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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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Delanaye P, Pottel H, Cavalier E, Flamant M, Stehlé T, Mariat C. Diagnostic standard: assessing glomerular filtration rate. Nephrol Dial Transplant 2024; 39:1088-1096. [PMID: 37950562 DOI: 10.1093/ndt/gfad241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Indexed: 11/12/2023] Open
Abstract
Creatinine-based estimated glomerular filtration rate (eGFR) is imprecise at individual level, due to non-GFR-related serum creatinine determinants, including atypical muscle mass. Cystatin C has the advantage of being independent of muscle mass, a feature that led to the development of race- and sex-free equations. Yet, cystatin C-based equations do not perform better than creatinine-based equations for estimating GFR unless both variables are included together. The new race-free Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation had slight opposite biases between Black and non-Black subjects in the USA, but has poorer performance than that the previous version in European populations. The European Kidney Function Consortium (EKFC) equation developed in 2021 can be used in both children and adults, is more accurate in young and old adults, and is applicable to non-white European populations, by rescaling the Q factor, i.e. population median creatinine, in a potentially universal way. A sex- and race-free cystatin C-based EKFC, with the same mathematical design, has also be defined. New developments in the field of GFR estimation would be standardization of cystatin C assays, development of creatinine-based eGFR equations that incorporate muscle mass data, implementation of new endogenous biomarkers and the use of artificial intelligence. Standardization of different GFR measurement methods would also be a future challenge, as well as new technologies for measuring GFR. Future research is also needed into discrepancies between cystatin C and creatinine, which is associated with high risk of adverse events: we need to standardize the definition of discrepancy and understand its determinants.
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Affiliation(s)
- Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium
- Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| | - Hans Pottel
- Department of Public Health and Primary Care, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium
| | - Martin Flamant
- Assistance Publique-Hôpitaux de Paris, Bichat Hospital, and Université Paris Cité, UMR 1149, Paris, France
| | - Thomas Stehlé
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Christophe Mariat
- Service de Néphrologie, Dialyse et Transplantation Rénale, Hôpital Nord, CHU de Saint-Etienne, France
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Sengul N, Gültürk I, Yilmaz M, Celik E, Paksoy N, Yekedüz E, Ürün Y, Basaran M, Özgüroğlu M. Safety and efficacy of nivolumab therapy in patients with metastatic renal cell carcinoma and impaired kidney function. Actas Urol Esp 2024; 48:273-280. [PMID: 38570033 DOI: 10.1016/j.acuroe.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Patients with renal insufficiency, usually defined as those with creatinine clearance < 40 mL/min, were excluded from pivotal clinical trials, especially in studies involving nivolumab therapy in patients with renal cell carcinoma (RCC). The aim of the study is to evaluate the efficacy and safety of nivolumab in patients with metastatic RCC (mRCC) stratified according to creatinine clearance. MATERIAL AND METHODS Data from mRCC patients treated with nivolumab were retrospectively analyzed. Patients were classified into two categories according to their estimated glomerular filtration rate (eGFR); the first category (C1) included patients with eGFR < 40 mL/min/1.73 m2 and the second category (C2) included those with eGFR ≥ 40 mL/min/1.73 m2. RESULTS Of the 95 patients enrolled, 1. group included 26 patients (27.4%) and 2. group included 69 patients (72.6%). None of the pts in category 1 were on hemodialysis. Overall incidence of adverse events was not statistically different between the two groups (P = .469). The overall response rate ORR was 50% in the first group and 42.0% in the second group (P = .486). Median overall survival (OS) was longer with 23.3 months in the 2. group versus 11 months in the 1. group (P = .415). CONCLUSION Renal insufficiency is a common problem in patients with advanced renal cancer since they often undergo nephrectomy and their renal function may also worsen while receiving tyrosine kinase inhibitor therapy. We found that there is no significant difference in the safety and efficacy of nivolumab treatment between two groups. Nivolumab appears to be a safe and effective agent in patients with renal impairment.
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Affiliation(s)
- N Sengul
- Servicio de Oncología Médica, Facultad de Medicina Cerrahpasa, Universidad de Estambul-Cerrahpasa, Estambul, Turkey
| | - I Gültürk
- Departamento de Oncología Médica, Bakirkoy Hospital de Formación e Investigación Dr. Sadi Konuk, Estambul, Turkey.
| | - M Yilmaz
- Departamento de Oncología Médica, Bakirkoy Hospital de Formación e Investigación Dr. Sadi Konuk, Estambul, Turkey
| | - E Celik
- Servicio de Oncología Médica, Facultad de Medicina Cerrahpasa, Universidad de Estambul-Cerrahpasa, Estambul, Turkey
| | - N Paksoy
- Servicio de Oncología Médica, Instituto de Oncología, Facultad de Medicina, Universidad de Estambul, Estambul, Turkey
| | - E Yekedüz
- Servicio de Oncología Médica, Facultad de Medicina, Universidad de Ankara, Ankara, Turkey
| | - Y Ürün
- Servicio de Oncología Médica, Facultad de Medicina, Universidad de Ankara, Ankara, Turkey
| | - M Basaran
- Servicio de Oncología Médica, Instituto de Oncología, Facultad de Medicina, Universidad de Estambul, Estambul, Turkey
| | - M Özgüroğlu
- Servicio de Oncología Médica, Facultad de Medicina Cerrahpasa, Universidad de Estambul-Cerrahpasa, Estambul, Turkey
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Trevisani F, Simeoni M, Bettiga A, Cinque A, Floris M. Measurement of Glomerular Filtration Rate in Patients Undergoing Renal Surgery for Cancer: Estimated Glomerular Filtration Rate versus Measured Glomerular Filtration Rate in the Era of Precision Medicine. Kidney Blood Press Res 2024; 49:336-344. [PMID: 38636485 DOI: 10.1159/000538854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND In the era of precision medicine, determining reliable renal function assessment remains a critical and debatable issue, especially in nephrology and oncology. SUMMARY This paper delves into the significance of accurately measured glomerular filtration rate (mGFR) in clinical practice, highlighting its essential role in guiding medical decisions and managing kidney health, particularly in the context of renal cancer (RC) patients undergoing nephrotoxic anti-cancer drugs. The limitations and advantages of traditional glomerular filtration rate (GFR) estimation methods, primarily using serum biomarkers like creatinine and cystatin C, are discussed, emphasizing their possible inadequacy in cancer patients. Specifically, newer formulae designed for GFR estimation in cancer patients may not perform at best in RC patients. The paper explores various methods for direct GFR measurement, including the gold standard inulin clearance and alternatives like iohexol plasma clearance. KEY MESSAGE Despite the logistical challenges of these methods, their implementation is crucial for accurate renal function assessment. The paper concludes by emphasizing the need for continued research and innovation in GFR measurement methodologies to improve patient outcomes, particularly in populations with complex medical needs.
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Affiliation(s)
- Francesco Trevisani
- Urological Research Institute (URI), Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Unit of Urology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Biorek srl, San Raffaele Scientific Institute, Milan, Italy
| | - Mariadelina Simeoni
- Department of Translational Medical Sciences University of Campania "Luigi Vanvitelli, Naples, Italy
| | - Arianna Bettiga
- Unit of Urology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Matteo Floris
- Department of Nephrology, Dialysis, and Transplantation, ARNAS G. Brotzu, Cagliari, Italy
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Butrovich MA, Qin J, Xue X, Ivy SP, Nolin TD, Beumer JH. Impact of the 2021 CKD-EPI equation on anticancer pharmacotherapy in black and non-black cancer patients. Cancer Lett 2024; 586:216679. [PMID: 38307411 PMCID: PMC10939791 DOI: 10.1016/j.canlet.2024.216679] [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: 12/09/2023] [Revised: 01/14/2024] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
Cancer and kidney disease disproportionately impact Black patients. The CKD-EPI2021 equation was developed to estimate glomerular filtration rate (eGFR) without using race. We assessed the impact of using CKD-EPI2021 instead of CKD-EPI2009 or Cockcroft-Gault (CG) on dosing and eligibility of anticancer drugs in Black and non-Black patients. Utilizing the National Cancer Institute Theradex database, deindexed eGFR (mL/min) was calculated for 3931 patients (8.6 % Black) using CKD-EPI2021, CKD-EPI2009, and CG. Dosing simulations based on each eGFR were performed for ten anticancer drugs with kidney function-based eligibility or dosing cutoffs. eGFR differences using CKD-EPI2021 versus CKD-EPI2009 varied between Black and non-Black patients (p < 0.001); on average, Black patients had 10.3 mL/min lower eGFR and non-Black patients had 4.2 mL/min higher eGFR using CKD-EPI2021. This corresponded to a difference in relative odds of cisplatin ineligibility using CKD-EPI2021 versus CKD-EPI2009; Black patients had 48 % higher odds of ineligibility and non-Black patients had 27 % lower odds of ineligibility using CKD-EPI2021 (p < 0.001). When using CKD-EPI2021 versus CG, eGFR differences were similar between Black and non-Black patients (p = 0.679) and relative difference in odds of cisplatin ineligibility did not vary. Using CKD-EPI2021 versus CKD-EPI2009 differentially impacts Black versus non-Black cancer patients; Black patients have lower calculated eGFR and are less likely to receive full doses of drug using CKD-EPI2021. From the historical default of CG, adopting CKD-EPI2021 would not disparately impact patients based on race, but would result in Black patients being less likely to receive full doses of drug than if CKD-EPI2009 were used.
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Affiliation(s)
- Morgan A Butrovich
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jiyue Qin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, NY, 10461, USA; Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
| | - Xiaonan Xue
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, NY, 10461, USA
| | - S Percy Ivy
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jan H Beumer
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Hematology/Oncology Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Inker LA, Chami A, Levey AS. Do We Need a New Creatinine-Based Estimated GFR Equation for Kidney Transplant Recipients? Am J Kidney Dis 2024; 83:257-259. [PMID: 37844726 DOI: 10.1053/j.ajkd.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/15/2023] [Accepted: 08/28/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
| | - Ashtar Chami
- Division of Transplant Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Stryczyńska-Mirocha A, Łącki-Zynzeling S, Borówka M, Niemir ZI, Kozak S, Owczarek AJ, Chudek J. A study indicates an essential link between a mild deterioration in excretory kidney function and the risk of neutropenia during cancer chemotherapy. Support Care Cancer 2023; 31:549. [PMID: 37656293 PMCID: PMC10473980 DOI: 10.1007/s00520-023-08015-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Neutropenia, defined as a number of neutrophils in patients' blood specimen lower than 1500 cells/μm3, is a common adverse event during myelosuppressive oncological chemotherapy, predisposing to febrile neutropenia (FN). Patients with coexisting moderate-to-severe chronic kidney disease (CKD) have an increased risk of FN, included in the guidelines for the primary prophylaxis of FN. However, this does not include mild kidney function impairment with estimated glomerular filtration rate (eGFR) 60-89 ml/min/1.73 m2. This prospective study analyzed the risk of neutropenia in patients on chemotherapy without indication for the primary prophylaxis of FN. METHODS The study enrolled 38 patients starting chemotherapy, including 26 (68.4%) patients aged 65 years or more. The median duration of follow-up was 76 days. The methodology of creatinine assessment enabled the use of the recommended CKD-EPI formula for identifying patients with a mild reduction of glomerular filtration. RESULTS Sixteen (42.1%) patients developed at least G2 neutropenia without episodes of FN. Only five (13.1%) patients had eGFR < 60 ml/min/1.73 m2, while 15 (62.5%) eGFR < 90 ml/min/1.73 m2. The relative risk of neutropenia in patients with impaired eGFR was over six times higher than in patients with eGFR > 90 ml/min/1.73 m2 (RR = 6.08; 95%CI:1.45-27.29; p < 0.01). CONCLUSIONS Our observation indicates that even a mild reduction in eGFR is a risk factor for the development of neutropenia and a potential risk factor for FN. Authors are advised to check the author instructions for the journal they are submitting to for word limits and if structural elements like subheadings, citations, or equations are permitted.
