Consensus Report from Oncology Advisory Board Meeting

Few International expert groups have provided recommen- dations on the management of acute kidney injury (AKI) specifically in cancer patients. Onco-nephrology curriculum of American Society of Nephrology (ASN) offers the following guidance on prevention and management of AKI and contrast-induced nephropathy (CIN) [1]: y y The Kidney Disease Improving Global Outcomes (KDIGO) work group has combined components of the RIFLE and AKIN classifications, to define AKI as: (1) a rise in serum creatinine (Cr) ≥ 0.3 mg/dL within 48 hours; (2) ≥ 1.5 times increase in serum Cr values from baseline within the prior 7 days; or (3) a urine output of < 0.5 mL/kg/h for 6 hours. y y Estimated glomerular filtration rate (eGFR) provides resonable estimate of renal function. y y In adults, the CKD-EPI or MDRD formula are most commonly used to estimate GFR . y y In children, the revised Schwartz formula is used to estimate GFR. y y Use the lowest dose of CM consistent with a diagnostic result. y y Risk factors for AKI include underlying CKD, diabetes mellitus, volume depletion, and co-administration of other nephrotoxins. y y In addition, high osmolar (>1400 mOsm/kg) and low osmolar (600–800 mOsm/kg) contrast agents are associated with a higher incidence of AKI in comparison to iso-osmolar (300 mOsm/kg) contrast . y y Preventive measures should be taken in patients with GFR, <60 mL/min including limiting contrast volume, using iso-osmolar contrast, prehydration with normal saline, and discontinuation of concurrent nephrotoxic agents. y y Several meta-analyses have examined the use of N-acetylcysteine in the prevention of CIN but results remain inconclusive, as is the use of bicarbonate. There is insufficient evidence to recommend hemodialysis or hemofiltration for the prevention or treatment of CIN. Note on International Guidelines on AKI Management In a very recent consensus statement from Italy, titled “Methods to Address Computed Tomography-Related Risk Factors in Oncology Patients: An Expert Opinion Based on Current Evidence” [2], practical methods to reduce risks in cancer patients related to CT examinations were derived from expert opinions based on the current literature, recently developed guidelines and technological advancements. The consensus mentions the following on the choice of CM in cancer patients: y y The use of CM with the lowest osmolarity is advisable, particularly in high-risk patients. Patients with cancer must be considered as a high-risk group , and iso-osmolar contrast media (IOCM) should be considered the first choice , particularly if the patients are affected by at least one of the following conditions: intra-arterial injection, diabetes mellitus, liver diseases, hypertension, pre-existing CKD (serumCr levels >2 mg/dL), hematocrit <30%, age over 70 years, cardiac diseases, and recent myocardial infarction (<1 month). Iodixanol is the first choice for patients with myeloma or patients with monoclonal gammopathies, independent of additional risk factors . Figure 1 depicts algorithm for the prevention and management of CI-AKI in interventional cardiac settings, as proposed by Peter McCullough and his colleagues. Taking into consideration the multitude of risk factors in cancer patients, there is a compelling need to develop this kind of an algorithm for cancer patients as well. Also, there is an emergent need for developing an India-specific, multi- specialty consensus report/management algorithm for best practices on CI-AKI management in oncology patients. References 1. Perazella MA. Online Curricula: Onco-Nephrology. Available at htt- ps:// www.asn-online.org/education/distancelearning/curricula/onco/ Accessed on 24/05/18. 2. Maestro LD, Laghi A, Ronco C. Methods to Address Computed Tomography-Related Risk Factors in Oncology Patients: An Expert Opinion Based on Current Evidence. Blood Purif . 2018;46:56–69.