Acute kidney injury in critically ill cancer patients: an update

Chemotherapy plus therapeutic plasmapheresis with 4% human albumin solution in multiple myeloma patients with acute kidney injury: a prospective, open-label, proof-of-concept study

As no unified treatment protocol or evidence yet exists for plasmapheresis without plasma, this study explored the outcomes of using 4% human albumin (ALB) solution as a replacement solution in patients undergoing plasma exchange for multiple myeloma (MM) patients with acute kidney injury (AKI). This study was prospectively registered (ChiCTR2000030640 and NCT05251896). Bortezomib-based chemotherapy plus therapeutic plasmapheresis (TPP) with 4% human ALB solution was assessed for three years in patients with MM aged >18 years, with AKI according to the Kidney Disease Improving Global Outcomes criteria, and without previous renal impairment from other causes. The primary endpoints were changes in renal function over 18 weeks and survival outcomes at 36 months. The secondary endpoints were the incidence of adverse reactions and symptom improvement. Among the 119 patients included in the analysis, 108 experienced renal reactions. The M protein (absolute changes: median -12.12%, interquartile ranges (IQRs) -18.62 to -5.626) and creatine (median -46.91 μmol/L, IQR -64.70 to -29.12) levels decreased, whereas the estimated glomerular filtration rate (eGFR) increased (median 20.66 mL/(min·1.73 m2), IQR 16.03-25.29). Regarding patient survival, 68.1% and 35.3% of patients survived for >12 and >36 months, respectively. The three symptoms with the greatest relief were urine foam, poor appetite, and blurred vision. All 11 patients (7.6%) who experienced mild adverse reactions achieved remission. In conclusion, in MM patients with AKI, plasma-free plasmapheresis with 4% human ALB solution and bortezomib-based chemotherapy effectively alleviated light chain damage to kidney function while improving patient quality of life.

Knockdown of circ-Gatad1 alleviates LPS induced HK2 cell injury via targeting miR-22-3p/TRPM7 axis in septic acute kidney

BACKGROUND

Sepsis is a life-threatening, systemic inflammatory disease that can lead to a variety of conditions, including septic acute kidney injury (AKI). Recently, multiple circular Rnas (circRNAs) have been implicated in the development of this disease.

METHODS

In this study, we aimed to elucidate the role of circ-Gatad1 in sepsis induced AKI and its potential mechanism of action. High-throughput sequencing was used to investigate abnormal expression of circRNA in AKI and healthy volunteer. Bioinformatics analysis and luciferase reporting analysis were used to clarify the interacted relationship among circRNA, miRNA and mRNA. HK2 cells were treated with lipopolysaccharide (LPS) to establish septic AKI cell model. HK2 cells were employ to analysis the ROS, inflammatory cytokines expression, proliferation and apoptosis under LPS condition.

RESULTS

The result show that the expression of circ-Gatad1 was increased in septic acute kidney patients. Downregulation circ-Gatad1 suppressed LPS-treated induced HK2 cells injury including apoptosis, proliferation ability, ROS and inflammatory cytokines level. Bioinformatics and luciferase report analysis confirmed that both miR-22-3p and TRPM7 were downstream targets of circ-Gatad1. Overexpression of TRPM7 or downregulation of miR-22-3p reversed the protective effect of si-circ-Gatad1 to HK2 after exposure to LPS (5 µg/ml) microenvironment.

CONCLUSION

In conclusion, knockdown of circ-Gatad1 alleviates LPS induced HK2 cell injury via targeting miR-22-3p/TRPM7 axis in septic acute kidney.

Type 2 Cystatins and Their Roles in the Regulation of Human Immune Response and Cancer Progression

Cystatins are a family of intracellular and extracellular protease inhibitors that inhibit cysteine cathepsins-a group of lysosomal cysteine proteases that participate in multiple biological processes, including protein degradation and post-translational cleavage. Cysteine cathepsins are associated with the development of autoimmune diseases, tumor progression, and metastasis. Cystatins are categorized into three subfamilies: type 1, type 2, and type 3. The type 2 cystatin subfamily is the largest, containing 10 members, and consists entirely of small secreted proteins. Although type 2 cystatins have many shared biological roles, each member differs in structure, post-translational modifications (e.g., glycosylation), and expression in different cell types. These distinctions allow the type 2 cystatins to have unique biological functions and properties. This review provides an overview of type 2 cystatins, including their biological similarities and differences, their regulatory effect on human immune responses, and their roles in tumor progression, immune evasion, and metastasis.

Acute kidney injury in children with haematological malignancy: a territory-wide study

BACKGROUND

In onco-nephrology, data on acute kidney injury (AKI) among children with haematological malignancies are scarce.

METHODS

A retrospective cohort study of all patients in Hong Kong diagnosed with haematological malignancies from 2019 to 2021 before 18 years of age, was conducted to investigate the epidemiology, risk factors and clinical outcomes of AKI during the first year of treatment. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria.

RESULTS

We included 130 children with haematological malignancy at median age of 9.4 years (IQR, 3.9-14.1). Of these patients, 55.4% were acute lymphoblastic leukemia (ALL), 26.9% were lymphoma and 17.7% were acute myeloid leukemia (AML). Thirty-five patients (26.9%) developed 41 AKI episodes during the first year of diagnosis, corresponding to 32 episodes per 100-patient-year. A total of 56.1% and 29.2% of the AKI episodes occurred during induction and consolidation chemotherapy respectively. Septic shock (n = 12, 29.2%) was the leading cause of AKI; 21 episodes (51.2%) were stage 3 AKI; 12 episodes (29.3%) were stage 2 AKI; and 6 patients required continuous kidney replacement therapies. Tumor lysis syndrome and impaired baseline kidney function were significantly associated with AKI on multivariate analysis (P = 0.01). History of AKI was associated with chemotherapy postponement (37.1% vs. 16.8%, P = 0.01), worse 12-month patient survival (77.1% vs. 94.7%, log rank P = 0.002) and lower disease remission rate at 12-month (68.6% vs. 88.4%, P = 0.007), compared to patients without AKI.

CONCLUSION

AKI is a common complication during treatment of haematological malignancies which is associated with worse treatment outcomes. A regular and dedicated surveillance program for at-risk patients should be studied in children with haematological malignancies for prevention and early detection of AKI. A higher resolution version of the Graphical abstract is available as Supplementary information.

Effect of cardiac function in patients with gastrointestinal cancer with or without acute kidney injury assessed using a non-invasive impedance cardiography: a case-control study

OBJECTIVES

This study aimed to analyze the possible causes of changes in cardiac function and investigate the feasibility of clinical assessment of gastrointestinal cancer in patients with or without acute kidney injury (AKI) assessed using a non-invasive impedance cardiography (ICG, Bioz. Cardio Dynamics, USA) to identify independent risk factors.

METHODS

Patients admitted to the Fourth Hospital of Hebei Medical University, China, between May 1, 2019, and February 15, 2022, were included in this study. A total of 51 patients with gastrointestinal cancer (31 men and 20 women, mean age 61.1 ± 10.9 years) with or without AKI were evaluated for ICG. A total of 19 patients underwent ultrasound cardiography (UCG) and ICG evaluations.

RESULT

There was a significant positive correlation between cardiac output (CO), cardiac index (CI), stroke volume (SV), left cardiac work index (LCWI), and ejection fraction (EF) measured using UCG and ICG. The relationship was observed between COICG and COUCG (r = 0.707, P = 0.001), CIICG and CIUCG (r = 0.718, P = 0.001), SVICG and SVUCG (r = 0.837, P < 0.001), and LCWIICG and EFUCG (r = 0.540, P = 0.017). Cardiac function parameters measured using ICG were statistically different between patients with gastrointestinal cancer with or without AKI (P ≤ 0.05). Multivariate analysis revealed that AKI independently affects cardiac function in patients with gastrointestinal cancer.