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Affiliation(s)
| | - Stanisław Łącki-Zynzeling
- Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia, Reymonta 8, 40-029 Katowice, Poland
| | - Maciej Borówka
- Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia, Reymonta 8, 40-029 Katowice, Poland
| | - Zofia I. Niemir
- Department of Nephrology, Transplantology and Internal Diseases, Poznań University of Medical Sciences, Poznań, Al. Przybyszewskiego 49, 60-355 Katowice, Poland
| | - Sylwia Kozak
- Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia, Reymonta 8, 40-029 Katowice, Poland
| | - Aleksander J. Owczarek
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| | - Jerzy Chudek
- Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia, Reymonta 8, 40-029 Katowice, Poland
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Kleeman SO, Thakir TM, Demestichas B, Mourikis N, Loiero D, Ferrer M, Bankier S, Riazat-Kesh YJ, Lee H, Chantzichristos D, Regan C, Preall J, Sinha S, Rosin N, Yipp B, de Almeida LG, Biernaskie J, Dufour A, Tober-Lau P, Ruusalepp A, Bjorkegren JL, Ralser M, Kurth F, Demichev V, Heywood T, Gao Q, Johannsson G, Koelzer VH, Walker BR, Meyer HV, Janowitz T. Cystatin C is glucocorticoid responsive, directs recruitment of Trem2+ macrophages, and predicts failure of cancer immunotherapy. CELL GENOMICS 2023; 3:100347. [PMID: 37601967 PMCID: PMC10435381 DOI: 10.1016/j.xgen.2023.100347] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 03/23/2023] [Accepted: 05/30/2023] [Indexed: 08/22/2023]
Abstract
Cystatin C (CyC), a secreted cysteine protease inhibitor, has unclear biological functions. Many patients exhibit elevated plasma CyC levels, particularly during glucocorticoid (GC) treatment. This study links GCs with CyC's systemic regulation by utilizing genome-wide association and structural equation modeling to determine CyC production genetics in the UK Biobank. Both CyC production and a polygenic score (PGS) capturing predisposition to CyC production were associated with increased all-cause and cancer-specific mortality. We found that the GC receptor directly targets CyC, leading to GC-responsive CyC secretion in macrophages and cancer cells. CyC-knockout tumors displayed significantly reduced growth and diminished recruitment of TREM2+ macrophages, which have been connected to cancer immunotherapy failure. Furthermore, the CyC-production PGS predicted checkpoint immunotherapy failure in 685 patients with metastatic cancer from combined clinical trial cohorts. In conclusion, CyC may act as a GC effector pathway via TREM2+ macrophage recruitment and may be a potential target for combination cancer immunotherapy.
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Affiliation(s)
- Sam O. Kleeman
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| | | | | | | | - Dominik Loiero
- Department of Pathology and Molecular Pathology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Miriam Ferrer
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| | - Sean Bankier
- BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Computational Biology Unit, Department of Informatics, University of Bergen, Bergen, Norway
| | | | - Hassal Lee
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| | - Dimitrios Chantzichristos
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology Diabetes and Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Claire Regan
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| | | | - Sarthak Sinha
- Department of Comparative Biology and Experimental Medicine, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Nicole Rosin
- Department of Comparative Biology and Experimental Medicine, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Bryan Yipp
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Luiz G.N. de Almeida
- Department of Biochemistry and Molecular Biology and Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | - Jeff Biernaskie
- Department of Comparative Biology and Experimental Medicine, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Antoine Dufour
- Department of Biochemistry and Molecular Biology and Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
| | | | - Arno Ruusalepp
- Department of Cardiac Surgery, Tartu University Hospital, Tartu, Estonia
| | - Johan L.M. Bjorkegren
- Department of Genetics & Genomic Sciences, Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Markus Ralser
- Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Kurth
- Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Todd Heywood
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| | - Qing Gao
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology Diabetes and Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Viktor H. Koelzer
- Department of Pathology and Molecular Pathology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Oncology and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Brian R. Walker
- BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Tobias Janowitz
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
- Cancer Institute, Northwell Health, New Hyde Park, NY, USA
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9
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Hatta T, Hase T, Hara T, Kimura T, Kojima E, Abe T, Horio Y, Goto Y, Ozawa N, Yogo N, Shibata H, Shimokata T, Oguri T, Yamamoto M, Yanagisawa K, Ando M, Ando Y, Kondo M, Ishii M, Hasegawa Y. Adjustment of creatinine clearance for carboplatin dosing in Calvert's formula and clinical efficacy for lung cancer. Cancer Med 2023; 12:15955-15969. [PMID: 37351560 PMCID: PMC10469651 DOI: 10.1002/cam4.6235] [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: 11/28/2022] [Revised: 05/12/2023] [Accepted: 06/01/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND The Cockcroft-Gault formula is commonly used as a substitute for glomerular filtration rate (GFR) in Calvert's formula for carboplatin dosing, where adjusting serum creatinine measured using the enzymatic method with 0.2 mg/dL has been suggested in Japan. However, the effects of these adjustments on efficacy in patients with non-small-cell lung cancer remain unknown. METHODS We conducted a post hoc analysis of the PREDICT1 study (CJLSG1201), a multicenter prospective observational trial of carboplatin-pemetrexed. Glomerular filtration rate values in Calvert's formula were back-calculated from the administered dosages of carboplatin and the reported value of the target area under the curve. We estimated the serum creatinine adjustments and divided the patients into crude and adjusted groups. RESULTS Patients in the crude group (N = 169) demonstrated similar efficacy to those in the adjusted group (N = 104) in progression-free survival (PFS) and overall survival (OS) (hazard ratio [HR], 1.02; 95% confidence interval [CI], 0.76-1.35; p = 0.916 vs. HR, 0.87; 95% CI, 0.65-1.17; p = 0.363), with higher grade 3-4 hematologic toxicity. Among patients aged ≥75 years, the crude group (N = 47) showed superior efficacy compared with the adjusted group (N = 17) in PFS and OS (HR, 0.37; 95% CI, 0.20-0.69; p = 0.002 vs. HR, 0.43; 95% CI, 0.23-0.82; p = 0.010). CONCLUSIONS Serum creatinine adjustment may be associated with similar efficacy compared to the crude serum creatinine value. In older patients, the adjustment should be cautiously applied owing to the potential for reduced efficacy.
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Affiliation(s)
- Takahiro Hatta
- Department of Respiratory MedicineNagoya University Graduate School of MedicineNagoyaJapan
| | - Tetsunari Hase
- Department of Respiratory MedicineNagoya University Graduate School of MedicineNagoyaJapan
| | - Toru Hara
- Department of Respiratory MedicineAnjo Kosei HospitalAnjoJapan
| | - Tomoki Kimura
- Department of Respiratory Medicine and AllergyTosei General HospitalSetoJapan
| | - Eiji Kojima
- Department of Respiratory MedicineKomaki City HospitalKomakiJapan
| | - Takashi Abe
- Department of Respiratory MedicineOgaki Municipal HospitalOgakiJapan
| | - Yoshitsugu Horio
- Department of Thoracic OncologyAichi Cancer Center HospitalNagoyaJapan
| | - Yasuhiro Goto
- Department of Respiratory MedicineFujita Health University School of MedicineToyoakeJapan
| | - Naoya Ozawa
- Department of Respiratory MedicineNagoya University Graduate School of MedicineNagoyaJapan
| | - Naoyuki Yogo
- Department of Respiratory MedicineNagoya University Graduate School of MedicineNagoyaJapan
| | - Hirofumi Shibata
- Department of Respiratory MedicineNagoya University Graduate School of MedicineNagoyaJapan
| | - Tomoya Shimokata
- Department of Clinical Oncology and ChemotherapyNagoya University HospitalNagoyaJapan
| | - Tetsuya Oguri
- Department of Education and Research Center for Community MedicineNagoya City University Graduate School of Medical SciencesNagoyaJapan
| | - Masashi Yamamoto
- Department of Respiratory MedicineNagoya Ekisaikai HospitalNagoyaJapan
| | - Kiyoshi Yanagisawa
- Division of Molecular and Cancer Medicine, Faculty of PharmacyMeijo UniversityNagoyaJapan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical ResearchNagoya University HospitalNagoyaJapan
| | - Yuichi Ando
- Department of Clinical Oncology and ChemotherapyNagoya University HospitalNagoyaJapan
| | - Masashi Kondo
- Department of Respiratory MedicineFujita Health University School of MedicineToyoakeJapan
| | - Makoto Ishii
- Department of Respiratory MedicineNagoya University Graduate School of MedicineNagoyaJapan
| | - Yoshinori Hasegawa
- Department of Respiratory MedicineNagoya University Graduate School of MedicineNagoyaJapan
- National Hospital Organization, Nagoya Medical CenterNagoyaJapan
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10
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Di Paola R, De A, Capasso A, Giuliana S, Ranieri R, Ruosi C, Sciarra A, Vitagliano C, Perna AF, Capasso G, Simeoni M. Impact of Thyroid Cancer Treatment on Renal Function: A Relevant Issue to Be Addressed. J Pers Med 2023; 13:jpm13050813. [PMID: 37240983 DOI: 10.3390/jpm13050813] [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: 03/24/2023] [Revised: 05/02/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Thyroid cancers require complex and heterogeneous therapies with different impacts on renal function. In our systematic literature review, we analyzed several aspects: renal function assessment, the impact of radiotherapy and thyroid surgery on kidney functioning, and mechanisms of nephrotoxicity of different chemotherapy, targeted and immunologic drugs. Our study revealed that the renal impact of thyroid cancer therapy can be a limiting factor in all radiotherapy, surgery, and pharmacological approaches. It is advisable to conduct a careful nephrological follow-up imposing the application of body surface based estimated Glomerular Filtration Rate (eGFR) formulas for the purpose of an early diagnosis and treatment of renal failure, guaranteeing the therapy continuation to thyroid cancer patients.
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Affiliation(s)
- Rossella Di Paola
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Ananya De
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Anna Capasso
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, The University of Texas, Austin, TX 75063, USA
| | - Sofia Giuliana
- Nephrology Unit, Department of Specialist General Surgery, University Hospital "Luigi Vanvitelli", 80131 Naples, Italy
| | - Roberta Ranieri
- Nephrology Unit, Department of Specialist General Surgery, University Hospital "Luigi Vanvitelli", 80131 Naples, Italy
| | - Carolina Ruosi
- Nephrology Unit, Department of Specialist General Surgery, University Hospital "Luigi Vanvitelli", 80131 Naples, Italy
| | - Antonella Sciarra
- Department of Oncologic Surgery, Translational Medical Sciences at University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Caterina Vitagliano
- Nephrology Unit, Department of Specialist General Surgery, University Hospital "Luigi Vanvitelli", 80131 Naples, Italy
| | - Alessandra F Perna
- Nephrology and Dialysis Unit, Department of Translational Medical Sciences at University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | | | - Mariadelina Simeoni
- Nephrology and Dialysis Unit, Department of Translational Medical Sciences at University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
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11
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Noce A, Marrone G, Di Lauro M, Mitterhofer AP, Ceravolo MJ, Di Daniele N, Manenti G, De Lorenzo A. The Onco-Nephrology Field: The Role of Personalized Chemotherapy to Prevent Kidney Damage. Cancers (Basel) 2023; 15:cancers15082254. [PMID: 37190182 DOI: 10.3390/cancers15082254] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/27/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023] Open
Abstract
In recent years, the onco-nephrology field has acquired a relevant role in internal medicine due to the growing number of cases of renal dysfunction that have been observed in cancer patients. This clinical complication can be induced by the tumor itself (for example, due to obstructive phenomena affecting the excretory tract or by neoplastic dissemination) or by chemotherapy, as it is potentially nephrotoxic. Kidney damage can manifest as acute kidney injury or represent a worsening of pre-existing chronic kidney disease. In cancer patients, physicians should try to set preventive strategies to safeguard the renal function, avoiding the concomitant use of nephrotoxic drugs, personalizing the dose of chemotherapy according to the glomerular filtration rate (GFR) and using an appropriate hydration therapy in combination with nephroprotective compounds. To prevent renal dysfunction, a new possible tool useful in the field of onco-nephrology would be the development of a personalized algorithm for the patient based on body composition parameters, gender, nutritional status, GFR and genetic polymorphisms.
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Affiliation(s)
- Annalisa Noce
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
- Nephrology and Dialysis Unit, Policlinico Tor Vergata, 00133 Rome, Italy
| | - Giulia Marrone
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Manuela Di Lauro
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Anna Paola Mitterhofer
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
- Nephrology and Dialysis Unit, Policlinico Tor Vergata, 00133 Rome, Italy
| | | | - Nicola Di Daniele
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
- Fondazione Leonardo per le Scienze Mediche Onlus, Policlinico Abano, 35031 Abano Terme (PD), Italy
| | - Guglielmo Manenti
- Department of Diagnostic Imaging and Interventional Radiology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Antonino De Lorenzo
- Section of Clinical Nutrition and Nutrigenomic, Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
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12
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Selby PR, Heffernan AJ, Yeung D, Warner MS, Peake SL, Hahn U, Wallis SC, Mcwhinney B, Ungerer JPJ, Shakib S, Roberts JA. Population Pharmacokinetics of Ganciclovir in Allogeneic Hematopoietic Stem Cell Transplant Patients. Antimicrob Agents Chemother 2023; 67:e0155022. [PMID: 36815858 PMCID: PMC10019199 DOI: 10.1128/aac.01550-22] [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: 12/07/2022] [Accepted: 01/26/2023] [Indexed: 02/24/2023] Open
Abstract
Treatment of cytomegalovirus (CMV) infection in allogeneic hematopoietic stem cell transplantation (alloHCT) patients with ganciclovir is complicated by toxicity and resistance. This study aimed to develop an intravenous ganciclovir population pharmacokinetic model for post-alloHCT patients and to determine dosing regimens likely to achieve suggested therapeutic exposure targets. We performed a prospective observational single-center pharmacokinetic study in adult alloHCT patients requiring treatment with intravenous ganciclovir for CMV viremia or disease. Samples were analyzed using a validated ultraperformance liquid chromatography method. Population pharmacokinetic analysis and Monte Carlo simulations (n = 1000) were performed using Pmetrics for R. Twenty patients aged 18 to 69 years were included in the study. A 2-compartment model with linear elimination from the central compartment and between occasion variability best described the data. Incorporating creatinine clearance (CLCR) estimated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and presence of continuous renal replacement therapy as covariates for ganciclovir clearance improved the model. Compared to current dosing recommendations, simulations demonstrated loading doses were required to achieve a target AUC24 of 80 to 120 mg.h/L on day 1 of induction therapy. Increased individualization of post-loading induction and maintenance doses based on CLCR is required to achieve the suggested exposures for efficacy (AUC24 >80/>40 mg.h/L for induction/maintenance) while remaining below the exposure thresholds for toxicity (AUC24 <120/<60 mg.h/L for induction/maintenance). Intravenous ganciclovir dosing in alloHCT patients can be guided by CLCR estimated by CKD-EPI. Incorporation of loading doses into induction dosing regimens should be considered for timely achievement of currently suggested exposures.
