1
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Muto S, Matsubara T, Inoue T, Kitamura H, Yamamoto K, Ishii T, Yazawa M, Yamamoto R, Okada N, Mori K, Yamada H, Kuwabara T, Yonezawa A, Fujimaru T, Kawano H, Yokoi H, Doi K, Hoshino J, Yanagita M. Chapter 1: Evaluation of kidney function in patients undergoing anticancer drug therapy, from clinical practice guidelines for the management of kidney injury during anticancer drug therapy 2022. Int J Clin Oncol 2023; 28:1259-1297. [PMID: 37382749 DOI: 10.1007/s10147-023-02372-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023]
Abstract
The prevalence of CKD may be higher in patients with cancer than in those without due to the addition of cancer-specific risk factors to those already present for CKD. In this review, we describe the evaluation of kidney function in patients undergoing anticancer drug therapy. When anticancer drug therapy is administered, kidney function is evaluated to (1) set the dose of renally excretable drugs, (2) detect kidney disease associated with the cancer and its treatment, and (3) obtain baseline values for long-term monitoring. Owing to some requirements for use in clinical practice, a GFR estimation method such as the Cockcroft-Gault, MDRD, CKD-EPI, and the Japanese Society of Nephrology's GFR estimation formula has been developed that is simple, inexpensive, and provides rapid results. However, an important clinical question is whether they can be used as a method of GFR evaluation in patients with cancer. When designing a drug dosing regimen in consideration of kidney function, it is important to make a comprehensive judgment, recognizing that there are limitations regardless of which estimation formula is used or if GFR is directly measured. Although CTCAEs are commonly used as criteria for evaluating kidney disease-related adverse events that occur during anticancer drug therapy, a specialized approach using KDIGO criteria or other criteria is required when nephrologists intervene in treatment. Each drug is associated with the different disorders related to the kidney. And various risk factors for kidney disease associated with each anticancer drug therapy.
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Affiliation(s)
- Satoru Muto
- Department of Urology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
| | - Takeshi Matsubara
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takamitsu Inoue
- Department of Renal and Urologic Surgery, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Hiroshi Kitamura
- Department of Urology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | | | - Taisuke Ishii
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Ryohei Yamamoto
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Naoto Okada
- Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
- Pharmacy Department, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Kiyoshi Mori
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Takashige Kuwabara
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takuya Fujimaru
- Department of Nephrology, St Luke's International Hospital, Tokyo, Japan
| | - Haruna Kawano
- Department of Urology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hideki Yokoi
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Junichi Hoshino
- Department of Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Kyoto, Japan
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Aklilu AM, Shirali AC. Chemotherapy-Associated Thrombotic Microangiopathy. Kidney360 2023; 4:409-422. [PMID: 36706238 PMCID: PMC10103319 DOI: 10.34067/kid.0000000000000061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/22/2022] [Indexed: 01/28/2023]
Abstract
Thrombotic microangiopathy (TMA) is a syndrome of microangiopathic hemolytic anemia and thrombocytopenia with end-organ dysfunction. Although the advent of plasma exchange, immunosuppression, and complement inhibition has improved morbidity and mortality for primary TMAs, the management of secondary TMAs, particularly drug-induced TMA, remains less clear. TMA related to cancer drugs disrupts the antineoplastic treatment course, increasing the risk of cancer progression. Chemotherapeutic agents such as mitomycin-C, gemcitabine, and platinum-based drugs as well as targeted therapies such as antiangiogenesis agents and proteasome inhibitors have been implicated in oncotherapy-associated TMA. Among TMA subtypes, drug-induced TMA is less well-understood. Treatment generally involves withdrawal of the offending agent and supportive care targeting blood pressure and proteinuria reduction. Immunosuppression and therapeutic plasma exchange have not shown clear benefit. The terminal complement inhibitor, eculizumab, has shown promising results in some cases of chemotherapy-associated TMA including in re-exposure. However, the data are limited, and unlike in primary atypical hemolytic uremic syndrome, the role of complement in the pathogenesis of drug-induced TMA is unclear. Larger multicenter studies and unified definitions are needed to elucidate the extent of the problem and potential treatment strategies.
