Renal Emergencies in the Cancer Patient: A Case-Based Session (April 13, 2018)

Chair: Mark Perazella

Three classes of agents are generally employed in the treatment of patients with cancer:

• Conventional chemotherapeutic agents
• Targeted anti-cancer therapies
• Cancer immunotherapies

Methotrexate-related renal injury

• Nephrotoxicity occurs with high-dose therapy (1-12 g/m²), rarely with long-term conventional dosing: AKI is primarily from acute tubular injury
• Precipitation of MTX/7-OH MTX crystals in distal tubular lumens
• Direct tubular injury (formation of oxygen radicals associated with adenosine deaminase activity)
• Treatment includes High-flux hemodialysis and Glucarbidase (carboxypeptidase-G2)
• Key reference: Perazella MA and Luciano RL, 2015

Anti-VEGF therapy

• Usually leads to HTN, proteinuria, and TMA. FSGS and MCD have also been reported mainly with Tyrosine kinase inhibitors
• Severe cases of HTN and nephrotic syndrome require treatment changes
• Key reference: Gurevich F and Perazella MA, 2009

Immunotherapy

• Anti-CTLA-4 and PD-1 and PDl1 inhibitors: Classic findings are AIN and, in some cases, rare immune complex GN
• Treatment with steroids usually reverses findings
• Transplant patients can have severe cases of rejection
• Key references: Jhaveri KD and Perazella MA, 2018; Wanchoo R et al, 2017

Chimeric Antigen Receptor T-cells therapy

• This new form of therapy can lead to a cytokine storm and prerenal AKI and some cases of TLS and ATN
• Anti Il-6 agents are used in treatment of the cytokine storm
• Key reference: Jhaveri KD and Rosner MH, 2018

– Post prepared by Kenar Jhaveri, AJKD Social Media Advisory Board member. Follow him @kdjhaveri.

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The NKF Spring Clinical Meeting abstracts are available in the April 2018 issue of AJKD. Check out more AJKDBlog coverage of #NKFClinicals!