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Affiliation(s)
- Philip R. Selby
- School of Medicine, University of Adelaide, Adelaide, Australia
- Pharmacy Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Aaron J. Heffernan
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David Yeung
- School of Medicine, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Haematology Unit, Royal Adelaide Hospital, Adelaide, Australia
- Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Morgyn S. Warner
- School of Medicine, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Sandra L. Peake
- School of Medicine, University of Adelaide, Adelaide, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Uwe Hahn
- School of Medicine, University of Adelaide, Adelaide, Australia
- SA Pathology, Adelaide, Australia
- Haematology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Steven C. Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Brett Mcwhinney
- Pathology Queensland, Queensland Health, Brisbane, Australia
| | - Jacobus P. J. Ungerer
- Pathology Queensland, Queensland Health, Brisbane, Australia
- Faculty of Health and Behavioural Science, University of Queensland, Brisbane, Australia
| | - Sepehr Shakib
- School of Medicine, University of Adelaide, Adelaide, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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13
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The past, present, and future of chemotherapy with a focus on individualization of drug dosing. J Control Release 2022; 352:840-860. [PMID: 36334860 DOI: 10.1016/j.jconrel.2022.10.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 10/14/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
While there have been rapid advances in developing new and more targeted drugs to treat cancer, much less progress has been made in individualizing dosing. Even though the introduction of immunotherapies such as CAR T-cells and checkpoint inhibitors, as well as personalized therapies that target specific mutations, have transformed clinical treatment of cancers, chemotherapy remains a mainstay in oncology. Chemotherapies are typically dosed on either a body surface area (BSA) or weight basis, which fails to account for pharmacokinetic differences between patients. Drug absorption, distribution, metabolism, and excretion rates can vary between patients, resulting in considerable differences in exposure to the active drugs. These differences result in suboptimal dosing, which can reduce efficacy and increase side-effects. Therapeutic drug monitoring (TDM), genotype guided dosing, and chronomodulation have been developed to address this challenge; however, despite improving clinical outcomes, they are rarely implemented in clinical practice for chemotherapies. Thus, there is a need to develop interventions that allow for individualized drug dosing of chemotherapies, which can help maximize the number of patients that reach the most efficacious level of drug in the blood while mitigating the risks of underdosing or overdosing. In this review, we discuss the history of the development of chemotherapies, their mechanisms of action and how they are dosed. We discuss substantial intraindividual and interindividual variability in chemotherapy pharmacokinetics. We then propose potential engineering solutions that could enable individualized dosing of chemotherapies, such as closed-loop drug delivery systems and bioresponsive biomaterials.
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14
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Sprangers B, Perazella MA, Lichtman SM, Rosner MH, Jhaveri KD. Improving Cancer Care for Patients With CKD: The Need for Changes in Clinical Trials. Kidney Int Rep 2022; 7:1939-1950. [PMID: 36090489 PMCID: PMC9458993 DOI: 10.1016/j.ekir.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/10/2022] [Accepted: 06/06/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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15
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Shirali AC, Sprangers B. Cancer Drug Dosing in Chronic Kidney Disease and Dialysis. Adv Chronic Kidney Dis 2022; 29:208-216.e1. [PMID: 35817528 DOI: 10.1053/j.ackd.2021.12.002] [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: 06/25/2021] [Revised: 10/20/2021] [Accepted: 12/08/2021] [Indexed: 11/11/2022]
Abstract
Patients with malignancies have a high prevalence of kidney disease and are often treated with antineoplastic agents that undergo kidney metabolism or excretion or clearance via renal replacement therapies. Thus, the dosing of these agents, including classic chemotherapeutic drugs, targeted therapies, and immunotherapy, must take into account patients' kidney function. In this review, we will discuss the pitfalls of accurate measurement of kidney function and how kidney disease affects both pharmacodynamic and pharmacokinetic properties of drugs. Lastly, we will discuss specific agents and summarize current dosing strategies for use in patients with chronic kidney disease and end-stage kidney disease.
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Affiliation(s)
- Anushree C Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium.
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16
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Costa E Silva VT, Gil LA, Inker LA, Caires RA, Costalonga E, Coura-Filho G, Sapienza MT, Castro G, Estevez-Diz MD, Zanetta DMT, Antonângelo L, Marçal L, Tighiouart H, Miao S, Mathew P, Levey AS, Burdmann EA. A prospective cross-sectional study estimated glomerular filtration rate from creatinine and cystatin C in adults with solid tumors. Kidney Int 2022; 101:607-614. [PMID: 35032521 DOI: 10.1016/j.kint.2021.12.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 11/18/2021] [Accepted: 12/09/2021] [Indexed: 01/06/2023]
Abstract
Current guidelines recommend estimating glomerular filtration rate (eGFR) using creatinine (eGFRcr) with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation as the first test for GFR evaluation, but the Cockcroft-Gault (CG) equation is still commonly used in oncology practice and clinical trials despite increasing evidence of its inaccuracy compared to measured GFR (mGFR). Guidelines recommend eGFR using cystatin C (eGFRcys) or both markers (eGFRcr-cys) as a confirmatory test, but neither was carefully evaluated in cancer patients. Therefore, we compared performance of the CKD-EPI equations and others to the CG equation in adults with a variety of solid tumors. The mGFR was determined by plasma clearance of 51Cr-EDTA. Bias was defined as the median of the differences between mGFR and eGFR while accuracy was defined as the percentage of estimates that differed by more than 30% from the measured GFR (1-P30). We prospectively recruited 1,200 patients between April 2015 and September 2017 with a mean age and mGFR of 58.8 years and 78.4 ml/min/1.73m2, respectively. Bias among eGFRcr equations varied from -8.1 to +6.1 ml/min/1.73 m2. CG was the least accurate, 1-P30 (95% confidence interval) was 24.9 (22.4- 27.3)%; CKD-EPI had 1-P30 of 19.1 (16.8-21.2)% while eGFRcr-cys had the best performance: bias -2.0 (-2.6 to -1.1) ml/min/1.73m2 and 1-P30 7.8 (6.3-9.4)%. Thus, the CG equation should not be preferred over CKD-EPI equation, and eGFRcr-cys can be used as a confirmatory test in adults with solid tumors. Hence, a major policy implication would be to adopt general practice guideline-recommended methods for GFR evaluation in oncology practice and clinical trials.
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Affiliation(s)
- 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.
| | - Luiz A Gil
- Laboratório de Investigação Médica (LIM) 66, Serviço de Geriatria, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Renato A Caires
- Serviço de Nefrologia, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Elerson Costalonga
- Serviço de Nefrologia, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - George Coura-Filho
- Serviço de Medicina Nuclear, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo T Sapienza
- Radiology and Oncology Department, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Gilberto Castro
- Serviço de Oncologia Clínica, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Maria Dp Estevez-Diz
- Serviço de Oncologia Clínica, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Dirce Maria T Zanetta
- Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Leila Antonângelo
- Laboratório de Investigação Médica (LIM) 03, Division of Clinical Pathology, University of São Paulo Medical School, São Paulo, Brazil
| | - Lia Marçal
- Laboratório de Investigação Médica (LIM) 03, Division of Clinical Pathology, University of São Paulo Medical School, São Paulo, Brazil
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Biostatistics, Epidemiology, and Research Design Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Paul Mathew
- Division of Hematology-Oncology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Emmanuel A Burdmann
- Laboratório de Investigação (LIM) 12, Serviço de Nefrologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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17
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Warwick J, Holness J. Measurement of Glomerular Filtration Rate. Semin Nucl Med 2022; 52:453-466. [DOI: 10.1053/j.semnuclmed.2021.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 12/21/2021] [Indexed: 01/21/2023]
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18
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Lees JS, Elyan BMP, Herrmann SM, Lang NN, Jones RJ, Mark PB. OUP accepted manuscript. Nephrol Dial Transplant 2022; 38:1071-1079. [PMID: 35090037 PMCID: PMC10157781 DOI: 10.1093/ndt/gfac011] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Indexed: 11/13/2022] Open
Abstract
Cancer is the second leading cause of death in people with chronic kidney disease (CKD) after cardiovascular disease. The incidence of CKD in patients with cancer is higher than in the non-cancer population. Across various populations, CKD is associated with an elevated risk of cancer incidence and cancer death compared with people without CKD, although the risks are cancer site-specific. Higher risk of cancer is detectable in mild CKD [estimated glomerular filtration rate (eGFR) 60-89 mL/min/1.73 m2], although this risk is more obvious if sensitive markers of kidney disease are used, such as cystatin C. Independent of eGFR, albuminuria is associated with increased risk of site-specific cancer incidence and death. Here, we explore the potential mechanisms for the increased risk of cancer observed in CKD, including patient factors (shared risks such as cardiometabolic disease, obesity, smoking, diet, lifestyle and environment), disease (genetic, inflammatory and infective) and treatment factors. In particular, we discuss the ways in which renal adverse events associated with conventional chemotherapies and newer systemic anti-cancer therapies (including targeted and immunotherapies) may contribute to worse cancer outcomes in people with CKD. Finally, we review the potential benefits of acknowledging increased risk of cancer in risk prediction tools used for the management of CKD.
