Kidney and Cancer Outcomes with Standard Versus Alternative Chemotherapy Regimens for First-Line Treatment of Metastatic Urothelial Carcinoma

Key Points

Many patients with metastatic urothelial carcinoma are deemed cisplatin-ineligible because of reduced kidney function. Options include split-dose cisplatin or carboplatin. There was no significant association between regimen type and AKI. Alternative regimens were associated with higher risk of progressive disease. There is a need to revisit cisplatin eligibility criteria and develop strategies to optimize cancer treatment for patients with CKD.

Background

Cisplatin-based chemotherapy regimens remain the optimal first-line treatment for patients with metastatic urothelial carcinoma (mUC). However, many patients are deemed cisplatin-ineligible, predominantly because of reduced kidney function. Other treatment options include split-dose cisplatin, carboplatin, and non–platinum-based regimens. We compared the incidence of AKI and cancer outcomes within three chemotherapy regimens.

Methods

We conducted a single-center retrospective study of patients with mUC who received first-line chemotherapy from 2005 to 2019. We compared standard gemcitabine–cisplatin (gem-cis) with two alternative regimens: (1 ) gem-cis split-dose regimen (split) with cisplatin divided over days 1 and 8 and (2 ) combination of gemcitabine–carboplatin or single-agent gemcitabine (gem/gem-carbo). The primary outcome was Kidney Disease Improving Global Outcomes–defined AKI. Secondary outcomes included overall survival and progression-free survival.

Results

We identified 183 patients (98 gem-cis, 32 split, and 53 gem/gem-carbo). Median baseline eGFR in the gem/cis group was 78 ml/min per 1.73 m2 (interquartile range, 66–91), in the split group 64 (48–77), and in the gem/gem-carbo 45 (33–57). There was no significant association between regimen type and incidence of AKI when adjusted for age, Eastern Cooperative Oncology Group, baseline eGFR, hypertension, diabetes, and visceral disease. The adjusted hazard ratios were 1.31 (95% confidence interval [CI], 0.61 to 2.78; P = 0.49) and 0.98 (95% CI, 0.46 to 2.07; P = 0.95) for split and gem/gem-carbo groups, respectively, versus gem-cis. Split and gem/gem-carbo regimens were associated with higher mortality and progressive disease relative to gem-cis with an adjusted hazard ratio of 1.54 (95% CI, 1.02 to 2.33; P = 0.04) and 1.96 (95% CI, 1.31 to 2.95; P < 0.01), respectively. Median progression free survival was 8.1 (interquartile range, 4.6–14.8), 6.1 (4.1–9.3), and 4.4 (2.3–8.6) months in the gem-cis, split, and gem/gem-carbo groups.

Conclusions

There was no significant difference in the incidence of AKI between the three regimens studied. However, standard gem-cis was associated with improved cancer outcomes. Novel regimens and kidney protective strategies are needed for patients with mUC with kidney disease.

Immunotherapy in oncology and the kidneys: a clinical review of the evaluation and management of kidney immune-related adverse events

Immune checkpoint inhibitors (ICI) are now widely used in the treatment of many cancers, and currently represent the standard of care for multiple malignancies. These agents enhance the T cell immune response to target cancer tissues, and have demonstrated considerable benefits for cancer outcomes. However, despite these improved outcomes, there are important kidney immune-related adverse events (iRAEs) associated with ICI. Acute tubulo-interstitial nephritis remains the most frequent kidney iRAE, however glomerular lesions and electrolytes disturbances are increasingly being recognized and reported. In this review, we summarize clinical features and identify risk factors for kidney iRAEs, and discuss the current understanding of pathophysiologic mechanisms. We highlight the evidence basis for guideline-recommended management of ICI-related kidney injury as well as gaps in current knowledge. We advocate for judicious use of kidney biopsy to identify ICI-associated kidney injury, and early use of corticosteroid treatment where appropriate. Selected patients may also be candidates for re-challenge with ICI therapy after a kidney iRAE, in view of current data on recurrent rates of kidney injury. Risk of benefits of re-challenge must be considered on an individual considering patient preferences and prognosis. Lastly, we review current knowledge of ICI use in the setting of patients with end-stage kidney disease, including kidney transplant recipients and those receiving dialysis, which suggest that these patients should not be summarily excluded from the potential benefits of these cancer therapies.

