Consensus Report from Oncology Advisory Board Meeting

Strategies for Prevention and Management of CI-AKI and the Role of Contrast in Oncology CT Settings • 19 after the last chemotherapy administration was found to be an independent risk factor for AKI (odds ratio 4.3, p=0.016) . Additionally, there appeared to be a higher risk of AKI in patients with hypertension and those receiving the combination of irinotecan and bevacizumab. It was concluded that CI-AKI is a serious problem associated with the use of CM in oncological patients undergoing CT examination, and the risk is increased if CECT is performed within 45 days of the last chemotherapy. Cisplatin is a widely used potent chemotherapeutic agent. It, however, is nephrotoxic and is notorious for causing AKI. Renal tubular dysfunction and cumulative renal impairment are important dose-limiting effects of cisplatin, which were noted to be affecting >50% of patients in early trials (before intensive hydration regimens were introduced). A yet another Turkish study assessed the incidence of AKI in hospitalized cancer patients receiving cisplatin and aimed to develop a risk prediction methodology for cisplatin-induced AKI to guide decisions on patient management and preventive measures [4]. Acute kidney injury occurred in 29.4% of cisplatin-treated patients. The authors looked at several potential risk factors for AKI, including demographic and tumor characteristics, comorbidities, cancer treatments, and previous CM exposure. Only CM use was found to be statistically greater in patients with AKI than in those without it (p=0.01). A significant difference was found when CM was administered <1 week prior to cisplatin therapy vs no CM exposure (45.6% vs 19.4%; p=0.01) or CM administered >1 week prior to cisplatin therapy (45.6% vs 24.7%; p=0.02). Overall, there was 2.56-fold increased risk when CM was administered ≤1 week before cisplatin vs no CM exposure (Fig. 6). It was concluded that CM exposure within 1 week of cisplatin-based chemotherapy significantly increased the risk of AKI. The above-described clinical trials also indicate that proximity between chemotherapy and CM use increases the risk of AKI, regardless of whether CM use precedes or follows chemotherapy (Fig. 7) [3, 4]. Summary Increased recognition of AKI is recommended in the clinical setting as it is a potentially preventable complication of CM use and encourages best practice in risk assessment and prevention of AKI. Contrast medium administration was the most strongly associated risk factor for AKI. The incidence and severity of renal toxicity increases with repeated usage of cisplatin-based chemotherapy and can become irreversible. Death was more common in patients who developed AKI. The studies suggest that proximity between chemotherapy and CM use increases the risk of AKI. There is a clinical need to predict the probability of AKI to make decisions about patients’ management and take measures to prevent or mitigate the nephrotoxic effects. References 1. Salahudeen AK, Doshi SM, Pawar T, et al . Incidence Rate, Clinical Correlates, and Outcomes of AKI in Patients Admitted to a Comprehensive Cancer Center. Clin J Am Soc Nephrol . 2013;8:347–354. 2. Hong SI, Ahn S, Lee YS, et al . Contrast-induced nephropathy (CIN) in patients with active cancer undergoing contrast-enhanced computed tomography. Support Care Cancer . 2016 Mar;24(3):1011–1017. 3. Cicin I, Erdogan B, Gulsen E, et al . Incidence of CIN in hospitalized patients with cancer. Eur Radiol . 2014 Jan;24(1):184–190. 4. Sendur MA, et al . Administration of contrast media just before cisplatin- based chemotherapy increases cisplatin-induced nephrotoxicity. J BUON . 2013;18(1):274–80. Fig. 7. Cumulative effect of chemotherapy and CM on AKI. AKI: acute kidney injury (Cicin, et al : ≥25% or ≥0.5 mg/dl increase in serum creatinine within 72 hours of CECT; Sendur, et al : ≥25% decrease in glomerular filtration rate from baseline); CECT: contrast-enhanced computed tomography; CM: contrast medium Source: [3, 4] Fig. 6. AKI in cancer patients receiving cisplatin. Source: [4] JB6810 01-2016AKI in cancerpatients Cumulative effect of chemotherapy and CM on AKI 1. Cicin I et al. Eur Radiol 2014; 24 : 184 – 190. 2. Sendur MA et al. J BUON 2013; 18 : 274 – 280. AKI: acute kidney injury (Cicin et al : ≥25% or ≥0.5 mg/dl increase in seru creatinine within 72 hours of CECT; Sendur et al : ≥25% decrease in glomerular filtration rate from baseline); CECT: contrast-enhanced computed tomography; CM: contrast medium Chemotherapy before CECT (Cicin et al ) [3] 35.3 10.7 0 20 40 60 80 100 Chemotherapy within 45 days before CECT (n=34) Chemotherapy more than 45 days before CECT or never (n=56) Patients with AKI, % CECT before chemotherapy (Sendur et al ) [4] 45.6 19.4 0 20 40 60 80 100 Exposure to CM ≤7 days before cisplatin administration No exposure to CM before cisplatin administration Patients with AKI, % p=0.005 p=0.01 JB 6810 01-2016AKI in cancerpatients AKI in cancer patients receiving cisplatin Overall AKI rate: • 29% (58/197 patients) 2.56-fold increased risk with CM ≤1 week before cisplatin vs no CM exposure AKI: acute kidney i jury (≥25% decr ase in glomerular filtration rate from baseline) CM: contrast medium 45.6 24.7 19.4 0 20 40 60 80 100 ≤7 days >7 days Never Patients with AKI, % CM exposure before cisplatin administration p=0.01 p=0.02 Sendur MA et al. J BUON 2013; 18 : 274 – 280.