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Affiliation(s)
- Jennifer S Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Benjamin M P Elyan
- Department of Renal Medicine, University Hospital Monklands, Airdrie, UK
| | | | - Ninian N Lang
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Robert J Jones
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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19
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Dudani S, Marginean H, Gotfrit J, Tang PA, Monzon JG, Dennis K, Kennecke HF, Powell ED, Babak S, Cheung WY, Vickers MM. The Impact of Chronic Kidney Disease in Patients With Locally Advanced Rectal Cancer Treated With Neoadjuvant Chemoradiation. Dis Colon Rectum 2021; 64:1471-1478. [PMID: 34657078 PMCID: PMC8568328 DOI: 10.1097/dcr.0000000000002116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with chronic kidney disease are commonly excluded from clinical trials. The impact of chronic kidney disease on outcomes in patients with locally advanced rectal cancer has not been previously studied. OBJECTIVE This study aimed to investigate the impact of chronic kidney disease on outcomes in patients with locally advanced rectal cancer. DESIGN This is a multi-institutional, retrospective cohort study. SETTINGS This study was conducted at academic and community cancer centers participating in the Canadian Health Outcomes Research Database Consortium Rectal Cancer Database. PATIENTS Consecutive patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation before curative-intent surgery from 2005 to 2013 were selected. MAIN OUTCOME MEASURES Disease-free survival, overall survival, pathologic complete response, and neoadjuvant chemotherapy/radiotherapy completion rate were the primary outcomes measured. RESULTS A total of 1254 patients were included. Median age was 62, and 29%/69% had clinical stage II and III disease. Median estimated creatinine clearance was 93 mL/min, with 11% <60 mL/min (n = 136). There was no significant difference in the completion rate of neoadjuvant chemotherapy (82% vs 85%, p = 0.36) or radiotherapy (93% vs 95%, p = 0.45) between patients with and without chronic kidney disease. Patients with chronic kidney disease were less likely to receive adjuvant chemotherapy (63% vs 77%, p < 0.01). On multivariate analysis, patients with chronic kidney disease had decreased disease-free survival (HR, 1.37; 95% CI, 1.03-1.82; p = 0.03) but not overall survival (HR, 1.23; 95% CI, 0.88-1.75; p = 0.23) or pathologic complete response (OR, 0.83; 95% CI, 0.50-1.39; p = 0.71). LIMITATIONS This study was limited by its retrospective design and by limited events for overall survival analysis. CONCLUSIONS In patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation, baseline chronic kidney disease was associated with less use of adjuvant chemotherapy and decreased disease-free survival. Chronic kidney disease was not independently associated with neoadjuvant chemotherapy/radiotherapy completion rate, pathologic complete response, or overall survival. These data suggest that patients with locally advanced rectal cancer with chronic kidney disease may have distinct outcomes and, accordingly, the results of landmark clinical trials may not be generalizable to this population. See Video Abstract at http://links.lww.com/DCR/B694. LA REPERCUSIN DE LA ENFERMEDAD RENAL CRNICA EN PACIENTES CON CNCER DE RECTO LOCALMENTE AVANZADO TRATADOS CON QUIMIORRADIOTERAPIA NEOADYUVANTE ANTECEDENTES:Los pacientes con enfermedad renal crónica generalmente se excluyen de los ensayos clínicos. La repercusión de la enfermedad renal crónica en el desenlace en pacientes con cáncer de recto localmente avanzado no se ha estudiado previamente.OBJETIVO:Investigar la repercusión de la enfermedad renal crónica en los desenlaces en pacientes con cáncer de recto localmente avanzado.DISEÑO:Estudio de cohorte retrospectivo multiinstitucional.ESCENARIO:Centros oncológicos académicos y comunitarios que participan en la base de datos de cáncer rectal del consorcio CHORD.PACIENTES:Pacientes consecutivos con cáncer de recto localmente avanzado, tratados con quimiorradioterapia neoadyuvante, previa a la cirugía con intención curativa del 2005 al 2013.PRINCIPALES VARIABLES EVALUADAS:Sobrevida libre de enfermedad, sobrevida global, respuesta patológica completa, tasa de conclusión de quimioterapia / radioterapia neoadyuvante.RESULTADOS:Se incluyeron 1254 pacientes. El promedio de edad fue de 62, y el 29% / 69% tenían enfermedad en estadio clínico II y III, respectivamente. El promedio de la depuración de creatinina estimada fue de 93 mililitros / minuto, con un 11% <60 mililitros / minuto (n = 136). No hubo diferencias significativas en la tasa de conclusión de la quimioterapia neoadyuvante (82% vs 85%, p = 0,36) o radioterapia (93% vs 95%, p = 0,45) entre pacientes con y sin enfermedad renal crónica. Los pacientes con enfermedad renal crónica tenían menos probabilidades de recibir quimioterapia adyuvante (63% contra el 77%, p <0,01). En el análisis multivariado, los pacientes con enfermedad renal crónica tenían una sobrevida libre de enfermedad menor (HR 1,37, IC 95% 1,03-1,82, p = 0,03) pero no en la sobrevida global (HR 1,23, IC 95% 0,88-1,75, p = 0,23) o respuesta patológica completa (OR 0,83, IC 95% 0,50-1,39, p = 0,71).LIMITACIONES:Diseño retrospectivo y acontecimientos limitados para el análisis de sobrevida global.CONCLUSIONES:En pacientes con cáncer de recto localmente avanzado tratados con quimiorradioterapia neoadyuvante, la enfermedad renal crónica de base se asoció con un menor uso de quimioterapia adyuvante y una menor sobrevida libre de enfermedad. La enfermedad renal crónica no se asoció de forma independiente con la tasa de conclusión de la quimioterapia / radioterapia neoadyuvante, la respuesta patológica completa o la sobrevida global. Estos datos sugieren que los pacientes con cáncer de recto localmente avanzado con enfermedad renal crónica pueden tener resultados distintos y, en consecuencia, los resultados de los ensayos clínicos de referencia pueden no ser generalizables a esta población. Consulte Video Resumen en http://links.lww.com/DCR/B694.
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Affiliation(s)
- Shaan Dudani
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
| | - Horia Marginean
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
| | - Joanna Gotfrit
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
| | - Patricia A. Tang
- Alberta Health Services/University of Calgary, Calgary, Alberta, Canada
| | | | - Kristopher Dennis
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
| | | | - Erin D. Powell
- Dr. H Bliss Murphy Cancer Centre, St. John’s, Newfoundland, Canada
| | - Sam Babak
- Alberta Health Services/University of Calgary, Calgary, Alberta, Canada
| | - Winson Y. Cheung
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Michael M. Vickers
- The Ottawa Hospital Cancer Centre/University of Ottawa, Ottawa, Ontario, Canada
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van de Velde ME, den Bakker E, Blufpand HN, Kaspers GL, Abbink FCH, Kors AWA, Wilhelm AJ, Honeywell RJ, Peters GJ, Stoffel-Wagner B, Buffart LM, Bökenkamp A. Carboplatin Dosing in Children Using Estimated Glomerular Filtration Rate: Equation Matters. Cancers (Basel) 2021; 13:cancers13235963. [PMID: 34885072 PMCID: PMC8656997 DOI: 10.3390/cancers13235963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022] Open
Abstract
Renal function-based carboplatin dosing using measured glomerular filtration rate (GFR) results in more consistent drug exposure than anthropometric dosing. We aimed to validate the Newell dosing equation using estimated GFR (eGFR) and study which equation most accurately predicts carboplatin clearance in children with retinoblastoma. In 13 children with retinoblastoma 38 carboplatin clearance values were obtained from individual fits using MWPharm++. Carboplatin exposure (AUC) was calculated from administered dose and observed carboplatin clearance and compared to predicted AUC calculated with a carboplatin dosing equation (Newell) using different GFR estimates. Different dosing regimens were compared in terms of accuracy, bias and precision. All patients had normal eGFR. Carboplatin exposure using cystatin C-based eGFR equations tended to be more accurate compared to creatinine-based eGFR (30% accuracy 76.3-89.5% versus 76.3-78.9%, respectively), which led to significant overexposure, especially in younger (aged ≤ 2 years) children. Of all equations, the Schwartz cystatin C-based equation had the highest accuracy and lowest bias. Although anthropometric dosing performed comparably to many of the eGFR equations overall, we observed a weight-dependent change in bias leading to underdosing in the smallest patients. Using cystatin C-based eGFR equations for carboplatin dosing in children leads to more accurate carboplatin-exposure in patients with normal renal function compared to anthropometric dosing. In children with impaired kidney function, this trend might be more pronounced. Anthropometric dosing is hampered by a weight-dependent bias.
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Affiliation(s)
- Mirjam E. van de Velde
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, 1081 HV Amsterdam, The Netherlands; (H.N.B.); (A.W.A.K.); (G.L.K.)
- Department of Pediatric Oncology/Hematology, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)20-444-6206; Fax: +31-(0)20-444-5122
| | - Emil den Bakker
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Nephrology, 1081 HV Amsterdam, The Netherlands; (E.d.B.); (A.B.)
| | - Hester N. Blufpand
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, 1081 HV Amsterdam, The Netherlands; (H.N.B.); (A.W.A.K.); (G.L.K.)
| | - Gertjan L. Kaspers
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, 1081 HV Amsterdam, The Netherlands; (H.N.B.); (A.W.A.K.); (G.L.K.)
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Floor C. H. Abbink
- Emma Children’s Hospital, Amsterdam UMC, Amsterdam Medical Center, Pediatric Oncology, 1081 HV Amsterdam, The Netherlands;
| | - Arjenne W. A. Kors
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, 1081 HV Amsterdam, The Netherlands; (H.N.B.); (A.W.A.K.); (G.L.K.)
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands
| | - Abraham J. Wilhelm
- Amsterdam UMC, Vrije Universiteit Amsterdam, Clinical Pharmacology and Pharmacy, 1081 HV Amsterdam, The Netherlands;
| | - Richard J. Honeywell
- Laboratory of Medical Oncology, Amsterdam University Medical Center, VUMC, 1081 HV Amsterdam, The Netherlands; (R.J.H.); (G.J.P.)
| | - Godefridus J. Peters
- Laboratory of Medical Oncology, Amsterdam University Medical Center, VUMC, 1081 HV Amsterdam, The Netherlands; (R.J.H.); (G.J.P.)
- Department of Biochemistry, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Birgit Stoffel-Wagner
- Institute for Clinical Chemistry and Clinical Pharmacology, University of Bonn-Medical Center, 53127 Bonn, Germany;
| | - Laurien M. Buffart
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands;
| | - Arend Bökenkamp
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Nephrology, 1081 HV Amsterdam, The Netherlands; (E.d.B.); (A.B.)
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21
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Cervantes CE, Kant S, Atta MG. The Link Between Conventional and Novel Anti-Cancer Therapeutics with Thrombotic Microangiopathy. Drug Metab Lett 2021; 14:97-105. [PMID: 34279209 DOI: 10.2174/1872312814666210716141633] [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: 01/06/2021] [Revised: 04/28/2021] [Accepted: 05/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Kidney disease associated with cancer and anti-cancer therapies has been increasingly recognized in the field of onco-nephrology. In particular, drug-induced nephrotoxicity has important implications since most chemotherapeutic agents have a nephrotoxic potential. Also, standard creatinine clearance methods used for the measurement of kidney function have been questioned in cancer patients due to factors like low muscle mass and poor nutritional status. Overestimations of the glomerular filtration rate, not only can increase the nephrotoxic potential of different agents, but also further limit the use of first-line therapies. OBJECTIVE This review covers specifically the drug-induced thrombotic microangiopathy and its two pathophysiologic mechanisms which include immune or idiosyncratic reactions, and non-immune or dose-dependent ones. CONCLUSION As novel cancer therapies are developed, it is paramount to pursue a better understanding of conventional and novel chemotherapeutic agents and their role in kidney disease.
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Affiliation(s)
- Carmen E Cervantes
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
| | - Sam Kant
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
| | - Mohamed G Atta
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland MD 21218, United States
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22
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Li X, Li Z, Wu X, Zhang M, Xu L, Hao X, Li H, Qiao P, Wang W. Serum uric acid variability increases the risk of postoperative chronic kidney disease in patients with renal cell carcinoma after radical nephrectomy. Urol Oncol 2021; 39:500.e1-500.e7. [PMID: 34187751 DOI: 10.1016/j.urolonc.2021.05.027] [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: 01/12/2021] [Revised: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Serum uric acid (SUA) level is associated with the progression of chronic kidney disease (CKD). However, little is known about the predictive value of SUA variability for postoperative CKD in patients with renal cell carcinoma after radical nephrectomy. We aimed to investigate the association of SUA variability with postoperative CKD in this population. METHOD 85 patients with preoperative estimated glomerular filtration rate (eGFR)≥60 ml/min/1.73 m2 were enrolled in this single-center retrospective study and followed up for at least 6 months. Intra-individual SUA variability was defined as the standard deviation (SD) of SUA and the patients were stratified into three groups according to the tertiles of SUA SD (the lower, middle and upper tertile). The association of SUA variability with postoperative CKD, defined as an eGFR<60 ml/min/1.73m2, was analyzed by Cox proportional hazard models and Kaplan-Meier analyses. RESULTS After a median follow-up time of 24(10-43) months, 44(51.7%) patients developed postoperative CKD. Kaplan-Meier curves showed that patients in the lower tertile had a longer CKD-free survival time [median CKD-free survival time 74(52.2-95.8) months] than those in the middle tertile [38(19.2-56.8) months] and upper tertile [21(17.9-24.1) months] (overall generalized Wilcoxon test: P=0.001; lower vs middle tertile: P=0.001; lower vs upper tertile: P<0.001). Adjusted Cox analyses indicated that increasing SUA SD tertiles were associated with a higher risk of postoperative CKD independent of baseline SUA, mean SUA during follow-up and other confounding variables. Compared with patients in the lower tertile, the risk for developing CKD increased by 4.6-fold for patients in the middle tertile and 7.9-fold in the upper tertile, respectively. CONCLUSION Increasing SUA variability was associated with an increased risk of postoperative CKD in patients with renal cell carcinoma after radical nephrectomy.
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Affiliation(s)
- Xin Li
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhen Li
- Clinical Research Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaojing Wu
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Muyin Zhang
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lili Xu
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xu Hao
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hao Li
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Panpan Qiao
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weiming Wang
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Li N, Huang H, Linsheng L, Lu H, Liu X. Improving glomerular filtration rate estimation by semi-supervised learning: a development and external validation study. Int Urol Nephrol 2021; 53:1649-1658. [PMID: 33710531 DOI: 10.1007/s11255-020-02771-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/21/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Accurate estimating glomerular filtration rate (GFR) is crucial both in clinical practice and epidemiological survey. We incorporated semi-supervised learning technology to improve GFR estimation performance. METHODS AASK [African American Study of Kidney Disease and Hypertension], CRIC [Chronic Renal Insufficiency Cohort] and DCCT [Diabetes Control and Complications Trial] studies were pooled together for model development, whereas MDRD [Modification of Diet in Renal Disease] and CRISP [Consortium for Radiological Imaging Studies of Polycystic Kidney Disease] studies for model external validation. A total of seven variables (Serum creatinine, Age, Sex, Black race, Diabetes status, Hypertension and Body Mass Index) were included as independent variables, while the outcome variable GFR was measured as the urinary clearance of 125I-iothalamate. The revised CKD-EPI [Chronic Kidney Disease Epidemiology Collaboration] creatinine equations was selected as benchmark for performance comparisons. Head-to-head performance comparisons from four-variable to seven-variable combination were conducted between revised CKD-EPI equations and semi-supervised models. RESULTS In each independent variables combination, the semi-supervised models consistently achieved superior results in all three performance indicators compared with corresponding revised CKD-EPI equations in the external validation data set. Furthermore, compared with revised four-variable CKD-EPI equation, the seven-variable semi-supervised model performed less biased (mean of difference: 0.03 [- 0.28, 0.34] vs 1.53 [1.28, 1.85], P < 0.001), more precise (interquartile range of difference: 7.94 [7.37, 8.50] vs 8.28 [7.76, 8.83], P = 0.1) and accurate (P30: 88.9% [87.4%, 90.2%] vs 86.0% [84.4%, 87.4%], P < 0.001. CONCLUSIONS The superior performance of the semi-supervised models during head-to-head comparisons supported the hypothesis that semi-supervised learning technology could improve GFR estimation performance.
