Tumour lysis syndrome

Predicting 72-Hour Fatality in Severe Hyperphosphatemia: A Comparative Analysis of Multivariate Logistic Regression and Machine Learning Models in a Single-Center Study

BACKGROUND

Hyperphosphatemia is associated with several serious diseases, including chronic kidney disease, tumor lysis syndrome (TLS), rhabdomyolysis, sepsis, and acute respiratory distress syndrome. This study investigates the critical issue of predicting 72-hour fatality in patients with severe hyperphosphatemia (≥ 10 mg/dL).

METHODS

We analyzed data from 530 patients treated at the Saitama Medical Center, Japan, from 2004 to 2019, including 153 72-hour fatalities. Multivariate logistic regression analysis (MLRA), Prediction One™ (Sony Network Communications Inc., Tokyo, Japan, https://predictionone.sony.biz/), and Light Gradient Boosting Machine (LightGBM) were used to predict fatalities. These methods were evaluated on a validation set of 331 patients from 2020 to 2023, including 104 fatalities. Calibration plots for training and validation data were used for comparison.

RESULTS

The fatality rate was 28.9% in the training data and 31.4% in the validation data. MLRA identified five fatality factors: age, low albumin, high aspartate aminotransferase, and elevated potassium and magnesium levels, with an area under the curve (AUC) of 0.848 (95% CI: 0.801, 0.890), sensitivity of 0.862, and specificity of 0.704. Prediction One™ achieved an AUC of 0.770 (95% CI: 0.722, 0.818), sensitivity of 0.654, and specificity of 0.769. LightGBM achieved an AUC of 0.948 (95% CI: 0.923, 0.973), sensitivity of 0.863, and specificity of 0.889. The validation calibration plot showed that MLRA had the closest regression coefficient to 1.0 at 0.903.

CONCLUSION

Although MLRA was the most accurate in predicting 72-hour fatalities, machine learning methods provided valuable insights into the importance of variables. Considering the high mortality rates associated with severe hyperphosphatemia, timely and accurate prognostication is essential in guiding immediate interventions and improving outcomes in emergency settings.

A pharmacovigilance study of etoposide in the FDA adverse event reporting system (FAERS) database, what does the real world say?

Introduction: Etoposide is a broad-spectrum antitumor drug that has been extensively studied in clinical trials. However, limited information is available regarding its real-world adverse reactions. Therefore, this study aimed to assess and evaluate etoposide-related adverse events in a real-world setting by using data mining method on the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) database. Methods: Through the analysis of 16,134,686 reports in the FAERS database, a total of 9,892 reports of etoposide-related adverse drug events (ADEs) were identified. To determine the significance of these ADEs, various disproportionality analysis algorithms were applied, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) algorithms. Results: As a result, 478 significant disproportionality preferred terms (PTs) that were identified by all four algorithms were retained. These PTs included commonly reported adverse events such as thrombocytopenia, leukopenia, anemia, stomatitis, and pneumonitis, which align with those documented in the drug's instructions and previous clinical trials. However, our analysis also uncovered unexpected and significant ADEs, including thrombotic microangiopathy, ototoxicity, second primary malignancy, nephropathy toxic, and ovarian failure. Furthermore, we examined the time-to-onset (TTO) of these ADEs using the Weibull distribution test and found that the median TTO for etoposide-associated ADEs was 10 days (interquartile range [IQR] 2-32 days). The majority of cases occurred within the first month (73.8%) after etoposide administration. Additionally, our analysis revealed specific high-risk signals for males, such as pneumonia and cardiac infarction, while females showed signals for drug resistance and ototoxicity. Discussion: These findings provide valuable insight into the occurrence of ADEs following etoposide initiation, which can potentially support clinical monitoring and risk identification efforts.

Malignancy diseases and kidneys: A nephrologist prospect and updated review

Acute kidney injury (AKI), chronic renal failure, and tubular abnormalities represent the kidney disease spectrum of malignancy. Prompt diagnosis and treatment may prevent or reverse these complications. The pathogenesis of AKI in cancer is multifactorial. AKI affects outcomes in cancer, oncological therapy withdrawal, increased hospitalization rate, and hospital stay. Renal function derangement can be recovered with early detection and targeted therapy of cancers. Identifying patients at higher risk of renal damage and implementing preventive measures without sacrificing the benefits of oncological therapy improve survival. Multidisciplinary approaches, such as relieving obstruction, hydration, etc., are required to minimize the kidney injury rate. Different keywords, texts, and phrases were used to search Google, EMBASE, PubMed, Scopus, and Google Scholar for related original and review articles that serve the article's aim well. In this nonsystematic article, we aimed to review the published data on cancer-associated kidney complications, their pathogenesis, management, prevention, and the latest updates. Kidney involvement in cancer occurs due to tumor therapy, direct kidney invasion by tumor, or tumor complications. Early diagnosis and therapy improve the survival rate. Pathogenesis of cancer-related kidney involvement is different and complicated. Clinicians' awareness of all the potential causes of cancer-related complications is essential, and a kidney biopsy should be conducted to confirm the kidney pathologies. Chronic kidney disease is a known complication in malignancy and therapies. Hence, avoiding nephrotoxic drugs, dose standardization, and early cancer detection are mandatory measures to prevent renal involvement.