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Affiliation(s)
- Abinet M. Aklilu
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Anushree C. Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
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3
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Abstract
A 65-year-old female patient with breast cancer and soft tissue sarcoma who
experienced a gemcitabine-induced thrombotic microangiopathies manifestation
visited the emergency department. The renal biopsy revealed endothelial cell
swelling, focal reduplication of glomerular basement membrane, and narrowed
capillary lumens with fibrin deposition and fragmented erythrocytes which are
compatible with thrombotic microangiopathies. The patient was presented with
organ injury, acute renal failure with the need for hemodialysis technique. The
patient recovered after the appropriate treatment. Continuous observation of
renal function during gemcitabine treatment regularly and withdrawal of
treatment if acute kidney injury occurs is essential as acute kidney injury
along with thrombotic microangiopathies may prove to be life-threatening.
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Affiliation(s)
- Mohammed Ali Madkhali
- Division of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
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4
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MacDougall KN, Schwartz B, Harewood J, Bukhari Z, Neculiseanu E. A Case of Gemcitabine-Induced Thrombotic Microangiopathy Treated With Ravulizumab in a Patient With Stage IV Pancreatic Cancer. Cureus 2021; 13:e13031. [PMID: 33680585 PMCID: PMC7931775 DOI: 10.7759/cureus.13031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A 47-year-old male with stage IV pancreatic cancer developed gemcitabine-induced thrombotic microangiopathy (GiTMA) after treatment with gemcitabine and nab-paclitaxel. GiTMA is a rare and life-threatening complication with an incidence ranging from 0.015% to 1.4% and reported mortality rate ranging from 50% to 90%. Clinically, GiTMA manifests as microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. Early identification of GiTMA is essential to initiate early treatment and improve survival. Treatment of GiTMA includes discontinuation of gemcitabine, along with initiation of steroids, therapeutic plasma exchange (TPE), rituximab, and eculizumab. To our knowledge, this is the first case of GiTMA treated with ravulizumab, a long-acting complement inhibitor. Given the increasing number of patients treated with gemcitabine and seriousness of this complication, it is important for physicians to be aware of this disease entity and maintain a high index of suspicion when evaluating patients with microangiopathic hemolytic anemia, thrombocytopenia, and renal failure.
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Affiliation(s)
| | - Benjamin Schwartz
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Janine Harewood
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Zaheer Bukhari
- Pathology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Elvira Neculiseanu
- Hematology and Oncology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
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Abstract
With rapid progress in cancer diagnosis and treatment in the last two decades, outcomes in oncological patients have improved significantly. However, the incidence of acute kidney injury (AKI) in this population has also increased significantly. AKI complicates many aspects of patients' care and adversely affects their prognoses; thus, accurately diagnosing the risk factors for AKI ensures appropriate management. AKI may be caused by pre-renal, intrinsic renal, and post-renal reasons, as well as for combined reasons. This review summarizes the potential etiologies of AKI according to the three classifications. For each underlying cause of AKI, the cancer itself and/or cancer treatment may contribute to a patient developing AKI. Therefore, we present disease- and treatment-related factors for each cause category, with special focus on immune checkpoint inhibitors, which are being used increasingly more often. It is important for nephrology services to be knowledgeable to provide the best level of care.