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Affiliation(s)
- Ningshan Li
- SJTU-Yale Joint Center for Biostatistics and Data Science, Department of Bioinformatics and Biostatistics, School of Life Science and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Hui Huang
- Cardiovascular Department, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Lv Linsheng
- Operation Room, The Third Affiliated Hospital of Sun Yat-Sen University, Guangdong, China
| | - Hui Lu
- SJTU-Yale Joint Center for Biostatistics and Data Science, Department of Bioinformatics and Biostatistics, School of Life Science and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, China.
- MoE Key Lab of Artificial Intelligence, AI Institute, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Engineering Research Center for Big Data in Pediatric Precision Medicine, Shanghai, China.
| | - Xun Liu
- Clinical Data Center of the Third Affiliated Hospital of Sun Yat-Sen University, Guangdong, China.
- Division of Nephrology, Department of Internal Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
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Williams EH, Flint TR, Connell CM, Giglio D, Lee H, Ha T, Gablenz E, Bird NJ, Weaver JMJ, Potts H, Whitley CT, Bookman MA, Lynch AG, Meyer HV, Tavaré S, Janowitz T. CamGFR v2: A New Model for Estimating the Glomerular Filtration Rate from Standardized or Non-standardized Creatinine in Patients with Cancer. Clin Cancer Res 2021; 27:1381-1390. [PMID: 33303580 PMCID: PMC9097346 DOI: 10.1158/1078-0432.ccr-20-3201] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/27/2020] [Accepted: 12/04/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Management of patients with cancer, specifically carboplatin dosing, requires accurate knowledge of glomerular filtration rate (GFR). Direct measurement of GFR is resource limited. Available models for estimated GFR (eGFR) are optimized for patients without cancer and either isotope dilution mass spectrometry (IDMS)- or non-IDMS-standardized creatinine measurements. We present an eGFR model for patients with cancer compatible with both creatinine measurement methods. EXPERIMENTAL DESIGN GFR measurements, biometrics, and IDMS- or non-IDMS-standardized creatinine values were collected for adult patients from three cancer centers. Using statistical modeling, an IDMS and non-IDMS creatinine-compatible eGFR model (CamGFR v2) was developed. Its performance was compared with that of the existing models Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Modification of Diet in Renal Disease (MDRD), Full Age Spectrum (FAS), Lund-Malmö revised, and CamGFR v1, using statistics for bias, precision, accuracy, and clinical robustness. RESULTS A total of 3,083 IDMS- and 4,612 non-IDMS-standardized creatinine measurements were obtained from 7,240 patients. IDMS-standardized creatinine values were lower than non-IDMS-standardized values in within-center comparisons (13.8% lower in Cambridge; P < 0.0001 and 19.3% lower in Manchester; P < 0.0001), and more consistent between centers. CamGFR v2 was the most accurate [root-mean-squared error for IDMS, 14.97 mL/minute (95% confidence interval, 13.84-16.13) and non-IDMS, 15.74 mL/minute (14.86-16.63)], most clinically robust [proportion with >20% error of calculated carboplatin dose for IDMS, 0.12 (0.09-0.14) and non-IDMS, 0.17 (0.15-0.2)], and least biased [median residual for IDMS, 0.73 mL/minute (-0.68 to 2.2) and non-IDMS, -0.43 mL/minute (-1.48 to 0.91)] eGFR model, particularly when eGFR was larger than 60 ml/minute. CONCLUSIONS CamGFR v2 can utilize IDMS- and non-IDMS-standardized creatinine measurements and outperforms previous models. CamGFR v2 should be examined prospectively as a practice-changing standard of care for eGFR-based carboplatin dosing.
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Affiliation(s)
- Edward H Williams
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, England, United Kingdom
| | - Thomas R Flint
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - Claire M Connell
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, England, United Kingdom
- University of Cambridge, Cambridge, England, United Kingdom
| | - Daniel Giglio
- Department of Oncology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Hassal Lee
- University of Cambridge School of Clinical Medicine, Cambridge, England, United Kingdom
| | - Taehoon Ha
- Cold Spring Harbor Laboratory, Cold Spring Harbor, New York
| | - Eva Gablenz
- Cold Spring Harbor Laboratory, Cold Spring Harbor, New York
| | - Nicholas J Bird
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom
| | - James M J Weaver
- The Christie NHS Foundation Trust, Manchester, England, United Kingdom
- University of Manchester, Manchester, England, United Kingdom
| | - Harry Potts
- University of Cambridge School of Clinical Medicine, Cambridge, England, United Kingdom
| | - Cameron T Whitley
- University of Cambridge School of Clinical Medicine, Cambridge, England, United Kingdom
| | - Michael A Bookman
- Gynecologic Oncology Therapeutics, Kaiser Permanente, San Francisco, California
| | - Andy G Lynch
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, England, United Kingdom
- School of Medicine, University of St Andrews, St Andrews, Scotland, United Kingdom
- School of Mathematics and Statistics, University of St Andrews, St Andrews, Scotland, United Kingdom
| | - Hannah V Meyer
- Cold Spring Harbor Laboratory, Cold Spring Harbor, New York
| | - Simon Tavaré
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, England, United Kingdom
- Columbia University, New York, New York
| | - Tobias Janowitz
- Cold Spring Harbor Laboratory, Cold Spring Harbor, New York.
- Northwell Health, New York, New York
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Motwani SS, Choueiri TK, Partridge AH, Hu J, Kaymakcalan MD, Waikar SS, Curhan GC. Comparison of Equations To Estimate Glomerular Filtration Rate and Their Impact on Frequency of Cisplatin-associated Acute Kidney Injury. KIDNEY360 2021; 2:205-214. [PMID: 35373014 PMCID: PMC8741004 DOI: 10.34067/kid.0000572020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 12/23/2020] [Indexed: 02/04/2023]
Abstract
Background Accurate estimation of kidney function is essential for patient selection and drug dosing in patients with cancer. eGFR equations are necessary for decision making and monitoring. Our aim was to identify which of these equations-estimated creatinine clearance (eCrCl) by Cockcroft-Gault (CG), eGFR by Modification of Diet in Renal Disease (eGFRMDRD), CKD Epidemiology Collaboration (eGFRCKD-EPI) or the recently proposed Janowitz-Williams equation (eGFRJ-W)-would be most suitable for GFR estimation among patients with cancer receiving cisplatin. Methods We assembled a cohort of 5274 patients with cancer treated with cisplatin-based chemotherapy at two large cancer centers. We ascertained the frequency of cisplatin-associated AKI (C-AKI) defined as a ≥0.3 mg/dl rise in serum creatinine over baseline. We compared baseline eGFR and eCrCl using Bland-Altman (B-A) plots, coefficients of variation (CV), and concordance correlation coefficients. We calculated the positive predictive value (PPV), negative predictive value (PPV), accuracy, and area under the curve (AUC). Results Patients were predominantly middle aged (median 58 years, IQR 49-66 years), overweight (median BMI 26.2, IQR 23.1-29.8 kg/m2), and White (88%), with a median baseline creatinine of 0.8 mg/dl and median cisplatin dose of 99 mg. C-AKI developed in 12% of the cohort. eGFRCKD-EPI had the highest PPV and AUC. eGFRCKD-EPI and eGFRMDRD, along with their BSA-modified counterparts, had the closest agreement with the lowest CV (7.2, 95% CI, 7.0 to 7.3) and the highest concordance. C-AKI was lowest when using eGFRCKD-EPI to define eGFR ≥60 ml/min per 1.73 m2. Conclusions On the basis of its superior diagnostic performance, eGFRCKD-EPI should be used to estimate GFR in patients being considered for cisplatin-based chemotherapy.
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Affiliation(s)
- Shveta S. Motwani
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Toni K. Choueiri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Ann H. Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jiani Hu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Sushrut S. Waikar
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Gary C. Curhan
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Channing Division of Network Medicine, Boston, Massachusetts
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Espi M, Teuma C, Novel-Catin E, Maillet D, Souquet PJ, Dalle S, Koppe L, Fouque D. Renal adverse effects of immune checkpoints inhibitors in clinical practice: ImmuNoTox study. Eur J Cancer 2021; 147:29-39. [PMID: 33607383 DOI: 10.1016/j.ejca.2021.01.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND/OBJECTIVES Acute Kidney Injury (AKI), induced by Checkpoint Inhibitors therapies (CPI-induced AKI), is an uncommon but severe Immune-Related Adverse Event (IRAE). The aim was to describe the epidemiology, risks factors, clinical, and laboratory characteristics of these renal adverse events (AEs) in a real-life cohort treatment. DESIGN/PARTICIPANTS Consecutive patients undergoing a checkpoint inhibitor (CPI) therapy at the Hôpital Lyon Sud from January 2015 to July 2017 were included. A systematic retrospective analysis of medical files was performed, monthly serum creatinine levels, associated treatments, and occurrence of other IRAEs data were collected. AKI episodes explained by classic AKI aetiologies (prerenal, obstructive, septic) were excluded from the analysis. RESULTS CPI-induced AKI incidence was 3.7% (13/352) and appeared to be time-dependent (7.7% (11/143) for patients with >3 months of CPI exposure), ranging from 1 to 16 months. All cases with available histology were acute tubulointerstitial nephritis (ATIN), with poor urinary sediment. The severity of AKI was mild (stage 1 in 50% of cases), with no need for renal-replacement therapy. Although CPI-induced AKI patients had more frequently other IRAEs (77% versus 39%), this was not associated with a greater risk of AKI. Pre-existing chronic kidney disease (defined as an estimated glomerular filtration rate (eGFR) <60 ml/min) was not associated with a greater risk of CPI-induced AKI. Treatments of CPI-induced AKI were heterogeneous, with discontinuation of CPIs, and inconstant systemic corticosteroid therapy. CONCLUSION The monitoring of renal function and early identification of AKI during CPIs treatment is essential. The optimal management of CPI-induced AKI remains unclear and requires a close collaboration between the oncology and nephrology departments. CLINICAL RELEVANCY STATEMENT Immune checkpoint inhibitors (CPIs) have dramatically improved patient outcomes in different malignant contexts such as melanoma, non-small cell lung cancers (NSCLC) and urologic cancers. Usually well-tolerated, CPIs are however associated with immune-related adverse events (IRAEs). Among them, acute kidney injury (AKI) is uncommon, and not well-described. Following the exponential increase in the prescription of CPIs, previously uncommon cases of IRAEs (such as AKI) have become common occurrence in referral centres. Data regarding the epidemiology, risk factors, or management of CPI-induced AKI are currently lacking or can be discordant. Data regarding CPI-induced AKI, in a large real-life cohort were reported herein.
