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Hanna PE, Ouyang T, Tahir I, Katz‐Agranov N, Wang Q, Mantz L, Strohbehn I, Moreno D, Harden D, Dinulos JE, Cosar D, Seethapathy H, Gainor JF, Shah SJ, Gupta S, Leaf DE, Fintelmann FJ, Sise ME. Sarcopenia, adiposity and large discordance between cystatin C and creatinine-based estimated glomerular filtration rate in patients with cancer. J Cachexia Sarcopenia Muscle 2024; 15:1187-1198. [PMID: 38646842 PMCID: PMC11154767 DOI: 10.1002/jcsm.13469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 12/15/2023] [Accepted: 03/06/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Creatinine-based estimated glomerular filtration rate (eGFRCRE) may overestimate kidney function in patients with sarcopenia. While cystatin C-based eGFR (eGFRCYS) is less affected by muscle mass, it may underestimate kidney function in patients with obesity. We sought to evaluate the relationship between body composition defined by computed tomography (CT) scans and discordance between creatinine, eGFRCRE and eGFRCYS in adult patients with cancer. METHODS This study is a cross-sectional study of consecutive adults with cancer with an abdominal CT scan performed within 90 days of simultaneous eGFRCRE and eGFRCYS measurements between May 2010 and January 2022. Muscle and adipose tissue cross-sectional areas were measured at the level of the third lumbar vertebral body using a validated deep-learning pipeline. CT-defined sarcopenia was defined using independent sex-specific cut-offs for skeletal muscle index (<39 cm2/m2 for women and <55 cm2/m2 for men). High adiposity was defined as the highest sex-specific quartile of the total (visceral plus subcutaneous) adiposity index in the cohort. The primary outcome was eGFR discordance, defined by eGFRCYS > 30% lower than eGFRCRE; the secondary outcome was eGFRCYS > 50% lower than eGFRCRE. The odds of eGFR discordance were estimated using multivariable logistic regression modelling. Unadjusted spline regression was used to evaluate the relationship between skeletal muscle index and the difference between eGFRCYS and eGFRCRE. RESULTS Of the 545 included patients (mean age 63 ± 14 years, 300 [55%] females, 440 [80.7%] non-Hispanic white), 320 (58.7%) met the criteria for CT-defined sarcopenia, and 136 (25%) had high adiposity. A total of 259 patients (48%) had >30% eGFR discordance, and 122 (22.4%) had >50% eGFR discordance. After adjustment for potential confounders, CT-defined sarcopenia and high adiposity were both associated with >30% eGFR discordance (adjusted odds ratio [aOR] 1.90, 95% confidence interval [CI] 1.12-3.24; aOR 2.01, 95% CI 1.15-3.52, respectively) and >50% eGFR discordance (aOR 2.34, 95% CI 1.21-4.51; aOR 2.23, 95% CI 1.19-4.17, respectively). A spline model demonstrated that as skeletal muscle index decreases, the predicted difference between eGFRCRE and eGFRCYS widens considerably. CONCLUSIONS CT-defined sarcopenia and high adiposity are both independently associated with large eGFR discordance. Incorporating valuable information from body composition analysis derived from CT scans performed as a part of routine cancer care can impact the interpretation of GFR estimates.