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Affiliation(s)
- Li-Yan Wang
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jia-Ni Wang
- National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zong-Li Diao
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yi-Ming Guan
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wen-Hu Liu
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Chatzikonstantinou T, Gavriilaki M, Anagnostopoulos A, Gavriilaki E. An Update in Drug-Induced Thrombotic Microangiopathy. Front Med (Lausanne) 2020; 7:212. [PMID: 32528969 PMCID: PMC7256484 DOI: 10.3389/fmed.2020.00212] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/29/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
| | - Maria Gavriilaki
- Laboratory of Clinical Neurophysiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Eleni Gavriilaki
- BMT Unit, Hematology Department, G Papanicolaou Hospital, Thessaloniki, Greece
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Schulte-Kemna L, Reister B, Bettac L, Ludwig U, Fürst D, Mytilineos J, Bergmann C, van Erp R, Schröppel B. Eculizumab in chemotherapy-induced thrombotic microangiopathy. Clin Nephrol Case Stud 2020; 8:25-32. [PMID: 32318323 PMCID: PMC7171698 DOI: 10.5414/cncs109836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 02/28/2020] [Indexed: 01/08/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is a rare but severe complication of tumors and their chemotherapeutic treatment. We report on two patients with chemotherapy-induced TMA who were successfully treated with a short course of the terminal complement inhibitor eculizumab. Both patients quickly achieved remission of microangiopathic hemolytic anemia and recovery of renal function. After withdrawal of eculizumab, remission was stable over an observation period of 47 months and 15 months, respectively. Our data show that eculizumab is effective in treating chemotherapy-induced TMA. Discontinuation of eculizumab is feasible once the complement-activating condition is controlled and the trigger is eliminated. Additional studies need to determine the optimal duration of complement-directed therapies and validate effective monitoring strategies after discontinuation of such therapy.
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Affiliation(s)
| | | | | | - Ulla Ludwig
- Section of Nephrology, University Hospital, Ulm
| | - Daniel Fürst
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg-Hessen, and University Hospital Ulm
- Institute of Transfusion Medicine, University of Ulm, and
| | - Joannis Mytilineos
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg-Hessen, and University Hospital Ulm
- Institute of Transfusion Medicine, University of Ulm, and
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8
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Abstract
A woman in her mid-70s with metastatic pancreatic adenocarcinoma presented with fatigue, nausea and bilateral leg swelling, 4 days after an intravenous gemcitabine infusion. Additional examination and laboratory tests showed mild hypertension, low haemoglobin, high lactate dehydrogenase, low platelet count and high serum creatinine. The patient was subsequently diagnosed with haemolytic uraemic syndrome (HUS), and gemcitabine administration was immediately ceased. The patient received a 5-day course of methylprednisolone, with a full recovery being made 10 days after diagnosis. Clinicians should be aware of the rare but serious complication of gemcitabine-induced HUS (GiHUS), as early diagnosis and management, which includes prompt discontinuation of gemcitabine, are crucial in promptly resolving this condition. This case report describes one treatment that can be used for the treatment of GiHUS, while briefly covering some other novel treatments that have been described in other studies.
