Consensus Report from Oncology Advisory Board Meeting

Imaging, especially with contrast-enhanced computed tomogra- phy (CECT), plays a pivotal role in cancer for diagnosis, staging, response assessment, and follow-up. Cancer patients are exposed to contrast medium (CM) many times, which may increase their already high risk of kidney impairment. Increased recognition of acute kidney injury (AKI) is recommended in the clinical setting as it is a potentially preventable complication of CM use and en- courages best practice in risk assessment and prevention of AKI. Clinical Evidence of AKI Risk in Cancer Patients An American study investigated the incidence and outcomes of AKI in cancer patients admitted to the M.D. Anderson Cancer Center over 3 months in 2006; admission was defined as hospital stay for >23 hours (including midnight) [1]. For inclusion in this cross-sectional analysis, the patients were required to have had serum creatinine (Cr) measurement at the time of admission and at least one more measurement during their hospital stay. A total of 3,558 patients met these criteria. AKI was diagnosed using modified Risk, Injury, Failure, Loss, ESRD (RIFLE) criterion of an increase in serum Cr of ≥50% during hospital stay. The rates of AKI and in-hospital mortality were noted to be 12% and 4.6%, respectively. AKI in comparison with no AKI significantly increased the risk of in-hospital mortality on both univariate and multivariate analyses (Fig. 1). Furthermore, worsening renal function, based on RIFLE categories, significantly increased the mortality risk. Approximately 55% of AKI cases occurred more than 48 hours after admission. AKI in comparison with no AKI was associated with approximately 2-fold increase in the length of hospital stay and hospital costs (Fig. 2). Contrast medium administration was the most strongly associated risk factor for AKI, as depicted in Figure 3. The frequency of AKI was noted to be higher with agents already known to be associated with nephrotoxicity, such as cisplatin, carboplatin, methotrexate, interleukin-2, rituximab, and ifosfamide. Review of Clinical Evidence of Contrast Induced- Acute Kidney Injury (CI-AKI) in Oncology Settings Based on the results of the meta-analysis, the investigators concluded that the rate of AKI is higher in cancer patients than non-cancer patients, with CM as the strongest risk factor for AKI, and an important step in minimizing the burden of AKI on healthcare resources in identification of patients at high risk. Korean experts have also investigated the rate of AKI in cancer patients and potential predictors of CI-AKI in them [2]. They performed a retrospective analysis of 820 patients presenting at the emergency department at a tertiary care academic medical centre between October 2014 and March 2015. The studied patients had active cancer, were without CKD and had normal or near-normal serum Cr at baseline (≤1.5 mg/dl). These patients underwent CECT with Fig. 1. Mortality in cancer patients with AKI: MD Anderson analysis. Source: [1] Fig. 2. Healthcare use in cancer patients with AKI: MD Anderson analysis. Source: [1] JB6810 01-2016AKI in cancerpatients Mortality in cancer patients with AKI: MD Anderson analysis 15.9% 2.7% 0 20 40 60 80 100 Patients with AKI (n=427) Patients without AKI (n=3,131) In-hospital mortality, % In-hospital mortality: 4.6% overall Odds ratio with AKI vs no AKI: • 7.41 (95% CI 5.36 – 10.24), univariate analysis • 4.47 (95% CI 3.16 – 6.32), multivariate analysis Salahudeen AK et al. Clin J Am Soc Nephrol 2013; 8 : 347 – 354. AKI: acute kidney injury (≥50% increase in serum creatinine) CI: confidence interval p<0.001 JB 6810 01-2016 AKI in cancerpatients Mortality in cancer patients with AKI: MD Anderson analysi 15.9% 2.7% 0 20 40 60 80 100 Patients with AKI (n=427) Patients without AKI (n=3,131) In-hospital mortality, % In-hospital mortality: 4.6% overall Odds ratio with AKI vs no AKI: • 7.41 (95% CI 5.36 – 10.24), univariate analysis • 4.47 (95% CI 3.16 – 6.32), multivariate analysis Salahudeen AK et al. Clin J Am Soc Nephrol 2013; 8 : 347 – 354. AKI: acute kidney injury (≥50% increase in serum creatinine) CI: confidence interval p<0.001 JB6810 01-2016AKI in cancerpatients Length of hospital stay Total hospital costs 40,164 82,835 0 20,000 40,000 60,000 80,000 100,000 Patients without AKI Patients with AKI Median hospital costs, US$ Healthcare use in cancer patients with AKI: MD Anderson analysis 5 10 0 2 4 6 8 10 12 Patients without AKI Patients with AKI Median hospitalisation, days Salahudeen AK et al. Clin J Am Soc Nephrol 2013; 8 : 347 – 354. AKI: acute kidney injury (≥50% increase in serum creatinine) p<0.001 p<0.001 • Median length of stay increased 100% and median hospital costs increased 106% in patients with AKI vs those without AKI