CONCLUSIONS

UCG and ICG methods are significantly associated with cardiac function in patients with or without AKI, and patients with gastrointestinal cancer with AKI are worse than those without AKI. AKI is an independent risk factor for cardiac function in patients with gastrointestinal cancer.

Tumor Markers as Predictors of Acute Kidney Injury Incidence and Staging of the Muscle-Invasive Bladder Cancer Receiving Chemoradiation Therapy

Background

Bladder cancer, as one of types of cancers within the urinary tract, is associated with a greater risk of acute kidney injury (AKI), resulting in a poorer prognosis, discontinuation of effective oncological treatments, longer hospitalization, and higher expenses. There is no discussion yet on tumor markers in bladder cancer. With the revolutionary advances in bladder cancer molecular subtyping over the past decade, the presence of tumor markers to assess the staging of bladder cancer has yet to be discussed. In this study, we intended to assess the relationship between tumor markers and incidence of AKI, also between tumor markers and the cancer staging.

Methods

This retrospective cross-sectional study utilized secondary data from 26 medical records of patients diagnosed with bladder cancer at the Adam Malik and Universitas Sumatera Utara Hospital between 2021and 2022. This study included all patients with bladder cancer who met the inclusion criteria. Continuous variables were reported as mean (standard deviation (SD)) and examined using an independent t-test. Categorical variables were reported as proportions, examined using Chi-square or Fisher's exact test. Pre- and post-tumor marker data were evaluated with dependent sample t-test for normal variance data, and Wilcoxon test for data with atypical distribution. P values were set at 0.05.

Results

CD44 (P = 0.003) and programmed cell death 1 (PD-1) (P = 0.030) were the only significant markers in their pre- and post-chemoradiation states among the four investigated tumor markers in this study. Meanwhile, PD-1 tumor marker levels were only found to be significant between AKI and pre-chemoradiation (P = 0.011). Even though the multivariate study of tumor staging did not show any statistical significance, both tumor markers CD44 and PD-1 showed a significant effect on the incidence of acute renal damage (P = 0.034).

Conclusions

Pre-chemoradiation PD-1 tumor markers showed promise as good predictive indicators for staging and AKI incidence in muscle-invasive bladder cancer patients undergoing chemoradiation therapy.

Impact of Developing Dialysis-Requiring Acute Kidney Injury on Long-Term Mortality in Cancer Patients with Septic Shock

(1) Background: Considering recent advances in both cancer and sepsis management, we chose to evaluate the associated factors for occurrence of septic acute kidney injury in cancer patients using a nationwide population-based cohort data. (2) Methods: Using data from the National Health Insurance Service of Korea, adult cancer patients who presented to emergency departments with septic shock from 2009 to 2017 were analyzed. A Cox-proportional hazard model was conducted to evaluate the clinical effect of sepsis-related acute kidney injury requiring dialysis. (3) Results: Among 42,477 adult cancer patients with septic shock, dialysis-requiring acute kidney injury occurred in 5449 (12.8%). Recovery from dialysis within 30 days was 77.9% and, overall, 30-day and 2-year mortality rates were 52.1% and 85.1%, respectively. Oncologic patients with dialysis-requiring acute kidney injury frequently occurred in males and patients with hematologic cancer. A multivariate Cox-proportional hazard model showed that dialysis-requiring acute kidney injury had the highest adjusted hazard ratio of 1.353 (95% confidence interval 1.313-1.395) for 2-year mortality. (4) Conclusions: Dialysis-requiring septic acute kidney injury did not occur commonly. However, it had a significant association with increased long-term mortality, which suggests emphasis should be placed on the prevention of acute kidney injury, particularly in male hematologic cancer patients.

The novel biomarker circ_0020339 drives septic acute kidney injury by targeting miR-17-5p/IPMK axis

PURPOSE

Sepsis is a systemic life-threatening inflammatory disease, which leads to septic acute kidney injury (AKI). Circular RNAs (circRNAs) are involved in septic AKI. Herein, we aimed to expound the action of circ_0020339 in septic AKI. The dysregulation of plasma circRNAs between patients with septic non-AKI and patients with septic AKI were screened by circRNA chip.

METHODS

The dysregulation of circ_0020339, microRNA (miR)-17-5p, and inositol polyphosphate multi kinase (IPMK) mRNA was detected by quantitative real-time polymerase chain reaction (qRT-PCR). Cell viability and apoptosis were measured by cell counting kit-8 (CCK-8) and flow cytometry, respectively. The release of serum creatinine (SCr), tissue inhibitor metalloproteinase-2 (TIMP-2), insulin-like growth factor binding protein-7 (IGFBP7), tumor necrosis factor (TNF)α and interleukin (IL)-1β was evaluated by enzyme-linked immunosorbent assay (ELISA). Bioinformatic analysis, dual-luciferase reporter assay and miRNA pull down assay were used to confirm the interaction between miR-17-5p and circ_0020339 or IPMK 3'untranslated region (UTR). Protein level of IPMK, TNF receptor-associated factor 6 (TRAF6), phosphorylated AKT (p-AKT)/total (t)-AKT, p-nuclear factor kappa-B (NF-κB) kinase (p-IKK)/t-IKK, p-inhibitor of NF-κB (p-IκB)α/t-IκBα, and p-p65/t-p65 were conducted by western blot.

RESULTS

Circ_0020339 was upregulated in the plasma of patients with septic AKI as well as LPS-treated HK2 cells and C57BL/6 mice relative to the corresponding counterparts. Functionally, circ_0020339 was positively correlated with markers of renal functional injury and inflammation in patients with septic AKI; si-circ_0020339 facilitated cell proliferation, while restrained cell apoptosis and inflammation in LPS-triggered HK2 cells; meanwhile, si-circ_0020339 restrained survival rate, renal functional injury and inflammation in LPS-triggered C57BL/6 mice. Furthermore, circ_0020339 and IPMK 3'UTR shared the same complementary sites with miR-17-5p.

CONCLUSION

si-circ_0020339 attenuated LPS-induced cell damage by targeting miR-17-5p/IPMK axis and inactivation of TRAF6/p-AKT/p-IKK/p-IκBα/p-p65. Altogether, plasma circ_0020339 serves as a novel diagnostic marker of patients with septic AKI.

Prognostic value of fibrinogen to albumin ratios among critically ill patients with acute kidney injury

Fibrinogen to albumin ratios (FAR) have shown to be a promising prognostic factor for improving the predictive accuracy in various diseases. This study explores FAR's prognostic significance in critically ill patients with acute kidney injury (AKI). All clinical data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care Database III version 1.4. All patients were divided into four groups based on FAR quartiles. The primary endpoint was in-hospital mortality. A generalized additive model was applied to explore a nonlinear association between FAR and in-hospital mortality. The Cox proportional hazards models were used to determine the association between FAR and in-hospital mortality. A total of 5001 eligible subjects were enrolled. Multivariate analysis demonstrated that higher FAR was an independent predictor of in-hospital mortality after adjusting for potential confounders (HR, 95% CI 1.23, 1.03-1.48, P = 0.025). A nonlinear relationship between FAR and in-hospital mortality was observed. FAR may serve as a potential prognostic biomarker in critically patients with AKI and higher FAR was associated with increased risk of in-hospital mortality among these patients.

Prognostic significance of albumin to alkaline phosphatase ratio in critically ill patients with acute kidney injury

OBJECTIVE

No epidemiological evidence has investigated the effect of albumin to alkaline phosphatase ratio (AAPR) on the prognosis among critically ill patients with acute kidney injury (AKI). We aimed to explore the prognostic value of AAPR in these patients.

METHODS

We extracted all clinical data from MIMIC III. ROC curve analysis was used to evaluate the discrimination of AAPR for predicting in-hospital mortality. A generalized additive model was applied to identify a nonlinear association between AAPR and in-hospital mortality. The Cox proportional hazards models were used to determine the association between AAPR and in-hospital and 30-day mortality.