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Affiliation(s)
- M Espi
- Service de Néphrologie, Hôpital Lyon Sud - Hospices Civils de Lyon, 69310, Pierre Bénite, France.
| | - C Teuma
- Service de Néphrologie, Hôpital Nord Ouest, 69400, Gleizé, France
| | - E Novel-Catin
- Service de Néphrologie, Hôpital Lyon Sud - Hospices Civils de Lyon, 69310, Pierre Bénite, France; ImmuCare (Immunology Cancer Research), Hospices Civils de Lyon, Lyon, France
| | - D Maillet
- Service D'Oncologie, Hôpital Lyon Sud - Hospices Civils de Lyon, 69310, Pierre Bénite, France; ImmuCare (Immunology Cancer Research), Hospices Civils de Lyon, Lyon, France
| | - P J Souquet
- Service de Pneumologie, Hôpital Lyon Sud - Hospices Civils de Lyon, 69310, Pierre Bénite, France; ImmuCare (Immunology Cancer Research), Hospices Civils de Lyon, Lyon, France
| | - S Dalle
- Service de Dermatologie, Hôpital Lyon Sud - Hospices Civils de Lyon, 69310, Pierre Bénite, France; ImmuCare (Immunology Cancer Research), Hospices Civils de Lyon, Lyon, France
| | - L Koppe
- Service de Néphrologie, Hôpital Lyon Sud - Hospices Civils de Lyon, 69310, Pierre Bénite, France; Univ. Lyon, CarMeN Lab, INSA-Lyon, INSERM U1060, INRA, Université Claude Bernard Lyon 1, F-69621, Villeurbanne, France; ImmuCare (Immunology Cancer Research), Hospices Civils de Lyon, Lyon, France
| | - D Fouque
- Service de Néphrologie, Hôpital Lyon Sud - Hospices Civils de Lyon, 69310, Pierre Bénite, France; ImmuCare (Immunology Cancer Research), Hospices Civils de Lyon, Lyon, France
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Jiang DM, Gupta S, Kitchlu A, Meraz-Munoz A, North SA, Alimohamed NS, Blais N, Sridhar SS. Defining cisplatin eligibility in patients with muscle-invasive bladder cancer. Nat Rev Urol 2021; 18:104-114. [PMID: 33432181 DOI: 10.1038/s41585-020-00404-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/29/2023]
Abstract
The current treatment paradigm for muscle-invasive bladder cancer (MIBC) consists of cisplatin-based neoadjuvant chemotherapy followed by local definitive therapy, or local definitive therapy alone for cisplatin-ineligible patients. Given that MIBC has a high propensity for distant relapse and is a chemotherapy-sensitive disease, under-utilization of chemotherapy is associated with suboptimal cure rates. Cisplatin eligibility criteria are defined for patients with metastatic bladder cancer by the Galsky criteria, which include creatinine clearance ≥60 ml/min. However, consensus is still lacking regarding cisplatin eligibility criteria in the neoadjuvant, curative MIBC setting, which continues to represent a substantial barrier to the standardization of patient care and clinical trial design. Jiang and colleagues accordingly suggest an algorithm for assessing cisplatin eligibility in patients with MIBC. Instead of relying on an absolute renal function threshold, their algorithm emphasizes a multidisciplinary and patient-centred approach. They also propose mitigation strategies to minimize the risk of cisplatin-induced nephrotoxicity in selected patients with impaired renal function. This new framework is aimed at reducing the inappropriate exclusion of some patients from cisplatin-based neoadjuvant chemotherapy (which leads to under-treatment) and harmonizing clinical trial design, which could lead to improved overall outcomes in patients with MIBC.
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Affiliation(s)
- Di Maria Jiang
- Division of Medical Oncology, Department of Medicine, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shilpa Gupta
- Department of Hematologic and Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Abhijat Kitchlu
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Alejandro Meraz-Munoz
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Scott A North
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Nimira S Alimohamed
- Department of Medicine, Division of Medical Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Normand Blais
- Division of Medical Oncology and Hematology, Department of Medicine, Centre Hospitalier de l'Université de Montréal; Université de Montréal, Montreal, Quebec, Canada
| | - Srikala S Sridhar
- Division of Medical Oncology, Department of Medicine, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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28
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Rosner MH, Jhaveri KD, McMahon BA, Perazella MA. Onconephrology: The intersections between the kidney and cancer. CA Cancer J Clin 2021; 71:47-77. [PMID: 32853404 DOI: 10.3322/caac.21636] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/12/2022] Open
Abstract
Onconephrology is a new subspecialty of nephrology that recognizes the important intersections of kidney disease with cancer. This intersection takes many forms and includes drug-induced nephrotoxicity, electrolyte disorders, paraneoplastic glomerulonephritis, and the interactions of chronic kidney disease with cancer. Data clearly demonstrate that, when patients with cancer develop acute or chronic kidney disease, outcomes are inferior, and the promise of curative therapeutic regimens is lessened. This highlights the imperative for collaborative care between oncologists and nephrologists in recognizing and treating kidney disease in patients with cancer. In response to this need, specific training programs in onconephrology as well as dedicated onconephrology clinics have appeared. This comprehensive review covers many of the critical topics in onconephrology, with a focus on acute kidney injury, chronic kidney disease, drug-induced nephrotoxicity, kidney disease in stem cell transplantation, and electrolyte disorders in patients with cancer.
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Kenar D Jhaveri
- Division of Kidney Disease and Hypertension, Zucker School of Medicine at Hofstra University, Great Neck, New York
| | - Blaithin A McMahon
- Division of Nephrology. Medical, University of South Carolina, Charleston, South Carolina
| | - Mark A Perazella
- Division of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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29
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Drug dosing in cancer patients with decreased kidney function: A practical approach. Cancer Treat Rev 2020; 93:102139. [PMID: 33370636 DOI: 10.1016/j.ctrv.2020.102139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
Correct drug dosing of anticancer agents is essential to obtain optimal outcomes. Overdosing will result in increased toxicity, treatment interruption and possible cessation of anticancer treatment. Underdosing may result in suboptimal anti-cancer effects and may increase the risk of cancer-related mortality. As it is practical nor feasible to perform therapeutic drug monitoring for all anti-cancer drugs, kidney function is used to guide drug dosing for those drugs whose primary mode of excretion is through the kidney. However, it is not well-established what method should be utilized to measure or estimate kidney function and the choice of method does influence treatment decisions regarding eligibility for anti-cancer drugs and their dose. In this review, we will provide an overview regarding the importance of drug dosing, the preferred method to determine kidney function and a practical approach to drug dosing of anticancer drugs.
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30
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Tsang C, Akbari A, Frechette D, Brown PA. Accurate determination of glomerular filtration rate in adults for carboplatin dosing: Moving beyond Cockcroft and Gault. J Oncol Pharm Pract 2020; 27:368-375. [PMID: 33297846 DOI: 10.1177/1078155220978446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Carboplatin is a cytotoxic chemotherapy drug developed in the 1980s which is still widely used today across various tumour types. Despite its common application, there remains a significant controversy and practice variation on its unique method of dosing by area under the curve (AUC). One potential reason for this variability stems from the reliance of using an estimated glomerular filtration rate (eGFR) as an extrapolation of the measured GFR (mGFR) which the commonly used Calvert equation was originally validated for. This review takes a novel and collaborative nephro-oncology approach to highlight the historical evolution of carboplatin dosing, methods for estimating GFR and its relative performance in the application of carboplatin dosing for adult patients. DATA SOURCES We reviewed all pertinent publications comparing carboplatin AUC-based dosing in adult patients based on the various methods of GFR measurements or estimations in order to provide a comprehensive description of each method's advantages and risks. DATA SUMMARY AND CONCLUSIONS The Cockcroft-Gault equation has been widely studied but newer eGFR equations, such as the CKD-Epidemiology Collaboration (CKD-EPI) or Janowitz-Williams equation have outperformed the Cockcroft-Gault in recent studies.
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Affiliation(s)
- Corey Tsang
- Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
| | - Ayub Akbari
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, ON, Canada.,Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dominque Frechette
- Department of Medicine, Centre Integré des Services Sociaux de l'Outaouais, Gatineau, Québec, Canada
| | - Pierre Antoine Brown
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, ON, Canada.,Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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31
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Porta C, Bamias A, Danesh FR, Dębska-Ślizień A, Gallieni M, Gertz MA, Kielstein JT, Tesarova P, Wong G, Cheung M, Wheeler DC, Winkelmayer WC, Małyszko J. KDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancer. Kidney Int 2020; 98:1108-1119. [PMID: 33126977 DOI: 10.1016/j.kint.2020.06.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 12/12/2022]
Abstract
The association between kidney disease and cancer is multifaceted and complex. Persons with chronic kidney disease (CKD) have an increased incidence of cancer, and both cancer and cancer treatments can cause impaired kidney function. Renal issues in the setting of malignancy can worsen patient outcomes and diminish the adequacy of anticancer treatments. In addition, the oncology treatment landscape is changing rapidly, and data on tolerability of novel therapies in patients with CKD are often lacking. Caring for oncology patients has become more specialized and interdisciplinary, currently requiring collaboration among specialists in nephrology, medical oncology, critical care, clinical pharmacology/pharmacy, and palliative care, in addition to surgeons and urologists. To identify key management issues in nephrology relevant to patients with malignancy, KDIGO (Kidney Disease: Improving Global Outcomes) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology in December 2018. This report covers issues related to kidney impairment and solid organ malignancies as well as management and treatment of kidney cancer. Knowledge gaps, areas of controversy, and research priorities are described.
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Affiliation(s)
- Camillo Porta
- Department of Internal Medicine and Therapeutics, University of Pavia and Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
| | - Aristotelis Bamias
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Greece
| | - Farhad R Danesh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alicja Dębska-Ślizień
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Luigi Sacco Department of Biomedical and Clinical Sciences, Università di Milano, Milan, Italy
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Petra Tesarova
- Department of Oncology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK; George Institute for Global Health, Sydney, Australia
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Poland.
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32
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Chang AR, George J, Levey AS, Coresh J, Grams ME, Inker LA. Performance of Glomerular Filtration Rate Estimating Equations Before and After Bariatric Surgery. Kidney Med 2020; 2:699-706.e1. [PMID: 33319195 PMCID: PMC7729215 DOI: 10.1016/j.xkme.2020.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Rationale & Objective Evaluation of glomerular filtration rate (GFR) is challenging in adults undergoing bariatric surgery because creatinine and cystatin C levels are influenced by changes in muscle and fat mass. Additionally, indexing of GFR by body surface area (BSA) may by affected by decreases in BSA. Study Design Prospective observational study. Setting & Participants 27 adults with body mass index (BMI) ≥ 35 kg/m2 who underwent measurement of GFR before and after bariatric surgery. Outcomes Indexed and nonindexed GFRs measured (mGFRs) using plasma iohexol clearance, indexed and nonindexed estimated GFR (eGFR) based on levels of creatinine, cystatin C, or both from Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Analytic Approach Bias and percent of estimates within 20% and 30% of mGFR (P20 and P30) for estimating equations were examined. Results Mean presurgery BMI was 49.5 (SD, 9.4) kg/m2, BSA was 2.42 (SD, 0.27) m2, nonindexed mGFR was 117.3 (SD, 34.1) mL/min, and indexed mGFR was 84.1 (SD, 22.0) mL/min/1.73 m2. After 6 months, mean BMI changed by –13.8 (95% CI, −15.9 to −11.8) kg/m2, BSA by −0.30 (95% CI, −0.33 to −0.27) m2, and nonindexed mGFR by −9.2 (95% CI, −17.2 to −1.1) mL/min, while indexed mGFR was unchanged at 5.1 (95% CI, −0.1 to 10.4) mL/min/1.73 m2. Nonindexed eGFRcr was unbiased (median bias, 5.0 [95% CI, −4.3 to 11.6] mL/min) before surgery, but overestimated mGFR (8.8 [95% CI, 1.8 to 16.9] mL/min) after surgery. Nonindexed eGFRcys underestimated mGFR before (median bias, −12.1 [95% CI, −21.4 to −1.2] mL/min) and after surgery (−11.2 [95% CI, −21.8 to −7.3] mL/min). Nonindexed eGFRcr-cys was unbiased before (median bias, −6.0 [95% CI, −11.0 to 1.0] mL/min) and after surgery (−2.0 [95% CI, −8.8 to 4.9] mL/min). Findings were similar for indexed eGFR compared with indexed mGFR. Limitations Small, mostly white sample. Conclusions Changes in indexed and nonindexed GFRs may be discordant after bariatric surgery in adults because of decreases in BSA. Indexed and nonindexed eGFRcr-cys may be less biased than indexed or nonindexed eGFRcr or eGFRcys because of opposite biases in estimating mGFR.
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Affiliation(s)
- Alex R. Chang
- Kidney Health Research Institute, Geisinger, Danville, PA
- Department of Population Health Sciences, Geisinger, Danville, PA
- Address for Correspondence: Alex R. Chang, MD, MS, 100 N Academy Ave, Danville, PA 17822.
| | - Jason George
- Department of Population Health Sciences, Geisinger, Danville, PA
| | | | - Josef Coresh
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
- Divison of Nephrology, Johns Hopkins University, Baltimore, MD
| | - Morgan E. Grams
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
- Divison of Nephrology, Johns Hopkins University, Baltimore, MD
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Maillard M, Le Louedec F, Thomas F, Chatelut E. Diversity of dose-individualization and therapeutic drug monitoring practices of platinum compounds: a review. Expert Opin Drug Metab Toxicol 2020; 16:907-925. [PMID: 33016786 DOI: 10.1080/17425255.2020.1789590] [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] [Indexed: 12/24/2022]
Abstract
Introduction: Platinum-derived drugs are commonly used for the treatment of solid tumors. The differences in chemical structures of these molecules lead to different pharmacological properties, in terms of indication, efficacy, and toxicity. Their pharmacokinetics (PK) differ according to their respective renal elimination and have led to many studies investigating their dose optimization. Area covered: This review attempts to summarize and compare PK and pharmacodynamics of cisplatin, carboplatin, and oxaliplatin, with an emphasis on differences of dose calculations and opportunities for therapeutic drug monitoring (TDM) in various patient populations. Expert opinion: Although cisplatin and carboplatin can be considered as analogs since they share the same DNA interacting properties, the slower hydrolysis of the latter results in a better safety profile. Carboplatin is the only drug in oncology to be administrated according to a target area under the curve of concentration versus time, considering that its PK variability is almost fully explained by renal function, not by body size. This enables individual dosing based on predicted carboplatin clearance (along with patients renal characteristics) or on actual clearance with TDM, especially in a high-dose protocol.