Tumor lysis syndrome promotes cancer chemoresistance and relapse through AMPK inhibition

Cancer is a disease caused when cells divide uncontrollably and spread into surrounding tissues. There are different therapeutic modalities that control cancer growth, of which surgery, chemotherapy, and radiotherapy. Chemotherapy is a cancer treatment approach in which medications are used to inhibit cell proliferation and tumor multiplication, thus avoiding invasion and metastasis and thus eradicate cancer. One of the common complications associated with cancer chemotherapy is rapid lysis of expanding tumor cells, known as tumor lysis syndrome (TLS). TLS is associated with number of metabolic changes such as hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia. Among the consequences of hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia is the inhibition of 5' AMP-activated protein kinase (AMPK). Inhibition of AMPK induced different cancer chemo-resistance mechanisms such as cancer stem cells (CSCs), p-glycoproteins, Octamer-binding transcription factor 4 (OCT-4), homeobox protein NANOG, Krüppel-like factor 4 (KLF4) and immune microenvironment and thus leads to poor response to chemotherapy and even relapses after treatment. Our review aims to uncover new mechanisms underlying the metabolic consequences of tumor lysis on AMPK in tumor microenvironment. In this review, we also investigated the effect of AMPK on different cancer chemo-resistance mechanisms such as cancer stem cells, p-glycoproteins, OCT-4, NANOG, KLF4 and immune microenvironment.

Correlation between Hyperkalemia and the Duration of Several Hospitalizations in Patients with Chronic Kidney Disease

(1) Background: This observational study aimed to verify the association between serum potassium levels and hospitalization days in patients with chronic kidney disease in a follow up of nine months. (2) Methods: Patients with chronic kidney disease were divided into group A (180 patients, potassium ≤ 5.1 mEq/L) and B (90 patients, potassium > 5.1 mEq/L). Student's t-test, Mann-Whitney test, Pearson's Chi-Square test, Pearson/Spearman's correlation test and linear regression test were performed in the entire sample and in stage-G4/5 subsample. (3) Results: Groups A and B differed for estimated glomerular filtration rate (eGFR) (34.89 (IQR, 16.24-57.98) vs. 19.8 (IQR, 10.50-32.50) mL/min/1.73 m2; p < 0.0001), hemoglobin (11.64 ± 2.20 vs. 10.97 ± 2.19 g/dL, p = 0.048), sum of hospitalization days (8 (IQR, 6-10) vs. 11 (IQR, 7-15) days; p < 0.0001) and use of angiotensin II receptor blockers (40.2% vs. 53.3%; p = 0.010). Considering patients with eGFR 6-30 mL/min/1.73 m2, differences in the sum of hospitalization days were confirmed. Multivariable regression analysis showed that hyperkalemia is an independent risk factor of increased hospital length. In stage G4-G5, regression analysis showed that hyperkalemia is the only independent risk factor (β = 2.93, 95% confidence interval, 0.077-5.794, p = 0.044). (4) Conclusions: We observed significantly greater odds of increased length of hospital stay among patients with higher potassium, mostly in stages G4-G5 chronic kidney disease.

Tumor Lysis Syndrome after Combination Therapy of Nivolumab and Sorafenib in a Woman with Advanced Hepatocellular Carcinoma

Tumor lysis syndrome (TLS) is a life-threatening emergency that usually develops in rapidly proliferating hematologic malignancies or advanced solid tumor following cytotoxic chemotherapy or therapeutic interventions. TLS is especially rare in patients with hepatocellular carcinoma (HCC). Therefore, we present a case of a female patient with newly diagnosed advanced HCC who developed TLS and hepatic failure after receiving combination therapy of nivolumab and sorafenib. To our knowledge, this is the first case of TLS in a patient with advanced HCC owing to combination therapy of nivolumab and sorafenib. We also reviewed the literature and summarized the characteristics of TLS in patients with advanced HCC receiving various therapeutic interventions. The overall mortality rate was 63% and regarding the management, transarterial chemoembolization (TACE) was the most common etiology. TACE-related TLS developed more rapidly than sorafenib-related TLS. Furthermore, the efficacy and safety of combination therapy of nivolumab and sorafenib should be further evaluated, and TLS should still be a concern, especially in patients with large tumor burden.

Tumor lysis syndrome in childhood malignancies

BACKGROUND

Tumor lysis syndrome (TLS) is the most common life-threatening oncological emergency encountered by physicians treating children with lymphoproliferative malignancies. Healthcare providers should be aware of the condition in order to prevent occurrence and prompt timely management to avoid severe consequences.

OBJECTIVE

To provide an update on the current understanding, evaluation, and management of tumor lysis syndrome in childhood malignancies.

METHODS

A PubMed search was performed in Clinical Queries using the keywords 'tumor lysis syndrome' and 'malignancies' with Category limited to clinical trials and reviews for ages from birth to 18 years.

RESULTS

There were 22 clinical trials and 37 reviews under the search criteria. TLS is characterized by acute electrolyte and metabolic disturbances resulting from massive and abrupt release of cellular contents into the circulation due to breakdown of tumor cells. If left untreated, it can lead to multiorgan compromise and eventually death. Apart from close monitoring and medical therapies, early recognition of risk factors for development of TLS is also necessary for successful management.

CONCLUSIONS

Prophylactic measures to patients at risk of TLS include aggressive fluid management and judicious use of diuretics and hypouricemic agents. Both allopurinol and urate oxidase are effective in reducing serum uric acid. Allopurinol should be used as prophylaxis in low-risk cases while urate oxidase should be used as treatment in intermediate to high-risk cases. There is no evidence on better drug of choice among different urate oxidases. The routine use of diuretics and urine alkalinization are not recommended. Correction of electrolytes and use of renal replacement therapy may also be required during treatment of TLS.