RESULTS

A total of 6894 eligible subjects were enrolled in this study. The relationship between AAPR and in-hospital mortality was nonlinear. Multivariate analysis demonstrated that lower AAPR (AAPR < 0.35) was an independent predictor of in-hospital and 30-day mortality after adjusting for potential confounders (HR 1.74, 95% CI 1.72-2.20, P < 0.001; HR 1.89, 95% CI 1.66-2.14, P < 0.001, respectively).

CONCLUSIONS

AAPR may serve as a potential prognostic biomarker in critically ill patients with AKI and lower AAPR was associated with increased risk of in-hospital and 30-day mortality among these patients.

Vancomycin therapeutic monitoring by measured trough concentration versus Bayesian-derived area under the curve in critically ill patients with cancer

The updated vancomycin guideline and recent studies suggested that trough concentrations may result in underestimation of the actual area under the curve (AUC), leading to excessive dosing and nephrotoxicity. With limited data available on critically ill cancer patients, this study aimed to compare the two methods in this patient population. This was a 5‐year retrospective study on patients treated with vancomycin in the intensive care unit (ICU) of a comprehensive cancer center. The measured trough concentration was compared to Bayesian‐derived AUC/minimum‐inhibitory‐concentration (MIC), considering MIC as 1. Trough concentrations of 15–20 mg/L and AUC of 400–600 mg h/L were considered the targeted goal. Multivariate analysis was performed to identify factors associated with an AUC below the targeted goal. During the study period, 316 patients were included. The mean age was 54 years ±16 (SD); most patients had solid tumors (75%), and 11% had neutropenia. A targeted goal AUC and trough were recorded in 128 (41%) patients and in 64 (20%) patients, respectively. Of the 128 patients with targeted goal AUC, 31 (24%) had targeted goal trough concentrations and 91 (71%) had trough concentrations below 15 mg/L. Furthermore, among the patients with targeted goal trough concentration (n = 64), 33 (52%) had higher than targeted goal AUC. Augmented renal clearance (ARC), defined as a calculated creatinine‐clearance ≥130 ml/min, was associated with an AUC below the targeted goal. In a cohort of critically ill patients with cancer, over two‐thirds of the patients with a targeted goal Bayesian AUC/MIC had trough concentrations below the targeted goal. ARC was associated with AUC below the targeted goal.

Management of acute kidney injury in gastrointestinal tumor: An overview

Gastrointestinal tumors remain a global health problem. Acute kidney injury (AKI) is a common complication during the treatment of gastrointestinal tumors. AKI can cause a decrease in the remission rate and an increase in mortality. In this review, we analyzed the causes and risk factors for AKI in gastrointestinal tumor patients. The possible mechanisms of AKI were divided into three groups: pretreatment, intrafraction and post-treatment causes. Treatment and prevention measures were proposed according to various factors to provide guidance to clinicians and oncologists that can reduce the incidence of AKI and improve the quality of life and survival rate of gastrointestinal tumor patients.

Association Between Serum Creatinine Concentrations and Overall Survival in Patients With Colorectal Cancer: A Multi-Center Cohort Study

Background

Colorectal cancer (CRC) is one of the most common malignancies throughout the world, with high rates of morbidity and mortality. Previous studies reported that serum creatinine (Scr) concentrations were associated with overall survival (OS) in cancer patients, but little is known about the association between Scr and OS in patients with CRC. This study investigated the relationship between Scr concentrations and OS in patients with CRC and examined possible effect modifiers.

Methods

A retrospective cohort, including 1,733 patients with CRC, was established from a multi-center clinical study. Patients were divided into low (<71 μmol/L in men or <59 μmol/L in women), normal (71-104 μmol/L in men or 59-85 μmol/L in women) and high (>104 μmol/L in men or >85 μmol/L in women) Scr groups. Cox regression analysis was used to examine association between Scr concentrations and OS. Stratified (subgroup) analyses were used to examine men and women separately. Interaction tests were used to evaluate associations between each variable and OS, as well as possible interactions of these variables with Scr levels. Cross-classified analyses were used only in men.

Results

Patients with low [hazard ratio (HR) = 1.43, 95% confidence interval (CI) = 1.19-1.72; P < 0.001] or high (HR = 1.89, 95% CI = 1.36-2.63; P < 0.001) Scr level had a significantly lower OS than patients with normal Scr levels. Significant interactions with Scr concentrations were observed for body mass index (P for interaction = 0.019) in men.

Conclusion

Low or high Scr concentration is associated with significantly lower OS in patients with CRC. Future study is warranted to investigate the underlying mechanism.

Acute Kidney Injury in Patients With Cancer: A Review of Onconephrology

Over the past 2 decades, significant research and advancements have been made in oncology and its therapeutics. Thanks to novel diagnostic methods, treatments, and supportive measures, patients with cancer live longer and have a better quality of life. However, an unforeseen consequence of this progress has been increasing medical complications, including acute kidney injury. The purpose of this review is to provide an overview of the epidemiology and most common causes of acute kidney injury in patients with cancer unrelated to oncological treatment.

Outcomes of kidney injury including dialysis and kidney transplantation in pediatric oncology and hematopoietic cell transplant patients

Pediatric oncology and hematopoietic cell transplant (HCT) patients are susceptible to both acute kidney injury (AKI) and chronic kidney disease (CKD). The etiologies of AKI vary but include tumor infiltration, radiation, drug-induced toxicity, and fluid and electrolyte abnormalities including tumor lysis syndrome. HCT patients can also have additional complications such as sinusoidal obstructive syndrome, graft-versus-host disease, or thrombotic microangiopathy. For patients with severe AKI requiring dialysis, multiple modalities can be used successfully, although continuous kidney replacement therapy (CKRT) is often the principal modality for critically ill patients. While increasing numbers of pediatric cancer and HCT patients are now surviving long term, they remain at risk for a number of chronic medical conditions, including CKD. Certain high-risk patients, due to underlying risk factors or treatment-related complications, eventually develop kidney failure and may require kidney replacement therapies. Management of co-morbidities and complications associated with kidney failure, including use of erythropoietin for anemia and potential need for ongoing cancer-related treatment while on dialysis, is an additional consideration in this patient population. Kidney transplantation can be successfully performed in pediatric cancer survivors, although additional features such as specific cancer diagnosis and duration of remission should be considered.

Circ_RASGEF1B Promotes LPS-Induced Apoptosis and Inflammatory Response by Targeting MicroRNA-146a-5p/Pdk1 Axis in Septic Acute Kidney Injury Cell Model

BACKGROUND

We intended to investigate the function of circular RNA RasGEF domain family member 1B (circ_RASGEF1B) in lipopolysaccharide (LPS)-induced septic acute kidney injury (AKI) cell model and its associated mechanism.

METHODS

TCMK-1 cells were exposed to 10 μg/mL LPS for 24 h to establish a septic AKI cell model. Mice were intraperitoneally injected with 10 mg/kg LPS to establish a septic AKI mice model. Reverse transcription quantitative polymerase chain reaction (RT-qPCR) and Western blot assay were used to measure RNA and protein expression, respectively. Cell viability and apoptosis were assessed by 3-(4,5-dimethyl-thiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and flow cytometry. Cell inflammatory response was analyzed using enzyme-linked immunosorbent assay. Dual-luciferase reporter assay was conducted to confirm the predicted target relationship between microRNA-146a-5p (miR-146a-5p) and circ_RASGEF1B or pyruvate dehydrogenase kinase 1 (Pdk1).

RESULTS

The circ_RASGEF1B level was upregulated in LPS-induced TCMK-1 cells and septic AKI mice models. LPS exposure reduced cell viability and promoted cell apoptosis and inflammatory response partly by upregulating circ_RASGEF1B. Circ_RASGEF1B bound to miR-146a-5p and miR-146a-5p interference partly overturned circ_RASGEF1B silencing-mediated effects in LPS-induced TCMK-1 cells. Pdk1 was a target of miR-146a-5p, and Pdk1 accumulation partly counteracted miR-146a-5p-induced influences in TCMK-1 cells upon LPS stimulation.