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Affiliation(s)
- Maud Maillard
- Laboratoire De Pharmacologie, Institut Claudius-Regaud, IUCT-Oncopole , Toulouse Cedex 9, France.,Cancer Research Center of Toulouse, INSERM UMR1037, Team 14 DIAD (Dose Individualization of Anticancer Drug) , Toulouse, France.,Faculté de Pharmacie, Université Paul Sabatier Toulouse III , Toulouse, France
| | - Félicien Le Louedec
- Laboratoire De Pharmacologie, Institut Claudius-Regaud, IUCT-Oncopole , Toulouse Cedex 9, France.,Cancer Research Center of Toulouse, INSERM UMR1037, Team 14 DIAD (Dose Individualization of Anticancer Drug) , Toulouse, France.,Faculté de Pharmacie, Université Paul Sabatier Toulouse III , Toulouse, France
| | - Fabienne Thomas
- Laboratoire De Pharmacologie, Institut Claudius-Regaud, IUCT-Oncopole , Toulouse Cedex 9, France.,Cancer Research Center of Toulouse, INSERM UMR1037, Team 14 DIAD (Dose Individualization of Anticancer Drug) , Toulouse, France.,Faculté de Pharmacie, Université Paul Sabatier Toulouse III , Toulouse, France
| | - Etienne Chatelut
- Laboratoire De Pharmacologie, Institut Claudius-Regaud, IUCT-Oncopole , Toulouse Cedex 9, France.,Cancer Research Center of Toulouse, INSERM UMR1037, Team 14 DIAD (Dose Individualization of Anticancer Drug) , Toulouse, France.,Faculté de Pharmacie, Université Paul Sabatier Toulouse III , Toulouse, France
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34
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Seiberth S, Terstegen T, Strobach D, Czock D. Accuracy of freely available online GFR calculators using the CKD-EPI equation. Eur J Clin Pharmacol 2020; 76:1465-1470. [PMID: 32562002 PMCID: PMC7481157 DOI: 10.1007/s00228-020-02932-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/09/2020] [Indexed: 11/30/2022]
Abstract
Purpose Estimated glomerular filtration rate (eGFR) as calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is used for detection of chronic kidney disease and drug dose adjustment. The purpose of the present study was to investigate the accuracy of freely available eGFR online calculators. Methods All identified CKD-EPI online calculators were run with five reference cases differing in age, sex, serum creatinine, and ethnicity. Conversion from eGFRindexed (unit ml/min per 1.73 m2) to eGFRnon-indexed (unit ml/min) and creatinine unit from milligramme/decilitre to micromole/litre was checked, if available. Results Only 36 of 47 calculators (76.6%) produced accurate eGFR results for all reference cases. Eight of 47 (17.0%) calculators were considered as faulty because of errors relating to ethnicity (4 calculators), to conversion of the eGFR unit (2 calculators), to erroneous eGFR values without obvious explanation (2 calculators), to conversion of the creatinine unit (1 calculator), and to an error in the eGFR unit displayed (1 calculator). Overall, 28 errors were found (range 59 to 147% of the correct eGFR value), the majority concerning calculation of eGFRindexed and the conversion to eGFRnon-indexed. Only 7 of 47 (14.9%) calculators offered conversion of the eGFR unit. Conclusions Erroneous calculations that might lead to inappropriate clinical decision-making were found in 8 of 47 calculators. Thus, online calculators should be evaluated more thoroughly after implementation. Conversion of eGFR units that might be needed for drug dose adjustments should be implemented more often. Electronic supplementary material The online version of this article (10.1007/s00228-020-02932-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Seiberth
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Theresa Terstegen
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Dorothea Strobach
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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35
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Rouanne M, Gaillard F, Meunier ME, Soorojebally Y, Phan H, Slimani-Thevenet H, Jannot AS, Neuzillet Y, Friedlander G, Froissart M, Botto H, Houillier P, Lebret T, Courbebaisse M. Measured glomerular filtration rate (GFR) significantly and rapidly decreases after radical cystectomy for bladder cancer. Sci Rep 2020; 10:16145. [PMID: 32999403 PMCID: PMC7528003 DOI: 10.1038/s41598-020-73191-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 09/07/2020] [Indexed: 11/09/2022] Open
Abstract
Precise determination of glomerular filtration rate (GFR) is essential for the management of patients with muscle-invasive bladder cancer (MIBC). We aim to describe the early evolution of measured GFR (mGFR) after radical cystectomy and urinary diversion (RCUD) and to identify risk factors for GFR decline. GFR measurement using 51Cr-EDTA continuous infusion, estimated GFR (eGFR) from five published equations and renal scintigraphy with split renal function determination were performed before and 6 months after RCUD. Chronic Kidney Disease (mGFR < 60 mL/min/1.73 m2) and GFR stages were defined according to the KDIGO guidelines using mGFR. Twenty-seven patients (men 85%, median age 65, IQR 59; 68 years) were included. A total of 20 (74%) patients experienced significant mGFR decline at 6 months postoperatively. Median mGFR decreased from 84.1 pre-operatively (IQR 65.3; 97.2) to 69.9 mL/min/1.73 m2 (IQR 55.0; 77.9) 6 months after surgery (p < 0.001). Thirteen (48%) patients had a progression to a worse GFR stage. Of the 22 patients without pre-operative CKD, 5 (23%) developed post-operative CKD. Diabetes mellitus was more frequent in patients in the highest tertile of relative mGFR decline (44% vs. 11%, p = 0.02) and platinum-based adjuvant chemotherapy tended to be more frequently used in these patients (44% vs. 17%, p = 0.06). Importantly, pre-operative weight was independently and negatively associated with post-operative mGFR and with mGFR slope in multivariable analyses. In this prospective series, we demonstrated that early and significant mGFR decline occurred after RCUD and perioperative platinum-based chemotherapy, especially in patients with diabetes mellitus and overweight.
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Affiliation(s)
- Mathieu Rouanne
- Department of Urology, Hôpital Foch, Université Paris-Saclay, 40, Rue Worth, 92150, Suresnes, France. .,UVSQ-Université Paris-Saclay, Paris, France.
| | - François Gaillard
- Department of Physiology, Functional Explorations Unit, Hôpital Européen Georges Pompidou, Paris, France
| | - Matthias E Meunier
- Department of Urology, Hôpital Foch, Université Paris-Saclay, 40, Rue Worth, 92150, Suresnes, France
| | - Yanish Soorojebally
- Department of Urology, Hôpital Foch, Université Paris-Saclay, 40, Rue Worth, 92150, Suresnes, France.,UVSQ-Université Paris-Saclay, Paris, France
| | - Hoang Phan
- Department of Biostatistics, Hôpital Européen Georges Pompidou, Paris, France
| | | | - Anne-Sophie Jannot
- Department of Biostatistics, Hôpital Européen Georges Pompidou, Paris, France
| | - Yann Neuzillet
- Department of Urology, Hôpital Foch, Université Paris-Saclay, 40, Rue Worth, 92150, Suresnes, France.,UVSQ-Université Paris-Saclay, Paris, France
| | - Gérard Friedlander
- Department of Physiology, Functional Explorations Unit, Hôpital Européen Georges Pompidou, Paris, France.,INSERM U1151-CNRS UMR8253, Paris, France.,Université Paris Descartes, Paris, France
| | - Marc Froissart
- Clinical Research Center and Trial Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Henry Botto
- Department of Urology, Hôpital Foch, Université Paris-Saclay, 40, Rue Worth, 92150, Suresnes, France
| | - Pascal Houillier
- Department of Physiology, Functional Explorations Unit, Hôpital Européen Georges Pompidou, Paris, France.,INSERM U1151-CNRS UMR8253, Paris, France.,INSERM U1138, CNRS ERL8228, Paris, France
| | - Thierry Lebret
- Department of Urology, Hôpital Foch, Université Paris-Saclay, 40, Rue Worth, 92150, Suresnes, France.,UVSQ-Université Paris-Saclay, Paris, France
| | - Marie Courbebaisse
- Department of Physiology, Functional Explorations Unit, Hôpital Européen Georges Pompidou, Paris, France.,Department of Nuclear Medicine, Hôpital Européen Georges Pompidou, Paris, France.,INSERM U1151-CNRS UMR8253, Paris, France
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36
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Jiang DM, North SA, Canil C, Kolinsky M, Wood LA, Gray S, Eigl BJ, Basappa NS, Blais N, Winquist E, Mukherjee SD, Booth CM, Alimohamed NS, Czaykowski P, Kulkarni GS, Black PC, Chung PW, Kassouf W, van der Kwast T, Sridhar SS. Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada. Bladder Cancer 2020. [DOI: 10.3233/blc-200291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.
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Affiliation(s)
- Di Maria Jiang
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Scott A. North
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Christina Canil
- Department of Internal Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON, Canada
| | - Michael Kolinsky
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Lori A. Wood
- Department of Medicine, Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Samantha Gray
- Department of Oncology, Saint John Regional Hospital, Department of Medicine, Dalhousie University, Saint John, NB, Canada
| | - Bernhard J. Eigl
- Department of Medicine, Division of Medical Oncology, BC Cancer - Vancouver, University of British Columbia, Vancouver, BC, Canada
| | - Naveen S. Basappa
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Normand Blais
- Department of Medicine, Division of Medical Oncology and Hematology, Centre Hospitalier de l’Université de Montréal; Université de Montréal, Montreal, QC, Canada
| | - Eric Winquist
- Department of Oncology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Som D. Mukherjee
- Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Nimira S. Alimohamed
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Piotr Czaykowski
- Department of Medical Oncology and Hematology, Cancer Care Manitoba, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Girish S. Kulkarni
- Departments of Surgery and Surgical Oncology, Division of Urology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Peter C. Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter W. Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Wassim Kassouf
- Department of Urology, McGill University Health Centre, Montreal, QC, Canada
| | | | - Srikala S. Sridhar
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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37
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Carboplatin dose capping affects pCR rate in HER2-positive breast cancer patients treated with neoadjuvant Docetaxel, Carboplatin, Trastuzumab, Pertuzumab (TCHP). Breast Cancer Res Treat 2020; 184:481-489. [PMID: 32860550 PMCID: PMC7599187 DOI: 10.1007/s10549-020-05868-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/06/2020] [Indexed: 10/26/2022]
Abstract
PURPOSE Estimated glomerular filtration rate (eGFR) is commonly used to calculate carboplatin doses and capping the eGFR may be used to reduce the risk of excessive dosing and toxicity. We sought to retrospectively examine the impact of our carboplatin guidelines on pathological complete response rates (pCR) and toxicity in women with HER2+ breast cancer receiving neoadjuvant docetaxel, carboplatin, trastuzumab and pertuzumab (TCHP). METHODS The delivered area under the curve (dAUC) was calculated [(actual carboplatin dose at cycle 1 ÷ dose calculated with uncapped/unbanded eGFR) × 6] and dichotomized at the median value. The impact of this and other clinical factors on pCR rate, dose intensity (DI) and toxicity was assessed. RESULTS 124 eligible patients were identified of whom 63.7% (79/124) achieved pCR. The median dAUC at cycle 1 was 5.75 mg × ml/min. Those with lower dAUC were more frequently younger and overweight/obese. Patients with lower dAUC had significantly inferior pCR rates of 54.8% (34/62) vs 72.6% (45/62), respectively (p = 0.040). Similar results were seen in the ER+ subgroup; 45.2% (19/42) vs 68.3% (28/41), p = 0.037%, whereas no significant difference was seen among ER- patients; 75.0% (15/20) vs 81.0% (17/21), p = 0.72. DI and toxicity were comparable between the two dAUC groups. CONCLUSIONS The overall pCR rate was high in patients with HER2+ breast cancer receiving the TCHP regimen; however, carboplatin dose capping resulted in inferior pCR rates, particularly in the ER+ subgroup. To ensure optimal dosing, isotopic measurement of renal function is warranted in patients who would otherwise have their eGFR and dose capped.