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Affiliation(s)
- Adarsh Das
- Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Dean
- Department of Medical Oncology, Saint John of God Hospital Subiaco, Subiaco, Western Australia, Australia
| | - Tim Clay
- Department of Medical Oncology, Saint John of God Hospital Subiaco, Subiaco, Western Australia, Australia
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9
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Daviet F, Rouby F, Poullin P, Moussi‐Francès J, Sallée M, Burtey S, Mancini J, Duffaud F, Sabatier R, Pourroy B, Grandvuillemin A, Grange S, Frémeaux‐Bacchi V, Coppo P, Micallef J, Jourde‐Chiche N. Thrombotic microangiopathy associated with gemcitabine use: Presentation and outcome in a national French retrospective cohort. Br J Clin Pharmacol 2019; 85:403-412. [PMID: 30394581 PMCID: PMC6339967 DOI: 10.1111/bcp.13808] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/09/2018] [Accepted: 10/21/2018] [Indexed: 12/14/2022] Open
Abstract
AIMS Gemcitabine has been associated with thrombotic microangiopathy (TMA). We conducted a national retrospective study of gemcitabine-associated TMA (G-TMA). METHODS From 1998 to 2015, all cases of G-TMA reported to the French Pharmacovigilance Network and the French TMA Reference Center, and cases explored for complement alternative pathway abnormalities, were analysed. RESULTS G-TMA was diagnosed in 120 patients (median age 61.5 years), after a median of 210 days of treatment, and a cumulative dose of 12 941 mg m-2 . Gemcitabine indications were: pancreatic (52.9%), pulmonary (12.6%) and breast (7.6%) cancers, metastatic in 34.2% of cases. Main symptoms were oedema (56.7%) and new-onset or exacerbated hypertension (62.2%). Most patients presented with haemolytic anaemia (95.6%) and thrombocytopenia (74.6%). Acute kidney injury was reported in 97.4% and dialysis was required in 27.8% of patients. Treatment consisted of: plasma exchange (PE; 39.8%), fresh frozen plasma (21.4%), corticosteroids (15.3%) and eculizumab (5.1%). A complete remission of TMA was obtained in 42.1% of patients and haematological remission in 23.1%, while 34.7% did not improve. The survival status was known for 52 patients, with 29 deaths (54.7%). Patients treated with PE, despite a more severe acute kidney injury, requiring dialysis more frequently, displayed comparable rates of remission, but with more adverse events. No abnormality in complement alternative pathway was documented in patients explored. CONCLUSION This large cohort confirms the severity of G-TMA, associated with severe renal failure and death. Oedema and hypertension could be monitored in patients treated with gemcitabine to detect early TMA. The benefit of PE or eculizumab deserves further investigation.
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Affiliation(s)
- Florence Daviet
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Franck Rouby
- Department of Clinical Pharmacology and Pharmacovigilance, Regional Centre of PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- Department of Clinical Pharmacology and PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- INSERM UMR_S 1106, INS, Inst Neurosciences SystemsAix Marseille UniversityMarseilleFrance
| | - Pascale Poullin
- Department of Apheresis, Regional Reference Center for Thrombotic MicroangiopathyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Julie Moussi‐Francès
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
| | - Marion Sallée
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| | - Stéphane Burtey
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
| | - Julien Mancini
- Department of Public HealthAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | - Florence Duffaud
- Department of Clinical OncologyAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | - Renaud Sabatier
- Department of Clinical Oncology, Institut Paoli Calmettes, Laboratory of Molecular OncologyAix‐Marseille UniversityCRCM INSERM UMR 1068MarseilleFrance
| | - Bertrand Pourroy
- Department of Parmacy, OncoPharma UnitAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
| | | | - Steven Grange
- Medical intensive care unit, Regional Center for Thrombotic Microangiopathy, Hôpital Charles NicolleRouen University HospitalRouenFrance
| | | | - Paul Coppo
- Department of Hematology, French Reference Center for Thrombotic Microangiopathy (www.cnr‐mat.fr)Paris 6 UniversityParisFrance
| | - Joëlle Micallef
- Department of Clinical Pharmacology and Pharmacovigilance, Regional Centre of PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- Department of Clinical Pharmacology and PharmacovigilanceAix‐Marseille UniversityAP‐HM Hôpital de la TimoneMarseilleFrance
- INSERM UMR_S 1106, INS, Inst Neurosciences SystemsAix Marseille UniversityMarseilleFrance
| | - Noémie Jourde‐Chiche
- Department of NephrologyAix‐Marseille UniversityAP‐HM Hôpital de la ConceptionMarseilleFrance
- Aix‐Marseille UniversityC2VN, INSERM 1263, INRA 1260MarseilleFrance
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Malyszko J, Kozlowska K, Kozlowski L, Malyszko J. Nephrotoxicity of anticancer treatment. Nephrol Dial Transplant 2018; 32:924-936. [PMID: 28339935 DOI: 10.1093/ndt/gfw338] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 08/10/2016] [Indexed: 12/12/2022] Open