CONCLUSION

Circ_RASGEF1B promoted LPS-induced apoptosis and inflammatory response in renal tubular epithelial cells partly by upregulating Pdk1 via acting as miR-146a-5p sponge.

Association of Acute Kidney Injury Receiving Kidney Replacement Therapy With Prognosis of Critically Ill Patients With and Without Cancer: A Retrospective Study

OBJECTIVES

To assess outcomes of cancer patients receiving kidney replacement therapy due to acute kidney injury in ICUs and compare these with other patient groups receiving kidney replacement therapy in ICUs.

DESIGN

Retrospective registry analysis.

SETTING

Prospectively collected database of 296,424 ICU patients.

PATIENTS

Patients with and without solid cancer with acute kidney injury necessitating kidney replacement therapy were identified and compared with those without acute kidney injury necessitating kidney replacement therapy.

INTERVENTIONS

Descriptive statistics were used to ascertain prevalence of acute kidney injury necessitating kidney replacement therapy and solid cancer in ICU patients. Association of acute kidney injury necessitating kidney replacement therapy and cancer with prognosis was assessed using logistic regression analysis. To compare the attributable mortality of acute kidney injury necessitating kidney replacement therapy, 20,154 noncancer patients and 2,411 cancer patients without acute kidney injury necessitating kidney replacement therapy were matched with 12,827 noncancer patients and 1,079 cancer patients with acute kidney injury necessitating kidney replacement therapy.

MEASUREMENTS AND MAIN RESULTS

Thirty-five thousand three hundred fifty-six ICU patients (11.9%) had solid cancer. Acute kidney injury necessitating kidney replacement therapy was present in 1,408 (4.0%) cancer patients and 13,637 (5.2%) noncancer patients. Crude ICU and hospital mortality was higher in the cancer group (646 [45.9%] vs 4,674 [34.3%], p < 0.001, and 787 [55.9%] vs 5,935 [43.5%], p < 0.001). In multivariable logistic regression analyses, odds ratio (95% CI) for hospital mortality was 1.73 (1.62-1.85) for cancer compared with no cancer 3.57 (3.32-3.83) for acute kidney injury necessitating kidney replacement therapy and 1.07 (0.86-1.33) for their interaction. In the matched subcohort, attributable hospital mortality of acute kidney injury necessitating kidney replacement therapy was 56.7% in noncancer patients and 48.0% in cancer patients.

CONCLUSIONS

Occurrence rate of acute kidney injury necessitating kidney replacement therapy and prognosis in ICU patients with solid cancer are comparable with other ICU patient groups. In cancer, acute kidney injury necessitating kidney replacement therapy is associated with higher crude hospital mortality. However, the specific attributable mortality conveyed by acute kidney injury necessitating kidney replacement therapy is actually lower in cancer patients than in noncancer patients. Diagnosis of cancer per se does not justify withholding kidney replacement therapy.

Comparative Risk of Renal Adverse Events in Patients Receiving Immune Checkpoint Inhibitors: A Bayesian Network Meta-Analysis

Background

Immune checkpoint inhibitors (ICIs) have brought a paradigm shift to cancer treatment. However, little is known about the risk of renal adverse events (RAEs) of ICI-based regimens, especially ICI combination therapy.

Methods

We carried out a network meta-analysis of randomized controlled trials (RCTs) to compare the risk of RAEs between ICI-based regimens and traditional cancer therapy, including chemotherapy and targeted therapy. Subgroup analysis was conducted based on tumor types.

Results

Ninety-five eligible RCTs involving 40,552 participants were included. The overall incidence of RAEs, grade 3–5 RAEs, acute kidney injury (AKI), and grade 3–5 AKI was 4.3%, 1.2%, 1.3%, and 0.8%, respectively. Both ICI-based treatment regimens and traditional cancer therapy showed significantly higher risk of RAEs and AKI than the placebo. Among ICI monotherapy, anti-PD-1 (RR: 0.51, 95%CI: 0.29–0.91) was significantly safer than anti-CTLA-4 in terms of RAEs. Anti-CTLA-4 showed significantly higher toxicity than anti-PD-1 (RR: 0.33, 95%CI: 0.14-0.77), anti-PD-L1 (RR: 0.38, 95%CI:0.16-0.91), and anti-PD-1 plus anti-CTLA-4 (RR: 0.32, 95%CI: 0.12-0.87) in terms of grade 3-5 RAEs. The difference was not significant between ICI monotherapy and traditional cancer therapy, except that targeted therapy seemed the least toxic therapy in terms of the incidence of AKI. Anti-CTLA-4 plus anti-PD-1 were associated with higher risk of RAEs than anti-PD-1 (RR: 1.61, 95%CI: 1.02–2.56). The difference was not significant between other dual ICI regimens and ICI monotherapy in terms of RAEs and AKI. ICI plus chemotherapy showed increased risk of both RAEs and AKI compared with ICI monotherapy, chemotherapy, and targeted therapy. The overall results remained robust in the meta-regression and sensitivity analyses.

Conclusions

Among ICI monotherapy, anti-CTLA-4 appeared to be associated with increased toxicity, especially in terms of grade 3–5 RAEs. Anti-CTLA-4 plus anti-PD-1 were associated with higher risk of RAEs than anti-PD-1. However, the difference was not significant between other dual ICI regimens and ICI monotherapy in terms of RAEs and AKI. ICIs plus chemotherapy seemed to be the most toxic treatment regimen in terms of RAEs, AKI, and grade 3–5 AKI.

Systematic Review Registration

PROSPERO, identifier CRD42020197039.

Epidemiology and prognosis of patients with a history of cancer admitted to intensive care. A multicenter observational study

OBJECTIVE

To assess the epidemiology and outcome at discharge of cancer patients requiring admission to the Intensive Care Unit (ICU).

DESIGN

A descriptive observational study was made of data from the ENVIN-HELICS registry, combined with specifically compiled variables. Comparisons were made between patients with and without neoplastic disease, and groups of cancer patients with a poorer outcome were identified.

SETTING

Intensive Care Units participating in ENVIN-HELICS 2018, with voluntary participation in the oncological registry.

PATIENTS

Subjects admitted during over 24 h and diagnosed with cancer in the last 5 years.

PRIMARY ENDPOINTS

The general epidemiological endpoints of the ENVIN-HELICS registry and cancer-related variables.

RESULTS

Of the 92 ICUs with full data, a total of 11,796 patients were selected, of which 1786 (15.1%) were cancer patients. The proportion of cancer patients per Unit proved highly variable (1%-48%). In-ICU mortality was higher among the cancer patients than in the non-oncological subjects (12.3% versus 8.9%; p < .001). Elective postoperative (46.7%) or emergency admission (15.3%) predominated in the cancer patients. Patients with medical disease were in more serious condition, with longer stay and greater mortality (27.5%). The patients admitted to the ICU due to nonsurgical disease related to cancer exhibited the highest mortality rate (31.4%).

CONCLUSIONS

Great variability was recorded in the percentage of cancer patients in the different ICUs. A total of 46.7% of the patients were admitted after undergoing scheduled surgery. The highest mortality rate corresponded to patients with medical disease (27.5%), and to those admitted due to cancer-related complications (31.4%).

The Role of Renal Pathology in the Prognosis and Recovery of Community-Acquired Acute Kidney Injury

OBJECTIVES

The determinants leading to different renal outcomes in community-acquired acute kidney injury (CA-AKI) and the influence of renal histological damage on the prognosis and recovery of CA-AKI are scarcely reported.

METHODS

Adult patients with CA-AKI admitted to Shanghai Changzheng Hospital with renal biopsy profiles from January 1, 2010, to December 31, 2018, were enrolled in our cohort. After 3 months of follow-up, clinical outcomes, including patient survival, dialysis requirement during hospitalization and at 3 months, CKD stage 3-5, and renal functional recovery at 3 months, were analyzed, and risk factors were identified.