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38
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Malyszko J, Tesarova P, Capasso G, Capasso A. The link between kidney disease and cancer: complications and treatment. Lancet 2020; 396:277-287. [PMID: 32711803 DOI: 10.1016/s0140-6736(20)30540-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 02/19/2020] [Accepted: 02/28/2020] [Indexed: 12/12/2022]
Abstract
Acute and chronic kidney disease encompasses a complex set of diseases that can both lead to, and result from, cancer. In particular, kidney disease can arise from the use of chemotherapeutic agents. Many of the current and newly developed cancer chemotherapeutic agents are nephrotoxic and can promote kidney dysfunction, which frequently manifests during the terminal stages of cancer. Given the link between kidney disease and cancer development and treatment, the aim of this Review is to highlight the importance of multidisciplinary collaboration between oncologists and nephrologists to predict and prevent chemotherapeutic-induced nephrotoxicity. As new therapies are introduced to treat cancer, new renal toxicities require proper diagnosis and management. We anticipate that multidisciplinary collaborations will lead to the development and implementation of guidelines for clinicians to improve the therapeutic management of patients with both cancer and renal impairment.
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Affiliation(s)
- Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Poland.
| | - Petra Tesarova
- Department of Oncology, Charles University, Prague, Czech Republic
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University Campania Luigi Vanvitelli, Naples, Italy; Biogem Institute, Ariano Irpino, Italy
| | - Anna Capasso
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, TX, USA
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Piscitani L, Sirolli V, Di Liberato L, Morroni M, Bonomini M. Nephrotoxicity Associated with Novel Anticancer Agents (Aflibercept, Dasatinib, Nivolumab): Case Series and Nephrological Considerations. Int J Mol Sci 2020; 21:E4878. [PMID: 32664269 PMCID: PMC7402330 DOI: 10.3390/ijms21144878] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022] Open
Abstract
Cancer patients have an incidence of about 60% kidney disease development and are at elevated risk of acute renal damage. Kidney disease in these patients is frequently associated with nephrotoxicity from the ongoing oncological treatment. New anticancer therapeutic strategies, such as targeted therapies and immunotherapies, offer substantial benefits in the treatment of many neoplasms. However, their use is associated with significant nephrotoxicity, which qualitatively differs from that seen with traditional cytotoxic chemotherapy, while the underlying mechanisms are complex and still to be clearly defined. Nephrologists need to be knowledgeable about the array of such renal toxicities for effective collaboration with the oncologist in the prevention and management of kidney involvement. Renal adverse effects may range from asymptomatic proteinuria to renal failure, and their prompt identification and timely treatment is essential for optimal and safe care of the patient. In this article, after presenting clinical cases we discuss the differing renal toxicity of three novel anticancer agents (aflibercept, dasatinib, and nivolumab) and possible measures to counter it.
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Affiliation(s)
- Luca Piscitani
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.P.); (V.S.); (L.D.L.)
| | - Vittorio Sirolli
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.P.); (V.S.); (L.D.L.)
| | - Lorenzo Di Liberato
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.P.); (V.S.); (L.D.L.)
| | - Manrico Morroni
- Department of Experimental and Clinical Medicine-Neuroscience and Cell Biology, School of Medicine, Università Politecnica delle Marche, Via Tronto 10/A, 60126 Ancona, Italy;
| | - Mario Bonomini
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.P.); (V.S.); (L.D.L.)
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40
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Carboplatin dosing in the era of IDMS-creatinine; the Cockroft-Gault formula no longer provides a sufficiently accurate estimate of glomerular filtration rate for routine use in clinical care. Gynecol Oncol 2020; 157:793-798. [DOI: 10.1016/j.ygyno.2020.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/15/2020] [Indexed: 11/20/2022]
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41
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How to assess kidney function in oncology patients. Kidney Int 2020; 97:894-903. [DOI: 10.1016/j.kint.2019.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/20/2019] [Accepted: 12/17/2019] [Indexed: 12/24/2022]
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42
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Sprangers B, Abudayyeh A, Latcha S, Perazella MA, Jhaveri KD. How to determine kidney function in cancer patients? Eur J Cancer 2020; 132:141-149. [PMID: 32361629 DOI: 10.1016/j.ejca.2020.03.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/29/2020] [Indexed: 12/18/2022]
Abstract
A precise and efficient method for estimating kidney function in cancer patients is important to determine their eligibility for clinical trials and surgery and to allow for appropriate dose adjustment of anti-cancer drugs, especially toxic drugs with a narrow therapeutic index. Since direct measurement of glomerular filtration rate (GFR) is cumbersome, several formulae have been developed to estimate kidney function. Most of these are based on serum creatinine concentration. Though the CKD-EPI formula is recognised as being the most accurate, there is an ongoing debate on which is the optimal formula for cancer patients. In this review, we provide an overview of different GFR estimating equations for kidney function and the advantages and disadvantages of each method and compare their performance in cancer patients. We discuss the importance of body surface area-indexing and propose a framework for evaluating kidney function in cancer patients.
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Affiliation(s)
- Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Both in Leuven, Belgium.
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sheron Latcha
- Renal Division, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark A Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA; Veterans Affairs Medical Center, West Haven, CT, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
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43
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McMahon BA, Rosner MH. GFR Measurement and Chemotherapy Dosing in Patients with Kidney Disease and Cancer. KIDNEY360 2020; 1:141-150. [PMID: 35372903 PMCID: PMC8809099 DOI: 10.34067/kid.0000952019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chemotherapeutic agents require precise dosing to ensure optimal efficacy and minimize complications. For those agents that are removed from the body by the kidney, accurate knowledge of GFR is critical. In addition, GFR needs to be determined rapidly, easily, and, if possible, with little additional cost. The ability to easily measure GFR also allows for rapid detection of nephrotoxicity. Current methodologies include direct clearance measurement of an indicator substance or estimation of creatinine clearance or GFR through regression equations that use a serum marker, such as creatinine or cystatin C. These methodologies all have shortfalls and limitations, some of which are specific to the patient with cancer. Newer methodologies that directly measure GFR are in clinical trials and offer the ability to rapidly and noninvasively provide accurate estimates of drug clearance as well as detection of nephrotoxicity. These methods offer the opportunity to refine drug dosing and improve outcomes.
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Affiliation(s)
- Blaithin A. McMahon
- Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina; and
| | - Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
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44
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Sprangers B, Jhaveri KD, Perazella MA. Improving Cancer Care for Patients With Chronic Kidney Disease. J Clin Oncol 2020; 38:188-192. [DOI: 10.1200/jco.19.02138] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Ben Sprangers
- Department of Microbiology, Immunology, and Transplantation, Laboratory of Molecular Immunology, Rega Institute, Katholieke Universiteit Leuven, and Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Mark A. Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, CT
- Veterans Affairs Medical Center, West Haven, CT
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45
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White-Koning M, Paludetto MN, Le Louedec F, Gladieff L, Chevreau C, Chatelut E, Puisset F. Formulae recently proposed to estimate renal glomerular filtration rate improve the prediction of carboplatin clearance. Cancer Chemother Pharmacol 2020; 85:585-592. [DOI: 10.1007/s00280-019-04020-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/17/2019] [Indexed: 12/21/2022]
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46
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47
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Agreement and Precision Analyses of Various Estimated Glomerular Filtration Rate Formulae in Cancer Patients. Sci Rep 2019; 9:19356. [PMID: 31852941 PMCID: PMC6920413 DOI: 10.1038/s41598-019-55833-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 12/02/2019] [Indexed: 12/18/2022] Open
Abstract
The accuracy of the estimated glomerular filtration rate (eGFR) in cancer patients is very important for dose adjustments of anti-malignancy drugs to reduce toxicities and enhance therapeutic outcomes. Therefore, the performance of eGFR equations, including their bias, precision, and accuracy, was explored in patients with varying stages of chronic kidney disease (CKD) who needed anti-cancer drugs. The reference glomerular filtration rate (GFR) was assessed by the 99mTc-diethylene triamine penta-acetic acid (99mTc-DTPA) plasma clearance method in 320 patients and compared with the GFRs estimated by i) the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, ii) the unadjusted for body surface area (BSA) CKD-EPI equation, iii) the re-expressed Modification of Diet in Renal Disease (MDRD) study equation with the Thai racial factor, iv) the Thai eGFR equation, developed in CKD patients, v) the 2012 CKD-EPI creatinine-cystatin C, vi) the Cockcroft-Gault formula, and vii) the Janowitz and Williams equations for cancer patients. The mean reference GFR was 60.5 ± 33.4 mL/min/1.73 m2. The bias (mean error) values for the estimated GFR from the CKD-EPI equation, BSA-unadjusted CKD-EPI equation, re-expressed MDRD study equation with the Thai racial factor, and Thai eGFR, 2012 CKD-EPI creatinine-cystatin-C, Cockcroft-Gault, and Janowitz and Williams equations were -2.68, 1.06, -7.70, -8.73, 13.37, 1.43, and 2.03 mL/min, respectively, the precision (standard deviation of bias) values were 6.89, 6.07, 14.02, 11.54, 20.85, 10.58, and 8.74 mL/min, respectively, and the accuracy (root-mean square error) values were 7.38, 6.15, 15.97, 14.16, 24.74, 10.66, and 8.96 mL/min, respectively. In conclusion, the estimated GFR from the BSA-unadjusted CKD-EPI equation demonstrated the least bias along with the highest precision and accuracy. Further studies on the outcomes of anti-cancer drug dose adjustments using this equation versus the current standard equation will be valuable.
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48
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Williams EH, Connell CM, Weaver JMJ, Beh I, Potts H, Whitley CT, Bird N, Al-Sayed T, Monaghan PJ, Fehr M, Cathomas R, Bertelli G, Quinton A, Lewis P, Shamash J, Wilson P, Dooley M, Poole S, Mark PB, Bookman MA, Earl H, Jodrell D, Tavaré S, Lynch AG, Janowitz T. Multicenter Validation of the CamGFR Model for Estimated Glomerular Filtration Rate. JNCI Cancer Spectr 2019; 3:pkz068. [PMID: 31750418 PMCID: PMC6846361 DOI: 10.1093/jncics/pkz068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/13/2019] [Accepted: 08/23/2019] [Indexed: 11/14/2022] Open
Abstract
Important oncological management decisions rely on kidney function assessed by serum creatinine-based estimated glomerular filtration rate (eGFR). However, no large-scale multicenter comparisons of methods to determine eGFR in patients with cancer are available. To compare the performance of formulas for eGFR based on routine clinical parameters and serum creatinine not calibrated with isotope dilution mass spectrometry, we studied 3620 patients with cancer and 166 without cancer who had their glomerular filtration rate (GFR) measured with an exogenous nuclear tracer at one of seven clinical centers. The mean measured GFR was 86 mL/min. Accuracy of all models was center dependent, reflecting intercenter variability of isotope dilution mass spectrometry-creatinine measurements. CamGFR was the most accurate model for eGFR (root-mean-squared error 17.3 mL/min) followed by the Chronic Kidney Disease Epidemiology Collaboration model (root-mean-squared error 18.2 mL/min).
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Affiliation(s)
- Edward H Williams
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Claire M Connell
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- Cambridge University Hospital NHS Trust, Cambridge, UK
- Department of Oncology, University of Cambridge, UK
| | | | - Ian Beh
- Western General Hospital, Edinburgh, UK
| | - Harry Potts
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Nicholas Bird
- Cambridge University Hospital NHS Trust, Cambridge, UK
| | | | - Phillip J Monaghan
- The Christie Pathology Partnership, The Christie NHS Foundation Trust, Manchester, UK
- University of Manchester, Faculty of Medical and Human Sciences, Institute of Inflammation and Repair, Manchester, UK
| | - Martin Fehr
- Clinic for Medical Oncology and Hematology, Cantonal Hospital St Gallen, Switzerland
| | - Richard Cathomas
- Division of Oncology/Hematology, Cantonal Hospital Graubünden, Switzerland
| | - Gianfilippo Bertelli
- Sussex Cancer Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Paul Lewis
- Institute of Life Science, Medical School, Swansea University, Swansea, UK
| | - Jonathan Shamash
- Department of Medical Oncology, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Peter Wilson
- Department of Medical Oncology, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Michael Dooley
- Alfred Health, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Susan Poole
- Alfred Health, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | | | - Helena Earl
- Cambridge University Hospital NHS Trust, Cambridge, UK
- Department of Oncology, University of Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Duncan Jodrell
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- Cambridge University Hospital NHS Trust, Cambridge, UK
| | - Simon Tavaré
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- Columbia University, New York, NY
| | - Andy G Lynch
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- School of Medicine/School of Mathematics and Statistics, University of St Andrews, St Andrews, UK
| | - Tobias Janowitz
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
- Cold Spring Harbor Laboratory, Cold Spring Harbor, New York, NY
- Northwell Health, New York, NY
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49
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Summary of the International Conference on Onco-Nephrology: an emerging field in medicine. Kidney Int 2019; 96:555-567. [DOI: 10.1016/j.kint.2019.04.043] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/02/2019] [Accepted: 04/05/2019] [Indexed: 01/10/2023]
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50
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Gourley C, Bookman MA. Evolving Concepts in the Management of Newly Diagnosed Epithelial Ovarian Cancer. J Clin Oncol 2019; 37:2386-2397. [PMID: 31403859 DOI: 10.1200/jco.19.00337] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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