894220 DOI: 10.1007/s10157-015-1115-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Accurate glomerular filtration rate (GFR) evaluation is significant for drug dosing of carboplatin, anticancer drug excreted mainly from kidney. Serum cystatin-C (sCys-C) is a GFR marker with little affected by body muscle mass volume. And GFR equations based on serum creatinine (eGFRcreat) and sCys-C (eGFRcys) were developed; however, accuracy of eGFRcys has not been elucidated fully among patients with cancer. Therefore, we analyzed the performance of GFR equations among patients with cancer whose GFR values were measured by inulin clearance (Cin). METHODS Study design was a cross-sectional study. Subjects were 41 patients with cancer whose GFR values were measured by Cin for drug dosing studies of carboplatin or S-1 in Nagoya University Hospital from 2007 to 2010 and 29 non-cancer patients. Correlation with Cin and slope of regression line were evaluated in eGFRcreat and eGFRcys. Single and multiple regression analyses were analyzed to identify associating factors with eGFRcreat/Cin or eGFRcys/Cin. RESULTS Age, body weight, body mass index (BMI) and sCr were different between cancer patients and non-cancer patients, but sCys-C and Cin were consistent in 2 groups. The slope of the regression line for Cin vs. eGFRcys with zero intercept in cancer patients was 1.10 (95 % CI: 1.02-1.17), which was significantly different from 1.0. In multiple regression analysis revealed that BMI and urinary creatinine excretion were significantly associated with eGFRcreat/Cin, and cancer was only associating factor with eGFRcys/Cin. CONCLUSION eGFRcys should not be used for evaluation of renal function in patients with cancer because it underestimates GFR.
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