Consensus Report from Oncology Advisory Board Meeting

Cancer is the fourth leading cause of death in India. Contrast-based imaging plays a pivotal role in diagnosis, staging, response assessment, and follow-up of cancer patients. However, contrast-induced renal toxicity represents an important cause of acute kidney injury (AKI) in these patients, whose renal function is already compromised due to the disease per se, chemotherapy, comorbidities and other factors. Onco-nephrology is a rapidly growing area of nephrology where kidney disease in cancer patients has become an important source of consultations, with the trend occurring over the last 10–15 years [1]. A substantial proportion of patients receiving contrast media (CM) are at risk of CI-AKI — 1-7% of patients overall [2] 30–37% of patients with underlying chronic kidney disease [3, 4] >50% of patients with multiple additional risk factors* [4]. Vast database shows the rate of contrast-induced AKI (CI- AKI) in cancer patients to range between 8-30% [5-9]. This high variability in the rate of CI-AKI is largely attributable to inhomogeneity in the terminology and definition of CI-AKI. It is, therefore, important to increase awareness about CI-AKI, as well as homogenize the terminology and definition to develop best practices protocol and mitigate the damage induced by CM. According to the most recent guidelines, CI-AKI may be defined as an increase in serum creatinine (Cr) of ≥ 0.3 mg/dl, or of ≥ 1.5–1.9 times baseline (Kidney Disease: Improving Global Outcomes [KDIGO] definition of AKI) in the 48–72 h following CM administration. CI-AKI in oncology patients is associated with increased mortality, duration of hospital stays and hospital cost. Overall, early recognition of CI-AKI is recommended as it is a potentially preventable complication of CM use. The choice of CM greatly influences the risk of CI-AKI in cancer patients. The osmolality of CM is a very important factor in preventing CI-AKI. Evolution of CT contrast has always focused on its osmolality. Closer the osmolality of the CM to that of blood, lesser will be the negative impact on volume balance. Also, care must be taken in cancer patients in terms of maintaining normal osmotic pressure in veins in order to minimize contrast-associated pain, which can be severe in oncology patients. It is also important to protect the kidneys from the ill-effects of CM. Hence, the choice of CM in these patients is of utmost importance. Despite significant incidence of CI-AKI in cancer patients, there are only a few International expert groups that have provided recommendations on the management of CI-AKI in these patients. American Society of Nephrology (ASN) has laid down strong guidelines in the onco-nephrology curriculum around CI-AKI. These suggestions could be extrapolated to cancer patients . Overall, while International guidelines on prevention and management of CI-AKI are available, currently there is an urgent need for developing an India-specific, multi- specialty consensus report/management algorithm for best practices on CI-AKI management in cancer patients. This booklet presents consensus report through panel discussions on the strategies for management of CI-AKI. References 1. Perazella M, Rosner M. Onco-Nephrology: Growth of the Kidney- Cancer Connection. Available at https://www.asn-online.org/education/ distancelearning/curricula/onco/Chapter1.pdf. Accessed on 14/05/18. 2. Berg KJ. Scand J Urol Nephrol. 2000;34:317–322. 3. Gruberg L, et al. J Am Coll Cardiol. 2000;5:1542–1548. 4. Mehran R, et al. J Am Coll Cardiol. 2004;44:1393–1399. 5. Hong SL, et al . Support Care Cancer . 2016; 24(3):1011–1017. 6. Salahudeen AK, et al . Clin J Am Soc Nephrol. 2013; 8:347–354. 7. Cicin I, et al . Eur Radiol . 2014;24(1):184–190. 8. Ng CS, et al . AJR Am J Roentgenol . 2010;195(2):414–422. 9. Sendur MA, et al . J BUON . 2013;18(1):274–280. Synopsis *Additional risk factors include hypotension, intra-aortic balloon pump, congestive heart failure, age >75 years, anaemia, and diabetes.