Consensus Report from Oncology Advisory Board Meeting

Strategies for Prevention and Management of CI-AKI and the Role of Contrast in Oncology CT Settings • 9 Table 3. Drugs causing electrolyte abnormalities. Drugs Pathological findings Clinical syndromes Epithelial growth factor (EGFR) antibody y y Inhibition of transient receptor potential cation channel, subfamily M, member 6 (TRPM6) in distal convoluted tubule y y Hypomagnesemia Cetuximab Panitumumab Imatinib y y Unknown y y Hypophosphatemia American Society of Nephrology; Onco-Nephrology Curriculum;2016. Fig. 2. Risk factors for AKI in patients with cancer. Intravenous iodinated contrast is a common cause of AKI in patients with cancer [1]. The risk for CI-AKI is likely to be relatively high among oncology patients. 2,3 Exposure to nephrotoxic agents – e.g. cytotoxic drugs, antibiotics, and analgesics [2] Complicated by other issues – e.g. anaemia, hypercalcaemia, and hyperuricaemia [2] Compromised by advancing age – predisposed to dehydration [3] and declining renal function [4] Even when baseline SCr is normal/near normal, a significant portion of cancer patients still seem to be at risk for CI-AKI [3] – with creatinine, a by-product of muscle metabolism, a low muscle mass may result in a low SCr that masks underlying renal insufficiency [3] – renal function tests may remain within normal ranges, despite up to 50% of nephrons being lost and the kidney being susceptible to further insults [5] 1. American Society of Nephrology. Onco-Nephrology Curriculum. Available at: www. asn-online.org/education/distancelearning/curricula/onco/Accessed on: 15.08.16. 2. Cicin I, et al. Eur Radiol. 2014;24(1):184-90. 3. Hong SI, et al. Support Care Cancer. 2016;24(3):1011-7. 4. American Society of Nephrology. Geriatric Nephrology Curriculum. Available at: www.asn-online.org/education/distancelearning/curricula/geriatrics/Accessed on: 15.08.16. 5. Sharma A, et al. Nephron Clin Pract. 2014;127(1-4):94-100. Multiple Risk Factors for AKI in Cancer Patients Patients with cancer are at an increased risk of AKI. Manifestations of kidney disease from chemotherapy and targeted therapy include AKI, proteinuria, electrolytes derangements, and thrombotic microangiopathy (TMA). Nearly one-half of patients with multiple myeloma have evidence of AKI on initial presentation, and 10% require dialysis [1]. A range of factors, including patient characteristics, such as age and comorbidities, as well as healthcare interventions may increase the risk of AKI in them. It may be possible to modify some of these factors before contrast-enhanced imaging, depending on the timeframe available (e.g. control of glucose levels and blood pressure). Figure 2 depicts multiple risk factors for AKI in oncology settings. At this juncture, it would be worthwhile to mention that creatinine is a by-product of muscle metabolism. A low muscle mass in cachexic cancer patients may result in a low serum creatinine (Cr), which may mask the underlying renal insufficiency. Summary Oncology patients might have higher incidence of CI-AKI compared to non-oncology patients. The benefits of contrast imaging, especially in oncology, have increased drastically. It is considered as “a ‘guiding hand’ of personalized medicine for cancer care.”The data on association of CI-AKI with chemotherapy is accumulating and research shows that certain chemotherapeutic agents predispose to CI-AKI more than others. Despite advances in diagnosis, treatment, and prevention of chemotherapy-induced kidney injury, significant challenges remain about this entity. Future research should be directed towards the development of antidote agents that protect normal cells and allow continuation of chemotherapy without compromising antitumor effects. Reference 1. Lahoti A, Humphreys B. AKI Associated with Malignancies. Available at https://www.asn-online.org/education/distancelearning/curricula/onco/ Chapter3.pdf. Accessed on 14/05/18.