RESULTS

A total of 294 patients with CA-AKI with renal pathology were identified for this cohort. Among 282 patients who survived 3 months after AKI, 59.6% completely recovered, 21.3% partially recovered, 21.3% progressed to stage 3-5 CKD without dialysis, and 17.7% maintained dialysis. Moreover, 70.4% of patients in the cohort presented with de novo intrinsic renal disease, except acute tubular necrosis or acute interstitial nephritis, on renal biopsy. In the multivariate analyses, clinical factors were more related to short-term outcomes and severity of CA-AKI, represented by mortality, in-hospital dialysis, and CRRT requirement, while pathological elements were more involved with CKD progression, including dialysis-dependent or stage 3-5 CKD, and renal function recovery at the 3-month follow-up. The detrimental influence of glomerular and arterial lesions on renal prognosis of CA-AKI was as critical as tubular and interstitial lesions.

CONCLUSIONS

Clinical and pathological parameters both contribute to patient and renal outcomes after CA-AKI. The value of renal biopsy should be recognized in prognostic prediction.

Acute Kidney Injury in the Patient with Cancer

Over the last three decades, advancements in the diagnosis, treatment, and supportive care of patients with cancer have significantly improved their overall survival. However, these advancements have also led to a higher rate of cancer-related complications. Acute kidney injury (AKI) and chronic kidney disease (CKD) are highly prevalent in patients with cancer, and they are associated with an increased risk of all-cause mortality. This bidirectional interplay between cancer and kidney, termed "the kidney-cancer connection" has become a very active area of research. This review aims to provide an overview of some of the most common causes of AKI in patients with cancer. Cancer therapy-associated AKI is beyond the scope of this review and will be discussed separately.

Onconephrology

Current advances in cancer chemotherapeutics have remarkably helped in rapid and definitive treatment options. However, these potent chemotherapeutics have been associated with severe renal toxicities that later impact treatment options. Acute kidney injury is common in patients with cancer. In hospitalized patients with cancer, acute kidney injury is associated with increased morbidity, mortality, length of stay, and costs. This article provides an overview of acute kidney injury caused by cancer or its treatment, including prerenal, tubular, glomerular diseases, infiltrative disease, tumor lysis syndrome, anticancer drug nephrotoxicity, hematopoietic stem cell transplantation-related acute kidney injury, and cancer-associated thrombotic microangiopathy.

Retrospective Analysis of Mortality Cases in Advanced and Metastatic Solid Tumors With Concurrent Prerenal Azotemia

BACKGROUND/AIM

A retrospective study of cases with metastatic or advanced solid tumors complicated with AKI (acute kidney injury) with prerenal azotemia.

PATIENTS AND METHODS

Criteria included: (1) advanced or metastatic solid tumors that led to mortality; (2) prerenal azotemia identified upon renal function evaluation and (3) BUN to Cr ratio (BCR)≥15. We also compared the outcomes of patients with BCR>20 with those of patients with BCR=15-20.

RESULTS

A total of 218 patients with solid tumors were enrolled. One hundred and forty (64%) and 78 (36%) patients had BCR>20 and 15-20, respectively. Before AKI occurrence, 136 (62%) had thromboembolic complications and 96 (44%) paraneoplastic syndromes. Median survival time was 1 week in all patients. Median survival time was statistically different between the groups with BCR15-20 and BCR>20 (p<0.005, log-rank test).

CONCLUSION

Cancer patients with concurrent AKI and prerenal azotemia carry a very poor prognosis.

EDTAKI: A Nephrology and Public Policy Committee (NPPC) Platform Call for More European Involvement in AKI

Acute Kidney Injury (AKI) is an often neglected but crucial element of clinical nephrology. The aim of the Nephrology Public Policy Committee (NPPC) of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) is to promote several key aspects of European nephrology. One of the targets proposed by NPPC was to advance European nephrology involvement in AKI. We undertook literature analyses to define the current position of European nephrology in the field of AKI compared to other regions, and about how different European countries compare to each other. It appeared that vis-à-vis countries with a comparable socio-economic status (the US, Australia, New Zealand, Canada), the European contribution was almost 50% lower. Within Europe, Central/Eastern Europe and countries with a lower gross domestic product (GDP) showed lower scientific output. Nephrologists contributed to less than half of the output. There was no trend for a change over the last decade. It is concluded that there is room to improve the contribution of European nephrology in the field of AKI. We propose a model on how to promote clinical collaboration on AKI across Europe, the creation of a pan-European nephrology network of interested units is proposed, to improve clinical outcomes, increase nephrologist involvement and awareness outside nephrology, and stimulate research on AKI in Europe. Accordingly, we also propose a list of research priorities and stress the need for more European funding of AKI research.

Knockdown of circ-FANCA alleviates LPS-induced HK2 cell injury via targeting miR-93-5p/OXSR1 axis in septic acute kidney injury

BACKGROUND

Sepsis is life-threatening disease with systemic inflammation and can lead to various diseases, including septic acute kidney injury (AKI). Recently, diverse circular RNAs (circRNAs) are considered to be involved in the development of this disease. In this study, we aimed to elucidate the role of circ-FANCA and the potential action mechanism in sepsis-induced AKI.

METHODS

HK2 cells were treated with lipopolysaccharide (LPS) to establish septic AKI cell model. The expression of circ-FANCA, microRNA-93-5p (miR-93-5p) and oxidative stress responsive 1 (OXSR1) mRNA was determined by quantitative real-time polymerase chain reaction (qRT-PCR). Cell viability was assessed using cell counting kit-8 (CCK-8) assay. Cell apoptosis and cell cycle distribution were measured by flow cytometry. The inflammatory response was monitored according to the release of pro-inflammatory cytokines via enzyme-linked immunosorbent assay (ELISA). The activities of oxidative indicators were examined using the corresponding kits. Dual-luciferase reporter assay and RNA immunoprecipitation (RIP) assay were applied to validate the interaction between miR-93-5p and circ-FANCA or OXSR1. Protein analysis was conducted through western blot.

RESULTS

Circ-FANCA was upregulated in septic AKI serum specimens and LPS-treated HK2 cells. Functionally, circ-FANCA knockdown facilitated cell proliferation and restrained apoptosis, inflammation and oxidative stress in LPS-triggered HK2 cells. Further mechanism analysis revealed that miR-93-5p was a target of circ-FANCA and circ-FANCA modulated LPS-induced cell damage by targeting miR-93-5p. Meanwhile, miR-93-5p overexpression repressed LPS-treated HK2 cell injury by sponging OXSR1. Furthermore, circ-FANCA regulated OXSR1 expression by sponging miR-93-5p. Besides, exosome-derived circ-FANCA was upregulated in LPS-induced HK2 cells, which was downregulated by GW4869.

CONCLUSION

Circ-FANCA knockdown attenuated LPS-induced HK2 cell injury by regulating OXSR1 expression via targeting miR-93-5p.

Acute kidney injury among hospitalized children with cancer

BACKGROUND

Few studies to date have analyzed the epidemiology of acute kidney injury (AKI) in children with cancer in developing countries. The aim of this study was to assess the incidence, risk profile and outcomes of AKI in Chinese children hospitalized with cancer.

METHODS

This multi-center study analyzed Chinese children hospitalized with cancer in 2013-2015. Electronic hospital and laboratory databases were screened to select pediatric patients with malignancy who had at least two Scr results within any 7-day window during their first 30 days of hospitalization. AKI events were identified and staged according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The incidence of and risk factors for AKI were analyzed, as were mortality rate, incidence of kidney recovery, and length of hospital stay.