Abstract
Severe adverse systemic drug events occur commonly as a result of treatment of cancer patients. Nephrotoxicity of chemotherapeutic agents remains a significant complication limiting the efficacy of the treatment. A variety of renal disease and electrolyte disorders can result from the drugs that are used to treat malignant disease. The kidneys are a major elimination pathway for many antineoplastic drugs and their metabolites. Tumour lysis syndrome, an emergency in haematooncology, occurs most often after the initiation of cytotoxic therapy in patients with high-grade lymphomas and acute lymphoblastic leukaemia. Chemotherapeutic agents can affect the glomerulus, tubules, interstitium and renal microvasculature, with clinical manifestations that range from asymptomatic elevation of serum creatinine to acute renal failure requiring dialysis. Some factors such as intravascular volume depletion, as well as concomitant use of other drugs or radiographic ionic contrast media, can potentiate or contribute to the nephrotoxicity. Cytotoxic agents can cause nephrotoxicity by a variety of mechanisms. The most nephrotoxic chemotherapeutic drug is cisplatin, which is often associated with acute kidney injury. Many other drugs such as alkylating agents, antimetabolites, vascular endothelial growth factor pathway inhibitors and epidermal growth factor receptor pathway inhibitors may have toxic effects on the kidneys. The aim of this review is to discuss the issue of nephrotoxicity associated with chemotherapy. In routine clinical practice, monitoring of kidney function is mandatory in order to identify nephrotoxicity early, allowing dosage adjustments or withdrawal of the offending drug.
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Affiliation(s)
- Jolanta Malyszko
- 2nd Department ofNephrology and Hypertension with Dialysis Unit, Medical University in Bialystok
| | - Klaudia Kozlowska
- 2nd Department ofNephrology and Hypertension with Dialysis Unit, Medical University in Bialystok
| | - Leszek Kozlowski
- Department of Oncological Surgery, Ministry of Interior Affairs Hospital, Bialystok, Poland
| | - Jacek Malyszko
- 1st Department of Nephrology and Transplantology with Dialysis Unit, Medical University in Bialystok, Bialystok, Poland
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11
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Bittar PG, Nickolich MS, Onwuemene OA. ASFA Category IV becomes Category I: Idiopathic thrombotic thrombocytopenic purpura in a patient with presumed gemcitabine-induced thrombotic microangiopathy. J Clin Apher 2017; 33:423-426. [PMID: 28940604 DOI: 10.1002/jca.21590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/28/2017] [Accepted: 09/12/2017] [Indexed: 11/11/2022]
Abstract
In the implementation of American Society for Apheresis national guidelines, the decision for therapeutic plasma exchange may be confounded by a clinical presentation that fits both a Category I and IV designation. We report the case of a 45-year-old female who presented with concern for a Category IV disorder, gemcitabine-induced thrombotic microangiopathy, and was ultimately diagnosed with a Category I disorder, idiopathic thrombotic thrombocytopenic purpura. This case highlights the importance of ruling out idiopathic TTP by a thorough evaluation for ADAMTS13 activity and inhibitor, even when an alternate thrombotic microangiopathy diagnosis may be likely.
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Affiliation(s)
- Peter G Bittar
- Duke University School of Medicine, Durham, North Carolina
| | - Myles S Nickolich
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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12
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Masias C, Vasu S, Cataland SR. None of the above: thrombotic microangiopathy beyond TTP and HUS. Blood 2017; 129:2857-63. [PMID: 28416509 DOI: 10.1182/blood-2016-11-743104] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/21/2017] [Indexed: 12/13/2022] Open
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are appropriately at the top of a clinician's differential when a patient presents with a clinical picture consistent with an acute thrombotic microangiopathy (TMA). However, there are several additional diagnoses that should be considered in patients presenting with an acute TMA, especially in patients with nondeficient ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity (>10%). An increased awareness of drug-induced TMA is also essential because the key to their diagnosis more often is an appropriately detailed medical history to inquire about potential exposures. Widespread inflammation and endothelial damage are central in the pathogenesis of the TMA, with the treatment directed at the underlying disease if possible. TMA presentations in the critically ill, drug-induced TMA, cancer-associated TMA, and hematopoietic transplant-associated TMA (TA-TMA) and their specific treatment, where applicable, will be discussed in this manuscript. A complete assessment of all the potential etiologies for the TMA findings including acquired TTP will allow for a more accurate diagnosis and prevent prolonged or inappropriate treatment with plasma exchange therapy when it is less likely to be successful.
