What are the recommendations for a patient with impaired renal function, given a creatinine level of 185 micromol/L, who is planned to start chemotherapy with Flot (Fluorouracil)?

From the Guidelines

I strongly recommend assessing and optimizing the patient's hydration status and evaluating their renal function before starting chemotherapy with Flot (Fluorouracil), given their impaired renal function with a creatinine level of 185 micromol/L. To accurately evaluate renal function, serum creatinine alone is insufficient, and creatinine clearance should be calculated using the abbreviated modification of diet in renal disease or Cockcroft-Gault equations, as suggested by the international society of geriatric oncology clinical practice recommendations 1. When selecting chemotherapy agents, preference should be given to those that are less likely to be influenced by renal clearance, are minimally nephrotoxic, or have established methods for preventing renal toxicity, according to the study published in the Annals of Oncology 1. Key considerations for the patient's treatment plan include:

• Evaluating renal function using direct methods such as 51 Cr-EDTA or inulin measurement, especially in cases of extreme obesity, cachexia, or very high and low creatinine values
• Avoiding or minimizing coadministration of known nephrotoxic drugs
• Ensuring adequate hydration before and after chemotherapy administration
• Closely monitoring renal function throughout the treatment period Given the potential for nephrotoxicity associated with certain chemotherapy agents, it is crucial to prioritize the patient's renal function and adjust the treatment plan accordingly to minimize the risk of further renal damage.

From the Research

Recommendations for Chemotherapy with Flot (Fluorouracil)

Given the patient's impaired renal function with a creatinine level of 185 micromol/L, the following points should be considered:

• The patient's renal function should be closely monitored during chemotherapy, as chemotherapeutic drugs are excreted by the kidneys and are potentially nephrotoxic 2.
• The glomerular filtration rate (GFR) should be accurately measured, as it is critical for determining the appropriate dose of chemotherapy 3.
• Estimating GFR using an algorithm that converts plasma creatinine concentration to GFR, such as the MDRD equation, may not be reliable in patients with impaired renal function 2, 4.
• Direct measurement of GFR using a method such as the (51)Cr-EDTA plasma clearance technique may be necessary to ensure accurate dosing of chemotherapy 2.
• The patient's creatinine level should be interpreted with caution, as there are various causes of factitious elevation of creatinine that do not reflect a true reduction in GFR 5.

Considerations for Dosing Chemotherapy

• The dose of Flot (Fluorouracil) should be adjusted according to the patient's GFR, with lower doses used in patients with impaired renal function 2, 3.
• The patient's renal function should be closely monitored during chemotherapy, and the dose of Flot (Fluorouracil) should be adjusted as needed to minimize the risk of nephrotoxicity 2, 3.
• The use of newer methodologies that directly measure GFR may offer the opportunity to refine drug dosing and improve outcomes in patients with impaired renal function 3.