RESULTS

Of the 9828 children with cancer, 1657 (16.9%) experienced AKI events, including 549 (5.6%) community-acquired (CA-AKI) and 1108 (11.3%) hospital-acquired AKI (HA-AKI) events. The three types of cancer with the highest incidence of AKI were urinary system cancer (25.8%), hepatic cancer (19.4%), and retroperitoneal malignancies (19.1%). The risk factor profiles of CA-AKI and HA-AKI events differed, with many HA-AKI events due to treatment with nephrotoxic agents. In-hospital death rates were 5.4% (90 of 1657) in children with and 0.9% (74 of 8171) in children without AKI events. AKI events were also associated with longer hospitalization and higher daily costs.

CONCLUSIONS

AKI events are common among Chinese children hospitalized for cancer and are associated with adverse in-hospital outcomes.

Risk of acute kidney injury and Clostridioides difficile infection with piperacillin/tazobactam, cefepime and meropenem with or without vancomycin

BACKGROUND

Empiric antimicrobial therapy for healthcare-acquired infections often includes vancomycin plus an antipseudomonal beta-lactam (AP-BL). These agents vary in risk for adverse events, including acute kidney injury (AKI) and Clostridium difficile infection (CDI). Studies have only examined these risks separately; thus, our objective was to simultaneously evaluate AKI and CDI risks with AP-BL in the same patient cohort.

METHODS

This retrospective cohort study included 789,200 Veterans Health Administration medical admissions from July 1, 2010 through June 30, 2016. The antimicrobials examined were vancomycin, cefepime, piperacillin/tazobactam, and meropenem. Cox proportional hazards regression was used to contrast risks for AKI and CDI across individual target antimicrobials and vancomycin combination therapies, including adjustment for known confounders.

RESULTS

With respect to the base rate of AKI among patients who did not receive a target antibiotic (4.6%), the adjusted hazards ratios for piperacillin/tazobactam, cefepime, and meropenem were 1.50 (95% CI: 1.43-1.54), 1.00 (0.95-1.05), 0.92 (0.83-1.01), respectively. Co-administration of vancomycin increased AKI rates (data not shown). Similarly, against the base rate of CDI (0.7%), these ratios were 1.21 (1.07-1.36), 1.89 (1.62-2.20), and 1.99 (1.55-2.56), respectively. Addition of vancomycin had minimal impact on CDI rates (data not shown).

CONCLUSIONS

Piperacillin/tazobactam increased AKI risk, which was exacerbated by concurrent vancomycin. Cefepime and meropenem increased CDI risk relative to piperacillin/tazobactam. Clinicians should consider the risks and benefits of AP-BL when selecting empiric regimens. Further well-designed studies evaluating the global risks of AP-BL and patient specific characteristics that can guide empiric selection are needed.

Machine Learning to Predict Contrast-Induced Acute Kidney Injury in Patients With Acute Myocardial Infarction

Objective: To develop predictive models for contrast induced acute kidney injury (CI-AKI) among acute myocardial infarction (AMI) patients treated invasively.

Methods: Patients with AMI who underwent angiography therapy were enrolled and randomly divided into training cohort (75%) and validation cohort (25%). Machine learning algorithms were used to construct predictive models for CI-AKI. The predictive models were tested in a validation cohort.

Results: A total of 1,495 patients with AMI were included. Of all the patients, 226 (15.1%) cases developed CI-AKI. In the validation cohort, Random Forest (RF) model with top 15 variables reached an area under the curve (AUC) of 0.82 (95% CI: 0.76–0.87), while the best logistic model had an AUC of 0.69 (95% CI: 0.62–0.76). ACEF (age, creatinine, and ejection fraction) model reached an AUC of 0.62 (95% CI: 0.53–0.71). RF model with top 15 variables achieved a high recall rate of 71.9% and an accuracy of 73.5% in the validation group. Random Forest model significantly outperformed logistic regression in every comparison.

Conclusions: Machine learning algorithms especially Random Forest algorithm improves the accuracy of risk stratifying patients with AMI and should be used to accurately identify the risk of CI-AKI in AMI patients.

Epidemiology and Outcome of Critically Ill Pediatric Cancer and Hematopoietic Stem Cell Transplant Patients Requiring Continuous Renal Replacement Therapy: A Retrospective Nationwide Cohort Study

Supplemental Digital Content is available in the text.

Acute kidney injury requiring continuous renal replacement therapy is a serious treatment-related complication in pediatric cancer and hematopoietic stem cell transplant patients. The purpose of this study was to assess epidemiology and outcome of these patients requiring continuous renal replacement therapy in the PICU.

Impact of acute kidney injury on anticancer treatment dosage and long-term outcomes: a pooled analysis of European Organisation for Research and Treatment of Cancer trials

BACKGROUND

The impact of kidney dysfunction on long-term outcomes of patients with advanced cancer remains unclear.

METHODS

Patients with advanced cancer included in trials conducted by the European Organisation for Research and Treatment of Cancer were eligible for this retrospective analysis. Acute kidney injury (AKI) was identified using serum creatinine levels and using adverse events reported by investigators. The impact of baseline estimated glomerular filtration rates (eGFRs) on progression-free survival (PFS) and overall survival (OS) was investigated. Pooled estimates of the impact of AKI on dose intensity, treatment duration, PFS and OS were obtained following a meta-analytic process.

RESULTS

Nine trials were included in this study, totalling 2872 metastatic patients with various tumour types and various systemic treatment types. Baseline eGFR had homogeneously no impact on PFS or OS. Most Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE) events occurred early during the course of the treatment. AKI was not associated with an increased rate of treatment discontinuation, while it decreased the study treatment dose intensity. Occurrence of a first RIFLE event significantly and homogeneously reduced PFS (pooled hazard ratio = 1.18, 95% confidence interval 1.07-1.30; P = 0.0012), while its impact on OS was more heterogeneous across trials.

CONCLUSION

AKI is associated with reduced treatment dose intensity and reduced PFS. Therefore, close monitoring of the kidney function during the first months of treatment should be included in clinical trial protocols and probably also in daily practice to enable early AKI diagnosis and management. Collaboration between oncologists and nephrologists is needed to reduce the risk of undertreatment of patients experiencing AKI.

Epidemiology and prognosis of patients with a history of cancer admitted to intensive care. A multicenter observational study

OBJECTIVE

To assess the epidemiology and outcome at discharge of cancer patients requiring admission to the Intensive Care Unit (ICU).

DESIGN

A descriptive observational study was made of data from the ENVIN-HELICS registry, combined with specifically compiled variables. Comparisons were made between patients with and without neoplastic disease, and groups of cancer patients with a poorer outcome were identified.

SETTING

Intensive Care Units participating in ENVIN-HELICS 2018, with voluntary participation in the oncological registry.

PATIENTS

Subjects admitted during over 24hours and diagnosed with cancer in the last 5 years.

PRIMARY ENDPOINTS

The general epidemiological endpoints of the ENVIN-HELICS registry and cancer-related variables.

RESULTS

Of the 92 ICUs with full data, a total of 11,796 patients were selected, of which 1786 (15.1%) were cancer patients. The proportion of cancer patients per Unit proved highly variable (1-48%). In-ICU mortality was higher among the cancer patients than in the non-oncological subjects (12.3% versus 8.9%; P<.001). Elective postoperative (46.7%) or emergency admission (15.3%) predominated in the cancer patients. Patients with medical disease were in more serious condition, with longer stay and greater mortality (27.5%). The patients admitted in ICU due to nonsurgical disease related to cancer exhibited the highest mortality rate (31.4%).

CONCLUSIONS

Great variability was recorded in the percentage of cancer patients in the different ICUs. A total of 46.7% of the patients were admitted after undergoing scheduled surgery. The highest mortality rate corresponded to patients with medical disease (27.5%), and to those admitted due to cancer-related complications (31.4%).