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13
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Ritchie GE, Fernando M, Goldstein D. Rituximab to treat gemcitabine-induced hemolytic-uremic syndrome (HUS) in pancreatic adenocarcinoma: a case series and literature review. Cancer Chemother Pharmacol 2016; 79:1-7. [PMID: 27497971 DOI: 10.1007/s00280-016-3123-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/29/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE Hemolytic-uremic syndrome (HUS) is a rare side effect of gemcitabine, which is reported as having a high morbidity and mortality despite interventions with standard HUS therapies including plasmapheresis. The purpose of this report was to describe the successful treatment of gemcitabine-induced HUS (G-HUS) with rituximab. It also aims to summarize the literature regarding the morbidity and mortality of G-HUS in pancreatic adenocarcinoma depending on the treatment given, ultimately providing some guidance for beneficial therapies. METHODS This is a retrospective report of three patients with pancreatic adenocarcinoma who developed G-HUS and were treated with a combination of therapies including rituximab. RESULTS All three patients received a combination of therapies to treat their HUS. One patient appeared to have some benefit with plasmapheresis. Resolution occurred following one course of rituximab for all three patients. This resolution has been long lasting with a minimum of eighteen month's follow-up. Similarly, in our literature review a variety of therapies were utilized, but immune therapies appear to reverse HUS if other therapies are failing. CONCLUSION Rituximab can be an effective therapy for reversal of hemolysis and stabilization of renal function in G-HUS when other therapies fail.
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Affiliation(s)
- Georgia E Ritchie
- Department of Medical Oncology and Renal Medicine, Prince of Wales Hospital, Barker St, Randwick, NSW, 2031, Australia. .,Prince of Wales Clinical School, University of New South Wales Medical School, Kensington, Australia.
| | - Mangalee Fernando
- Department of Medical Oncology and Renal Medicine, Prince of Wales Hospital, Barker St, Randwick, NSW, 2031, Australia.,Prince of Wales Clinical School, University of New South Wales Medical School, Kensington, Australia
| | - David Goldstein
- Department of Medical Oncology and Renal Medicine, Prince of Wales Hospital, Barker St, Randwick, NSW, 2031, Australia.,Prince of Wales Clinical School, University of New South Wales Medical School, Kensington, Australia
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14
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Tognetti L, Garosi G, Rongioletti F, Fimiani M, Rubegni P. Livedo racemosa and hemolytic uremic syndrome induced by gemcitabine. Int J Dermatol 2016; 55:e555-6. [DOI: 10.1111/ijd.13062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/02/2015] [Accepted: 04/08/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Linda Tognetti
- Division of Medical, Surgical and Neurological Sciences; Department of Dermatology; University of Siena; Siena Italy
| | - Guido Garosi
- Nephrology and Dialysis Unit; University Hospital of Siena; Siena Italy
| | - Franco Rongioletti
- Section of Dermatology; Department of Health Sciences and Division of Pathology; University of Genoa; Genoa Italy
| | - Michele Fimiani
- Division of Medical, Surgical and Neurological Sciences; Department of Dermatology; University of Siena; Siena Italy
| | - Pietro Rubegni
- Division of Medical, Surgical and Neurological Sciences; Department of Dermatology; University of Siena; Siena Italy
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