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Rosner MH, DeMauro Renaghan A. Disorders of Divalent Ions (Magnesium, Calcium, and Phosphorous) in Patients With Cancer. Adv Chronic Kidney Dis 2021; 28:447-459.e1. [PMID: 35190111 DOI: 10.1053/j.ackd.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
Disorders of the divalent ions (magnesium, calcium, and phosphorous) are frequently encountered in patients with cancer. Of these, hypomagnesemia, hypocalcemia, hypercalcemia, and hypophosphatemia are seen most commonly. These electrolyte disturbances may be related to the underlying malignancy or due to side effects of anticancer therapy. When caused by a paraneoplastic process, these abnormalities may portend a poor prognosis. Importantly, the development of severe electrolyte derangements may be associated with symptoms that negatively impact quality of life, preclude the administration of critical chemotherapeutic agents, or lead to life-threatening complications that require hospitalization and emergent treatment. In accordance, prompt recognition and treatment of these disorders is key to improving outcomes in patients living with cancer. This review will discuss selected derangements of the divalent ions seen in this population, with a focus on paraneoplastic and therapy-associated etiologies.
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Flythe JE, Assimon MM, Tugman MJ, Chang EH, Gupta S, Shah J, Sosa MA, Renaghan AD, Melamed ML, Wilson FP, Neyra JA, Rashidi A, Boyle SM, Anand S, Christov M, Thomas LF, Edmonston D, Leaf DE. Characteristics and Outcomes of Individuals With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care Units in the United States. Am J Kidney Dis 2021; 77:190-203.e1. [PMID: 32961244 PMCID: PMC7501875 DOI: 10.1053/j.ajkd.2020.09.003] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022]
Abstract
RATIONALE & OBJECTIVE Underlying kidney disease is an emerging risk factor for more severe coronavirus disease 2019 (COVID-19) illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing chronic kidney disease (CKD) and investigated the association between the degree of underlying kidney disease and in-hospital outcomes. STUDY DESIGN Retrospective cohort study. SETTINGS & PARTICIPANTS 4,264 critically ill patients with COVID-19 (143 patients with pre-existing kidney failure receiving maintenance dialysis; 521 patients with pre-existing non-dialysis-dependent CKD; and 3,600 patients without pre-existing CKD) admitted to intensive care units (ICUs) at 68 hospitals across the United States. PREDICTOR(S) Presence (vs absence) of pre-existing kidney disease. OUTCOME(S) In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/cardiac arrest, thromboembolic events, major bleeds, and acute liver injury (secondary). ANALYTICAL APPROACH We used standardized differences to compare patient characteristics (values>0.10 indicate a meaningful difference between groups) and multivariable-adjusted Fine and Gray survival models to examine outcome associations. RESULTS Dialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median of 4 [IQR, 2-9] days for maintenance dialysis patients; 7 [IQR, 3-10] days for non-dialysis-dependent CKD patients; and 7 [IQR, 4-10] days for patients without pre-existing CKD). More dialysis patients (25%) reported altered mental status than those with non-dialysis-dependent CKD (20%; standardized difference=0.12) and those without pre-existing CKD (12%; standardized difference=0.36). Half of dialysis and non-dialysis-dependent CKD patients died within 28 days of ICU admission versus 35% of patients without pre-existing CKD. Compared to patients without pre-existing CKD, dialysis patients had higher risk for 28-day in-hospital death (adjusted HR, 1.41 [95% CI, 1.09-1.81]), while patients with non-dialysis-dependent CKD had an intermediate risk (adjusted HR, 1.25 [95% CI, 1.08-1.44]). LIMITATIONS Potential residual confounding. CONCLUSIONS Findings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies in this vulnerable population.
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Affiliation(s)
- Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC.
| | - Magdalene M Assimon
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, NC
| | - Matthew J Tugman
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, NC
| | - Emily H Chang
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, NC
| | - Shruti Gupta
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jatan Shah
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Marie Anne Sosa
- Division of Nephrology, Department of Medicine, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Amanda DeMauro Renaghan
- Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Michal L Melamed
- Department of Medicine/Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - F Perry Wilson
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, CT
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Arash Rashidi
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Suzanne M Boyle
- Section of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Shuchi Anand
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Marta Christov
- Division of Nephrology, Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Leslie F Thomas
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic in Arizona, Scottsdale, AZ
| | - Daniel Edmonston
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Renal Section, Durham VA Medical Center, Durham, NC
| | - David E Leaf
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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Cortazar FB, Kibbelaar ZA, Glezerman IG, Abudayyeh A, Mamlouk O, Motwani SS, Murakami N, Herrmann SM, Manohar S, Shirali AC, Kitchlu A, Shirazian S, Assal A, Vijayan A, Renaghan AD, Ortiz-Melo DI, Rangarajan S, Malik AB, Hogan JJ, Dinh AR, Shin DS, Marrone KA, Mithani Z, Johnson DB, Hosseini A, Uprety D, Sharma S, Gupta S, Reynolds KL, Sise ME, Leaf DE. Clinical Features and Outcomes of Immune Checkpoint Inhibitor-Associated AKI: A Multicenter Study. J Am Soc Nephrol 2020; 31:435-446. [PMID: 31896554 PMCID: PMC7003302 DOI: 10.1681/asn.2019070676] [Citation(s) in RCA: 199] [Impact Index Per Article: 49.8] [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: 07/09/2019] [Accepted: 11/21/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Despite increasing recognition of the importance of immune checkpoint inhibitor-associated AKI, data on this complication of immunotherapy are sparse. METHODS We conducted a multicenter study of 138 patients with immune checkpoint inhibitor-associated AKI, defined as a ≥2-fold increase in serum creatinine