Acute kidney injury in cancer patients

The increasing prevalence of neoplasias is associated with new clinical challenges, one of which is acute kidney injury (AKI). In addition to possibly constituting a clinical emergency, kidney failure significantly interferes with the choice and continuation of antineoplastic therapy, with prognostic implications in cancer patients. Some types of neoplasia are more susceptible to AKI, such as multiple myeloma and renal carcinoma. In cancer patients, AKI can be divided into pre-renal, renal (intrinsic), and post-renal. Conventional platinum-based chemotherapy and new targeted therapy agents against cancer are examples of drugs that cause an intrinsic renal lesion in this group of patients. This topic is of great importance to the daily practice of nephrologists and even constitutes a subspecialty in the field, the onco-nephrology.

Acute kidney injury in critically ill patients with solid tumours

Background

Patients with solid tumours are at risk for acute kidney injury (AKI), however, epidemiological data are limited.

Methods

We conducted a study that included patients with solid tumours admitted to a single-centre intensive care unit (ICU) from January 2011 to December 2015. We analysed factors associated with the occurence of AKI, ICU and Day-90 mortality.

Results

Two-hundred and four patients were included. The incidence of AKI was 59%, chiefly related to sepsis (80%), hypovolaemia (40%) and outflow tract obstruction (17%). Renal replacement therapy was implemented in 12% of the patients, with a hospital mortality of 39%. Independent predictors of AKI were: Simplified Acute Physiological Score II (SAPS II) [odds ratio (OR) 1.05; 95% confidence interval (95% CI) 1.02-1.07; P < 0.001], abdominal or pelvic cancer (OR 2.84; 95% CI 1.35-5.97; P = 0.006), nephrotoxic chemotherapy within the previous 3 months (OR 3.84; 95% CI 1.67-8.84; P = 0.002) and sepsis (OR 2.74; 95% CI 1.30-5.77; P = 0.008). Renal recovery at Day 90 was inversely related to AKI severity. ICU, hospital and Day-90 mortality were 15, 29 and 37%, respectively. Factors independently associated with ICU mortality were: total serum protein (OR per 10 g/L, 0.44; 95% CI 0.23-0.86; P = 0.02) and SAPS II (OR 1.04; 95% CI 1.01-1.07; P = 0.02), while Day-90 mortality was associated with performance status 3-4 (OR 6.59; 95% CI 2.42-18; P < 0.001) and total serum protein (OR 0.60; 95% CI 0.38-0.94; P = 0.02).

Conclusions

AKI in patients with solid tumours was frequent and renal recovery gradually decreased in proportion to AKI severity. However, AKI was not independently associated with a higher short-term mortality.

Acute kidney injury in the patient with cancer

Dramatic advances in the care of patients with cancer have led to significant improvement in outcomes and survival. However, renal manifestations of the underlying cancer as well as the effects of anti-neoplastic therapies leave patients with significant morbidity and chronic kidney disease risks. The most common renal manifestations associated with cancer include acute kidney injury (AKI) in the setting of multiple myeloma, tumor lysis syndrome, post-hematopoietic stem cell therapy, and AKI associated with chemotherapy. Knowledge of specific risk factors, modification of risk and careful attention to rapid AKI diagnosis are critical for improving outcomes.

Incidence, Risk Factors, and Clinical Outcomes of Acute Kidney Injury Caused by Palliative Chemotherapy in Lung Cancer

Purpose: Acute kidney injury (AKI) affects cancer therapy outcome and increases morbidity and mortality in cancer patients. We investigated the incidence, risk factors, and clinical outcomes of AKI caused by palliative chemotherapy in lung cancer patients.

Materials and Methods: Between January 2005 and November 2014, 207 lung cancer patients who had been treated with first-line palliative chemotherapy were enrolled. Renal function was assessed during every cycle of chemotherapy. AKI was defined based on changes in serum creatinine levels as described in the Kidney Disease: Improving Global Outcomes guidelines. Clinical outcomes were evaluated depending on AKI occurrence during the first-line chemotherapy.

Results: Of the 207 patients, 36 (17.4%) experienced AKI. Among the 36 patients who developed AKI during chemotherapy, 33 (91.8%) had AKI stage I. Although 19 patients (52.7%) with AKI during chemotherapy progressed to chronic kidney disease (CKD), no patients were reported to progress to end-stage renal disease (ESRD). The number of chemotherapy cycles was independently associated with chemotherapy-induced AKI in multivariate analysis (OR = 1.71, 95% CI 1.29-2.26, p < 0.001). The median follow-up duration was 83 months. Patients with AKI during chemotherapy (AKI group) showed significantly longer time to treatment failure than patients without AKI (non-AKI group) (4.2 vs. 2.5 months, p < 0.001). However, the median overall survival (11.7 vs. 8.8 months, p = 0.147) and progression-free survival (5.5 vs. 5.2 months, p = 0.347) were not different between the groups.

Conclusions: AKI that developed during chemotherapy was mostly of mild degree and its prognosis was favorable. The occurrence of AKI was associated with the number of chemotherapy cycles administered. AKI did not adversely affect survival of lung cancer patients during chemotherapy.

Acute kidney injury predicts all-cause mortality in patients with cancer

Background

Acute kidney injury (AKI) is a critical issue in cancer patients because it is not only a morbid complication but also able to interrupt timely diagnostic evaluation or planned optimal treatment. However, the impact of AKI on overall mortality in cancer patients remains unclear.

Methods

We conducted a retrospective cohort study of 67 986 cancer patients, from 2004 to 2013 to evaluate the relationship between AKI and all‐cause mortality. We used KDIGO AKI definition and grading system.

Results

During 3.9 ± 3.1 years of follow‐up, 33.8% of the patients experienced AKI at least once. Among AKI events, stage 1, 2, and 3 was 71.0%, 13.8%, and 15.1%, respectively. AKI incidence was highest in hematologic malignancies, followed by urinary tract cancer, and hepatocellular carcinoma. Male sex, older age, underlying diabetes and hypertension, lower serum albumin and plasma hemoglobin, more frequent radio‐contrast exposure, entrance of clinical trials, and receiving chemotherapy were associated with AKI occurrence. AKI development was an independent risk factor for elevated mortality in cancer patients with dose‐responsive manner (Stage 1, hazard ratio [HR] 1.183, 95% confidence interval [CI] 1.145‐1.221, P < 0.001; Stage 2, HR 1.710, 95% CI 1.629‐1.796; Stage 3, HR 2.000, 95% CI 1.910‐2.095; No AKI, reference group) even after adjustment. This tendency was reproduced in various cancer types except thyroid cancer and in various treatment modalities, however, not shown in patients with baseline renal dysfunction.

Conclusion

AKI was an independent risk factor for all‐cause mortality in overall cancer patients with dose‐responsive manner.

Plasma neutrophil gelatinase-associated lipocalin and factors related to acute kidney injury and mortality in critically ill cancer patients

Rationale

Acute kidney injury (AKI) is a frequent complication in critically ill cancer patients.

Objectives

To assess plasma neutrophil gelatinase-associated lipocalin (NGAL) levels and risks factors associated with AKI and mortality.

Methods

We recruited 96 critically ill cancer patients and followed them prospectively. Plasma NGAL levels were determined at intensive care unit (ICU) admission and at 48 hours. We generated receiver operating characteristic curves to assess the ability of NGAL to predict AKI. Logistic regression analysis was performed to determine risks factors associated with AKI. Cox-regression analysis was performed to evaluate 6-month mortality.

Measurements and main results

From 96 patients, 60 (63%) developed AKI and 33 (55%) were classified as stages 2 and 3. In patients without AKI at admission, plasma NGAL levels revealed an area under the curve (AUC) = 0.522 for all AKI stages and an AUC = 0.573 for stages 2 and 3 AKI (85% sensitivity and 67% specificity for a 50.66 ng/mL cutoff). We identified sequential organ failure assessment (SOFA) score (without renal parameters) at admission as an independent factor for developing stages 2 and 3 AKI, and haemoglobin as a protective factor. We observed that metastatic disease, dobutamine use and stage 3 AKI were independent factors associated with 6-month mortality.