Acute kidney injury within 100 days post allogeneic hematopoietic cell transplantation is associated with increased risk of post-transplant complications and poor transplant outcomes

Allogeneic hematopoietic cell transplantation (HCT) offers cure for some patients with hematological diseases but is associated with significant risk of morbidity and mortality. We investigated the incidence of AKI and its impact on transplant outcomes among 408 patients transplanted at Princess Margaret Hospital Cancer Centre, Toronto, Canada. The overall incidence of AKI at 100 days was 64.2%. Compared to those with no AKI, patients who developed AKI had inferior 2-y overall survival (OS), 44.7% vs. 62.4% (P = 0.0004), higher 2-y transplant related mortality (TRM) 36.8% vs. 18.7% (P = 0.0003), lower 2-y graft-vs-host disease (GVHD)- and relapse-free survival (GRFS), 21.0% vs. 39.8% (P = 0.0002), and higher 100-day grade 3-4 acute GVHD (aGVHD), 12.4% vs. 6.3% (P = 0.01). There was no difference in 2-y incidence of relapse between the AKI and non-AKI groups, 24.2% vs. 24.3% (P = 0.84), 100-day grade 2-4 aGVHD, 27.7% vs. 25.7 (P = 0.41) or 2-y moderate-severe chronic GVHD, 24.0% vs. 21.6% (P = 0.79). Patients who develop AKI within 100 days of HCT have inferior OS and GRFS with higher rates of TRM and grade 3-4 aGVHD. These results highlight the importance of close monitoring of renal function, multidisciplinary collaboration, and implementation of protective strategies throughout HCT to optimize transplant and kidney outcomes.

Chronic kidney disease, survival and graft-versus-host-disease/relapse-free survival in recipients of allogeneic hematopoietic stem cell transplant

Background

Advances in allogeneic hematopoietic stem cell transplant (HSCT) have increased patient survival, although substantial treatment-related toxicity remains, including chronic kidney disease (CKD). We assessed the association between CKD and survival and transplant-specific outcomes in HSCT recipients.

Methods

We conducted a retrospective study of all 408 adult patients with allogenic HSCT at Princess Margaret Cancer Centre (Toronto, Canada, 2015–18). We used logistic regression to identify risk factors for CKD at 1 year post-transplant. Associations between CKD at 1 year and overall survival, relapse-free survival, graft-versus-host-disease (GVHD)-free/relapse-free survival, relapse and transplant-related mortality were examined using extended time-varying Cox models. In a sensitivity analysis, we restricted the cohort to survivors at 1 year, using standard Cox proportional hazard models to examine associations between CKD and overall survival, relapse-free survival and GVHD-free/relapse-free survival, and Fine and Gray's competing risk models to determine associations between CKD and relapse/transplant-related mortality.

Results

The prevalence of CKD at 1 year was 19% (46 patients) with median follow-up of 23 months. Multivariable regression identified age at transplant [adjusted OR (aOR) 1.09, 95% confidence interval (95% CI) = 1.05–1.14; P < 0.0001), female gender (aOR 2.83, 95% CI = 1.34–5.97; P = 0.006) and acute kidney injury during the first 100 days (aOR 3.86, 95% CI = 1.70–8.73; P = 0.001) as risk factors for CKD at 1 year. Patients with CKD at 1 year had significantly poorer overall survival than those without CKD, when adjusted for relevant covariates [adjusted HR (aHR) 1.93, 95% CI = 1.02–3.66; P = 0.04 in the time-varying Cox model, and aHR 2.06, 95% CI = 1.04–4.07; P = 0.04 using the standard Cox model]. CKD at 1 year was also associated with worse GVHD-free/relapse-free survival (aHR 1.65, 95% CI = 1.04–2.61; P = 0.03).

Conclusions

CKD adversely affects the long-term prognosis for allogeneic HSCT recipients, with increased mortality risk and worse GVHD-free/relapse-free survival.

Estimating glomerular filtration rate in patients with acute kidney injury: a prospective multicenter study of diagnostic accuracy

BACKGROUND

Estimating glomerular filtration rate (GFR) in acute kidney injury (AKI) is challenging, with limited data comparing estimated and gold standard methods to assess GFR. The objective of our study was to assess the performance of the kinetic estimated GFR (KeGFR) and Jelliffe equations to estimate GFR in AKI, using a radioisotopic method (technetium-diethylenetriaminepentaacetic acid) as a reference measure.

METHODS

We conducted a prospective multicenter observational study in hospitalized patients with AKI. We computed the Jelliffe and KeGFR equations to estimate GFR and compared these estimations to measured GFR (mGFR) by a radioisotopic method. The performances were assessed by correlation, Bland-Altman plots and smoothed and linear regressions. We conducted stratified analyses by age and chronic kidney disease (CKD).

RESULTS

The study included 119 patients with AKI, mostly from the intensive care unit (63%) and with Stage 1 AKI (71%). The eGFR obtained from the Jelliffe and KeGFR equations showed a good correlation with mGFR (r = 0.73 and 0.68, respectively). The median eGFR by the Jelliffe and KeGFR equations was less than the median mGFR, indicating that these equations underestimated the mGFR. On Bland-Altman plots, the Jelliffe and KeGFR equations displayed a considerable lack of agreement with mGFR, with limits of agreement >40 mL/min/1.73 m2. Both equations performed better in CKD and the KeGFR performed better in older patients. Results were similar across AKI stages.

CONCLUSIONS

In our study, the Jelliffe and KeGFR equations had good correlations with mGFR; however, they had wide limits of agreement. Further studies are needed to optimize the prediction of mGFR with estimatation equations.