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Affiliation(s)
- Paul E. Hanna
- Division of Nephrology, Department of MedicineMedical College of WisconsinMilwaukeeWIUSA
| | - Tianqi Ouyang
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Ismail Tahir
- Department of RadiologyMassachusetts General HospitalBostonMAUSA
| | - Nurit Katz‐Agranov
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Qiyu Wang
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Lea Mantz
- Department of RadiologyMassachusetts General HospitalBostonMAUSA
- Department of Diagnostic and Interventional RadiologyUniversity Medical Center of the Johannes Gutenberg University MainzMainzGermany
| | - Ian Strohbehn
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Daiana Moreno
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Destiny Harden
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - James E. Dinulos
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Duru Cosar
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Harish Seethapathy
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Justin F. Gainor
- Division of Hematology and Oncology, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Sachin J. Shah
- Division of General Internal Medicine, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | - Shruti Gupta
- Division of Renal Medicine, Department of MedicineBrigham and Women's HospitalBostonMAUSA
- Adult Survivorship ProgramDana‐Farber Cancer InstituteBostonMAUSA
| | - David E. Leaf
- Division of General Internal Medicine, Department of MedicineMassachusetts General HospitalBostonMAUSA
| | | | - Meghan E. Sise
- Division of Nephrology, Department of MedicineMassachusetts General HospitalBostonMAUSA
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Impact of Elevated LDH on Cystatin C-Based Glomerular Filtration Rate Estimates in Patients with Cancer. J Clin Med 2022; 11:jcm11185458. [PMID: 36143104 PMCID: PMC9503681 DOI: 10.3390/jcm11185458] [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: 08/24/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The determination of renal function is crucial for the clinical management of patients with cancer. The glomerular filtration rate (GFR) serves as a key parameter, estimated by creatinine clearance determination in 24-h collected urine (CrCl) as well as equation-based approaches (eGFR) relying on serum creatinine (eGFR CKD EPIcrea) or serum cystatin C (eGFR cystatin C). Serum creatinine and serum cystatin C levels differentially depend on muscle and tumor mass, respectively. Although muscle and tumor mass may thus represent confounding factors, comparative studies for eGFR estimate approaches in cancer patients are lacking. Methods: The present study retrospectively analyzed GFR estimates based on equations of creatinine (eGFRcr), cystatin C (eGFRcys) and combined creatinine-cystatin C levels (eGFRcr-cys) in a subset of patients. The associations of LDH with cystatin C or LDH with eGFRcr, eGFRcys and GFRcr-cys were explored. Results: The laboratory values of 123 consecutive patients were included. The median age was 59 (24−87) and 47.2% were female. There was a statistically significant difference in the mean of CKD EPIcrea (85.17 ± 21.63 mL/min/1.73 m2), CKD EPIcys (61.16 ± 26.03 mL/min/1.73 m2) and CKD EPIcrea-cys (70.42 ± 23.89 mL/min/1.73 m2) (p < 0.0001). Spearman’s correlation analysis revealed a significant correlation of elevated plasma LDH >1.5 UNV and cystatin C values (r = 0.270, p < 0.01, n = 123). LDH values >1.5 UNV were associated with significantly lower CKD EPIcys (r = 0.184, p < 0.01) or CKD EPIcrea-cys (r = 0.226, p < 0.05) estimates compared to CKD EPIcrea. Conclusions: The inclusion of cystatin C as a biomarker led to a lower eGFR estimates compared to creatinine alone or in a combination of both cystatin C and creatinine. The level of cystatin C correlated with the level of LDH, suggesting that the use of cystatin C-based calculations of GFR in cancer patients with elevated LDH should be used with caution.
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High serum cystatin C levels in juvenile myelomonocytic leukemia patients without abnormal kidney function. Pediatr Nephrol 2022; 37:1687-1691. [PMID: 35059855 DOI: 10.1007/s00467-021-05418-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND In pediatric cancer patients, the estimated glomerular filtration rate based on serum cystatin C (CysC) was reported to be suitable for estimating kidney function because of low serum creatinine (Cr) and high serum β2-microglobulin. Recently, however, serum CysC levels have been reported to be elevated in some cancer patients other than those with juvenile myelomonocytic leukemia (JMML), regardless of normal kidney function. CASE REPORTS We describe two pediatric cases of JMML with an elevated serum CysC level. Urinalysis tests showed no abnormalities and no evidence of nephritis or nephropathy, and there were no findings indicating abnormal kidney function, such as Cr clearance in one case or the estimated glomerular filtration rate based on serum Cr in both cases, except for the serum CysC levels. There were no other causes of a high serum CysC level, including hyperthyroidism and steroid administration. The patients were treated with a conventional dosage of drugs, and their serum CysC levels decreased to the normal range when they were in complete remission after treatment. CONCLUSION An elevated serum CysC level may reflect tumor burden independent of kidney function in JMML patients. Therefore, creatinine or inulin clearance should be determined to more accurately estimate kidney function for administering an optimal dose of anticancer drugs. In addition, a high serum CysC level may be a potential biomarker of cancer progression.