or new dialysis requirement directly attributed to an immune checkpoint inhibitor. We also collected data on 276 control patients who received these drugs but did not develop AKI. RESULTS Lower baseline eGFR, proton pump inhibitor use, and combination immune checkpoint inhibitor therapy were each independently associated with an increased risk of immune checkpoint inhibitor-associated AKI. Median (interquartile range) time from immune checkpoint inhibitor initiation to AKI was 14 (6-37) weeks. Most patients had subnephrotic proteinuria, and approximately half had pyuria. Extrarenal immune-related adverse events occurred in 43% of patients; 69% were concurrently receiving a potential tubulointerstitial nephritis-causing medication. Tubulointerstitial nephritis was the dominant lesion in 93% of the 60 patients biopsied. Most patients (86%) were treated with steroids. Complete, partial, or no kidney recovery occurred in 40%, 45%, and 15% of patients, respectively. Concomitant extrarenal immune-related adverse events were associated with worse renal prognosis, whereas concomitant tubulointerstitial nephritis-causing medications and treatment with steroids were each associated with improved renal prognosis. Failure to achieve kidney recovery after immune checkpoint inhibitor-associated AKI was independently associated with higher mortality. Immune checkpoint inhibitor rechallenge occurred in 22% of patients, of whom 23% developed recurrent associated AKI. CONCLUSIONS This multicenter study identifies insights into the risk factors, clinical features, histopathologic findings, and renal and overall outcomes in patients with immune checkpoint inhibitor-associated AKI.
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Affiliation(s)
- Frank B. Cortazar
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts;,New York Nephrology Vasculitis and Glomerular Center, Albany, New York
| | - Zoe A. Kibbelaar
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ilya G. Glezerman
- Renal Service, Memorial Sloan Kettering Cancer Center and Weil Cornell Medical College, New York, New York
| | - Ala Abudayyeh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Omar Mamlouk
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shveta S. Motwani
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts;,Dana Farber Cancer Institute, Boston, Massachusetts
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | - Anushree C. Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Abhijat Kitchlu
- Division of Nephrology, University of Toronto, University Health Network, Ontario, Canada
| | | | - Amer Assal
- Division of Hematology-Oncology, Columbia University Medical Center, New York, New York
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri
| | - Amanda DeMauro Renaghan
- Division of Nephrology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - David I. Ortiz-Melo
- Division of Nephrology, Duke University Medical Center, Durham, North Carolina
| | - Sunil Rangarajan
- Divisions of Nephrology and Hematology-Oncology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - A. Bilal Malik
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Jonathan J. Hogan
- Division of Nephrology, Hypertension and Electrolytes, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alex R. Dinh
- Division of Nephrology, Hypertension and Electrolytes, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Daniel Sanghoon Shin
- Division of Hematology and Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California;,Division of Hematology and Oncology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Kristen A. Marrone
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zain Mithani
- Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, Florida
| | - Douglas B. Johnson
- Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Afrooz Hosseini
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Deekchha Uprety
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Shreyak Sharma
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kerry L. Reynolds
- Division of Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Meghan E. Sise
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Renaghan AD, Jaimes EA, Malyszko J, Perazella MA, Sprangers B, Rosner MH. Acute Kidney Injury and CKD Associated with Hematopoietic Stem Cell Transplantation. Clin J Am Soc Nephrol 2019; 15:289-297. [PMID: 31836598 PMCID: PMC7015091 DOI: 10.2215/cjn.08580719] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hematopoietic stem cell transplantation is a life-saving therapy for many patients with cancer, as well as patients with some nonmalignant hematologic disorders, such as aplastic anemia, sickle cell disease, and certain congenital immune deficiencies. Kidney injury directly associated with stem cell transplantation includes a wide range of structural and functional abnormalities, which may be vascular (hypertension, thrombotic microangiopathy), glomerular (albuminuria, nephrotic glomerulopathies), and/or tubulointerstitial. AKI occurs commonly after stem cell transplant, affecting 10%-73% of patients. The cause is often multifactorial and can include sepsis, nephrotoxic medications, marrow infusion syndrome, hepatic sinusoidal obstruction syndrome, thrombotic microangiopathy, infections, and graft versus host disease. The risk of post-transplant kidney injury varies depending on patient characteristics, type of transplant (allogeneic versus autologous), and choice of chemotherapeutic conditioning regimen (myeloablative versus nonmyeloablative). Importantly, AKI is associated with substantial morbidity, including the need for KRT in approximately 5% of patients and the development of CKD in up to 60% of transplant recipients. AKI has been associated universally with higher all-cause and nonrelapse mortality regardless of transplant type, and studies have consistently shown extremely high (>80%) mortality rates in those patients requiring acute dialysis. Accordingly, prevention, early recognition, and prompt treatment of kidney injury are essential to improving kidney and patient outcomes after hematopoietic stem cell transplantation, and for realizing the full potential of this therapy.
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Affiliation(s)
| | - Edgar A Jaimes
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Mark A Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut.,Veterans Affairs Medical Center, West Haven, Connecticut
| | - Ben Sprangers
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Belgium; and.,Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
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