Clinical Value of Complement Activation Biomarkers in Overt Diabetic Nephropathy

Background

Experimental studies support a role of complement activation in diabetic nephropathy (DN), yet few clinical correlates exist. We evaluated urinary levels of sC5b-9 membrane attack complex (MAC) in patients with overt DN, and examined its association with the glomerular filtration rate (GFR) decline, proteinuria, and inflammatory biomarkers. We explored different complement pathways and compared our findings to autoimmune glomerulonephritis.

Methods

We prospectively followed 83 patients with DN and obtained repeated measurements of proteinuria, complement fragments (sC5b-9, C4a, C1q, mannose-binding lectin–associated serine protease [MASP]-1, and factor Bb), monocyte chemoattractant protein-1 (MCP-1), and transforming growth factor (TGF)-β1. We assessed independence and interactions using general linear models and repeated measures analyses and compared levels with subjects with active focal and segmental glomerulosclerosis, ANCA-associated vasculitis, and membranous and IgA nephropathies (n = 63).

Results

The diabetic cohort had an initial GFR of 25 ± 9 ml/min per 1.73 m² and a renal function decline of 2.9 ± 3.0 ml/min per 1.73 m² per year. All complement biomarkers were strongly intercorrelated and associated with biomarker inflammation and fibrosis, proteinuria, and the rate of renal function decline. There was a significant interaction (P = 0.03) between the level of proteinuria and urinary sC5b-9: in individuals with higher levels of urinary MAC, the relationship between proteinuria and the rate of renal function decline was more pronounced than in those with low urinary MAC. Finally, patients with DN had levels of urinary sC5b-9 comparable to autoimmune glomerulonephritis, when stratified by the level of proteinuria.

Conclusion

Urinary MAC is present in patients with overt DN at levels comparable to autoimmune glomerulonephritis and correlates with the GFR decline, supporting that complement activation and its measurement are clinically relevant in DN.

Self-administered prescriptions of oral steroids and antibiotics in chronic obstructive pulmonary disease: are we doing more harm than good?

Patients with chronic obstructive pulmonary disease (COPD) are often given a prescription for a short course of oral steroids and antibiotics for self-administration during an acute exacerbation. The main objective of this study was to determine the impact of such prescriptions on medical care utilization, and steroids and antibiotics intake. This retrospective cohort study included patients with moderate to severe COPD participating in a self-management programme. We compared the number of unplanned medical visits (including hospitalizations) and the utilization of systemic steroids (number of short courses, number of days on treatment) and antibiotics (number of treatments) over a period of six months following registration to the programme in patients who received such a prescription and those who did not. Data were collected from hospital and community pharmacy files. A total of 89 patients were included; 46 received a self-administered prescription. During the study period, we found no difference between the two groups in the number of unplanned medical visits. However, we observed small but significant differences in the number of short courses of Prednisone ( P = 0.018) and antibiotics ( P = 0.006). This translated in an important difference in the number of days on steroids over the same period (`Prescription' group: 26; controls: 8; P = 0.005). Self-administered prescriptions may increase steroids and antibiotics utilization in patients with moderate to severe COPD, without reducing the number of unplanned medical visits. Chronic Respiratory Disease 2007; 4: 143—147

[Experiences with various scores in evaluating the prognosis of postoperative intensive care patients]

At the intensive care unit of the Clinic for General and Abdominal Surgery and the Clinic for Emergency Medicine in Mainz, various scores (APACHE II score, HIS, TISS, ASA score), laboratory parameters (serum creatinine, white blood count, platelet count, serum lactate, serum elastase, Quick), body temperature, age as well as presence of a malignant underlying or associated disease, were analyzed with regard to their prognostic significance in 169 postoperative admissions. Apart from univariate analysis (Wilcoxon test) and a multivariate analysis (stepwise logistic regression), the value of the scores is demonstrated on the basis of sensitivity, specificity and correctness, as well as the behaviour of the scores at certain decisive points (cut-off point). Of the parameters studied, the APACHE II score, the HISS, the TISS and serum lactate had a significant influence on the outcome of intensive care. Examination of these scores and serum lactate at different decisive points (false-positive rate of 0%, point of highest sensitivity, point of maximal correctness) showed the TISS to have the best results. The TISS has, with a sensitivity of 100%, a false-positive rate of 41%, compared with 55% for the HIS, 81% for the APACHE II and 82% for serum lactate. With a false-positive rate of 0%, the sensitivity of the TISS is only 10%, of APACHE II and serum lactate 5% and of the HIS 0%. The patient with the highest HIS score has survived. The serum lactate level is another good parameter that is a lot easier to determine and is comparable to the APACHE II score and the HIS in its prognostic significance. Thus, scores are suitable for the estimation of the prognosis in certain patient groups. However, insufficient discrimination between patients who die and patients who survive means that these parameters cannot be used for individual therapeutic decisions in severely ill patients. The decision between the institution or cessation of intensive care is made by the physician or the medical team. Due to the use of prognostic factors, such as scores, decision-making can be objectified and therefore made easier.