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Barth DM, Otto D, Wang P, Alkhasova MS, Barreto EF. Use of Cystatin C to Assess Immunotherapy Toxicity in a Patient With Melanoma. J Pharm Pract 2022; 35:308-310. [PMID: 35484868 DOI: 10.1177/0897190020966201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The advent of immunotherapy has improved outcomes of patients in a number of cancers.1 While immunotherapy helps the immune system recognize malignant cells, it also can lead to adverse effects that mimic autoimmune diseases including, but not limited to, rash, colitis, pneumonitis, and nephritis. Diagnosis of immunotherapy related nephritis is based on serum creatinine trends, which can be falsely elevated in the setting of high muscle mass. Cystatin C is an adjunctive kidney biomarker that can estimate glomerular filtration rate independent of muscle mass. We present a case where the use of cystatin C avoided unnecessary therapy interruption in a young, athletic man being treated with nivolumab for melanoma. Further research is needed to define the role cystatin C in monitoring kidney function during immunotherapy.
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Affiliation(s)
- Dylan M Barth
- Department of Pharmacy, 24560University of Utah Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Danielle Otto
- Department of Pharmacy, 4530University of Kentucky Healthcare, Lexington, KY, USA
| | - Peng Wang
- Department of Oncology, 4530University of Kentucky Healthcare, Lexington, KY, USA
| | - Maria S Alkhasova
- Department of Oncology, 4530University of Kentucky Healthcare, Lexington, KY, USA
| | - Erin F Barreto
- Department of Pharmacy Services, Robert D. and Patricia Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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Cystatin C and cystatin SN as possible soluble tumor markers in malignant uveal melanoma. Radiol Oncol 2021; 56:83-91. [PMID: 34957724 PMCID: PMC8884861 DOI: 10.2478/raon-2021-0049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/21/2021] [Indexed: 11/22/2022] Open
Abstract
Background The aim of the study was to determine the concentration of endogenous cystatin C and cystatin SN, as potential tumor biomarkers, in the serum and biological fluids of the eye in both healthy controls and patients with uveal melanoma. Patients and methods The concentration of both cystatins was determined in the intraocular fluid (IOF), tear fluid, and serum of patients with uveal melanoma and compared to baseline measurements in IOF, tears, serum, cerebral spinal fluid, saliva and urine of healthy controls. Results The concentration of cystatin C in all the biological matrices obtained from healthy controls significantly exceeded the concentration of cystatin SN and was independent of gender. Cystatin C concentrations in the tear fluid of patients with uveal melanoma (both the eye with the malignancy, as well as the contralateral, non-affected eye), were significantly greater than cystatin C concentrations in the tear fluid of healthy controls and was independent of tumor size. The concentration of cystatin SN in IOF of patients with uveal melanoma was significantly less than the corresponding concentration of cystatin SN in healthy controls. Conclusions The ratio of cystatins (CysC:CysSN) in both the serum and tear fluid, as well as the concentration of cystatin SN in IOF, would appear to strongly suggest the presence of uveal melanoma. It is further suggested that multiple diagnostic criteria be utilized if a patient is suspected of having uveal melanoma, such as determination of the cystatin C and cystatin SN concentrations in serum, tears, and IOF, ocular fundus and ultrasound imaging, and biopsy with histopathological evaluation.