Conclusions

In our cohort of critically ill cancer patients, NGAL did not predict AKI. SOFA score was a risk factor for developing AKI, and haemoglobin level was a protective factor for developing AKI. The independent factors associated with 6-month mortality included metastatic disease, dobutamine use, lactate and stage 3 AKI.

Epidemiology and outcomes of acute kidney injury in hospitalized cancer patients in China

Acute kidney injury (AKI) is a common complication in cancer patients, but the data are lacking in Asian countries. We aimed to assed the epidemiology, correlated risk factors and outcomes of AKI in cancer patients from China. We conducted a nationwide cohort study of cancer patients who were admitted to 25 general and children hospitals across China from January 1, 2013 to December 31, 2015. We obtained patient-level data from the electronic hospitalization information system and laboratory databases of all inpatients who had at least two serum creatinine tests within any 7-day window during their first 30 days of hospitalization. AKI was defined and staged according to Kidney Disease Improving Global Outcomes criteria. Incidence rate and risk factor profiles for AKI were examined. Outcomes of interest included in-hospital mortality, length of stay and daily costs. A total of 136,756 adult cancer patients were assessed in our study. The overall incidence of AKI was 7.5%, of which 1.6% were community acquired and 5.9% hospital acquired. The top three cancer types with high incidence of AKI were bladder cancer, leukemia, and lymphoma. Risk factors for community-acquired and hospital-acquired AKI were similar, including age, increased baseline serum creatinine, shock and urinary tract obstruction. In-hospital death occurred in 12.0% with AKI vs. 0.9% cancer patients without AKI. After adjustment for confounders, the severe AKI was associated with higher risk of in-hospital death, prolonged length of stay and higher daily costs. Clinicians should increase their awareness of AKI in hospitalized cancer patients.

Association Between Increased Levels of Cystatin C and the Development of Cardiovascular Events or Mortality: A Systematic Review and Meta-Analysis

BACKGROUND

Cystatin C seems promising for evaluating the risk of cardiovascular events and mortality.

OBJECTIVE

To evaluate the association between high levels of cystatin C and the development of cardiovascular events or mortality.

METHODS

The articles were selected in the Medline/PubMed, Web of Science, and Scielo databases. The eligibility criteria were prospective cohort observational trials that assessed the association of high serum levels of cystatin C with the development of cardiovascular events or mortality in individuals with normal renal function. Only studies that evaluated the mortality outcome compared the fourth with the first quartile of cystatin C and performed multivariate Cox's proportional hazard regression analysis were included in the meta-analysis. A p value < 0,05 was considered significant.

RESULTS

Among the 647 articles found, 12 were included in the systematic review and two in the meta-analysis. The risk of development of adverse outcomes was assessed by eight studies using the hazard ratio. Among them, six studies found an increased risk of cardiovascular events or mortality. The multivariate regression analysis was performed by six studies, and the risk of developing adverse outcomes remained significant after the analysis in four of these studies. The result of the meta-analysis [HR = 2.28 (1.70-3.05), p < 0.001] indicated that there is a significant association between high levels of cystatin C and the risk of mortality in individuals with normal renal function.

CONCLUSION

There is a significant association between high levels of cystatin C and the development of cardiovascular events or mortality in individuals with normal renal function.

Neutrophil-lymphocyte ratio is associated with all-cause mortality among critically ill patients with acute kidney injury

BACKGROUND

Inflammation plays a critical role in the development of acute kidney injury (AKI). Neutrophil-lymphocyte ratio (NLR) is a biomarker of systemic inflammation used to predict the prognostic outcome of several diseases. We conducted a retrospective cohort study to investigate if NLR can be used as a biomarker to predict the mortality of AKI.

METHODS AND RESULTS

Records of critically ill patients with AKI were extracted from the Medical Information Mart for Intensive Care Database III version 1.3 (MIMIC-III v1.3). The primary outcome was 30-day mortality and the two secondary outcomes were in hospital and 90-day mortality. We used the Cox proportional hazards models to assess the association between different categories of NLR and outcomes. This analysis included data for 13,678 eligible subjects, with a total of 2,588 30-day, 2,224 in-hospital and 3,545 90-day deaths during the follow-up period. For 30-day mortality, an increased risk of mortality was associated with a higher level of NLR. The HR (95% confidence interval [CI]) of upper tertile (NLR > 12.14) was 1.37 (1.17-1.60) in a multivariate model when compared with that of the lower tertile (NLR < 5.55). In the quintile analysis, we confirmed the upward trend with HR (95% CI) of the fifth quintile (NLR > 17.4) of 1.35 (1.08, 1.69) in a multivariate model compared to the first quintile (NLR < 3.82). A similar tendency was observed for 90-day mortality. In the analysis of in-hospital mortality, the HR of fifth quintile (NLR > 17.4) showed a slight decrease.

CONCLUSIONS

Our analysis indicates that a higher level of NLR is associated with increased risk of 30-day and 90-day mortality in AKI patients. The similar upward trend is not detected in analysis of in-hospital mortality.

Impact of Urgent Chemotherapy in Critically Ill Patients

OBJECTIVE

Compare the mortality between critically ill patients who received urgent chemotherapy for a cancer-related life-threatening complication with matched patients (controls) who did not received it.

DESIGN

Propensity score-matched retrospective study.

SETTING

Adult intensive care unit in an oncological hospital.

PARTICIPANTS

All adults with solid tumor or hematological malignancies who received at least 1 day of urgent intravenous chemotherapy for a cancer-related life-threatening complication. Using the propensity score method adjusted for 10 variables, patients who received urgent chemotherapy were matched to patients who did not.

INTERVENTIONS

None.

MAIN OUTCOMES MEASURES

Intensive care unit and hospital mortality.

RESULTS

Forty-seven patients (57% with solid tumors and 43% with hematological malignancies) who received urgent chemotherapy were matched to 94 controls. At intensive care unit admission, patients were similar except that those who received urgent chemotherapy were less likely to have received chemotherapy previously (36% vs 85%; P < .01). The intensive care unit (48.9% vs 23.4%; P < .01) and hospital (76.6% vs 46.8%; P < .01) mortality of the patients who received urgent chemotherapy was higher than the controls. The subgroup analysis showed that the higher mortality was limited to patients with solid tumor.

CONCLUSION

The use of urgent chemotherapy is associated with an increase in the intensive care unit and hospital mortality of unselected critically ill patients with solid tumors but not in patients with hematological malignancies.

AF1q Contributes to Adriamycin-Induced Podocyte Injury by Activating Wnt/β-Catenin Signaling

BACKGROUND/AIMS

Injury of podocytes plays an important role in decline of glomerular filtration and proteinuria. It is well-known that proteinuria is associated with numerous chronic kidney diseases (CKD). However, the underlying mechanism of podocyte injury remains unclear.

METHODS

We used reverse transcription-quantitative PCR (RT-qPCR) to compare the expression level of the ALL1-fused from the chromosome 1q (AF1q) gene in mice and mouse podocytes (MPC5) with or without Adriamycin (ADR) treatment. The effects of AF1q on Wnt/ β-catenin signaling were investigated by determining the expressions of desmin, snail, WT1, nephrin and E-cadherin using western blotting.

RESULTS

We found that AF1q expression was elevated in podocytes treated with ADR than untreated cells. AF1q overexpression directly led to podocytes injury with increased levels of desmin and snail. Luciferase activity of TOPflash reporter was significantly increased in cells with AF1q overexpression than wild type cells whereas deletion of T-cell-factor-7 (TCF7) eliminated this effect. Immunoprecipitation assay evidenced that AF1q interacted with TCF7 and promoted both transcriptional and translational expressions of TCF7. Overexpression of AF1q increased protein expression of β-catenin. However, in podocytes with deletion of TCF7, AF1q was not able to promote β-catenin expression.

CONCLUSION

Our findings demonstrated that aberrant expression of AF1q may activate Wnt/β-catenin signaling and result in podocyte injury.

Critical Care Prognosis and Outcomes in Patients with Cancer

Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.