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Teaford HR, Barreto JN, Vollmer KJ, Rule AD, Barreto EF. Cystatin C: A Primer for Pharmacists. PHARMACY 2020; 8:E35. [PMID: 32182861 PMCID: PMC7151673 DOI: 10.3390/pharmacy8010035] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/22/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Pharmacists are at the forefront of dosing and monitoring medications eliminated by or toxic to the kidney. To evaluate the effectiveness and safety of these medications, accurate measurement of kidney function is paramount. The mainstay of kidney assessment for drug dosing and monitoring is serum creatinine (SCr)-based estimation equations. Yet, SCr has known limitations including its insensitivity to underlying changes in kidney function and the numerous non-kidney factors that are incompletely accounted for in equations to estimate glomerular filtration rate (eGFR). Serum cystatin C (cysC) is a biomarker that can serve as an adjunct or alternative to SCr to evaluate kidney function for drug dosing. Pharmacists must be educated about the strengths and limitations of cysC prior to applying it to medication management. Not all patient populations have been studied and some evaluations demonstrated large variations in the relationship between cysC and GFR. Use of eGFR equations incorporating cysC should be reserved for drug management in scenarios with demonstrated outcomes, including to improve pharmacodynamic target attainment for antibiotics or reduce drug toxicity. This article provides an overview of cysC, discusses evidence around its use in medication dosing and in special populations, and describes practical considerations for application and implementation.
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Affiliation(s)
- Hilary R. Teaford
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
| | - Jason N. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
| | - Kathryn J. Vollmer
- College of Pharmacy and Health Sciences, Drake University, Des Moines, IA 50311, USA;
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA;
- Division of Epidemiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
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Leto G, Crescimanno M, Flandina C. On the role of cystatin C in cancer progression. Life Sci 2018; 202:152-160. [DOI: 10.1016/j.lfs.2018.04.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/17/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023]
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Incorporating Cystatin C to Predict Methotrexate Elimination in Patients with CNS Lymphoma and Suspicious Renal Function. Case Rep Hematol 2018; 2018:7169897. [PMID: 29780646 PMCID: PMC5892267 DOI: 10.1155/2018/7169897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/18/2018] [Indexed: 01/26/2023] Open
Abstract
High-dose methotrexate (MTX; ≥1 g/m2) is a renally eliminated and nephrotoxic first-line therapy for central nervous system (CNS) lymphoma. Creatinine-based estimation of renal function is the recommended approach to dosing MTX in these cases, but nonrenal determinants of creatinine production and elimination in cancer patients such as malnutrition and cachexia lead to overestimation of glomerular filtration rate (GFR) by this method and a heightened risk for drug toxicity. Serum cystatin C is one of the first readily available, relatively inexpensive, endogenous biomarkers to emerge as a practical adjunct to creatinine for estimation of renal function for drug dosing. In this report, we describe two cases where cystatin C was used in conjunction with creatinine to inform MTX dosing for CNS lymphoma. In both cases, the estimated GFR was nearly 40% lower with the combination of the two biomarkers compared to creatinine-only estimates. Empiric MTX dose reductions as a product of these results likely spared the patients sustained exposure to toxic drug concentrations and facilitated earlier administration of supportive care interventions. Further prospective investigations with validated dosing regimens including cystatin C are warranted for high-dose MTX.
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Tanaka S, Ando K, Kobayashi K, Hida T, Ito K, Tsushima M, Morozumi M, Machino M, Ota K, Seki T, Suzuki K, Nishida Y, Ishiguro N, Hasegawa Y, Imagama S. Serum cystatin C level is associated with locomotive syndrome risk and can be an early predictor in community-living people: The Yakumo study. Mod Rheumatol 2018; 28:1035-1040. [DOI: 10.1080/14397595.2018.1441675] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Satoshi Tanaka
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kei Ando
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tetsuro Hida
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kenyu Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Mikito Tsushima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masayoshi Morozumi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kyotaro Ota
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Taisuke Seki
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Koji Suzuki
- Faculty of Medical Technology, School of Health Science, Fujita Health University, Aichi, Japan
| | - Yoshihiro Nishida
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yukiharu Hasegawa
- Department of Rehabilitation, Kansai University of Welfare Science, Osaka, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
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