How is chemotherapy nephropathy managed in cancer treatment?

Management of Chemotherapy Nephropathy in Cancer Treatment

The management of chemotherapy nephropathy requires early identification of nephrotoxicity, preventive strategies, and specific interventions tailored to the type of kidney injury, with the primary goal of preserving renal function while maintaining effective cancer treatment. 1

Types of Chemotherapy-Induced Kidney Injury

• Cytotoxic chemotherapeutic drugs are the most common cause of kidney injury, with platinum-containing compounds (especially cisplatin) being particularly nephrotoxic 1
• Acute tubular injury (ATI) is the most common kidney lesion pattern in chemotherapy nephropathy 1
• Other kidney lesions associated with chemotherapy include:
  • Thrombotic microangiopathy (TMA) 1
  • Podocytopathies 1
  • Tubulopathies (Fanconi syndrome, salt and magnesium wasting, nephrogenic diabetes insipidus) 1
  • Acute/chronic tubulointerstitial nephritis 1, 2
  • Crystalline nephropathy 1

Preventive Strategies

For Cisplatin-Induced Nephrotoxicity

• Administer cisplatin using a 6-8 hour infusion with intravenous hydration and mannitol to reduce nephrotoxicity 3
• Monitor renal function closely, as renal toxicity is first noted during the second week after a dose and is manifested by elevations in BUN, creatinine, serum uric acid, and/or decreased creatinine clearance 3
• Ensure renal function returns to normal before administering another dose of cisplatin 3
• Elderly patients require special attention as they may be more susceptible to nephrotoxicity 3

For Contrast-Enhanced Imaging During Cancer Treatment

• Do not withhold contrast media CT scans if benefits outweigh risks, even in patients with CKD 1
• For patients with CKD G4-G5, consider reducing contrast dose and using iso-osmolar contrast media 1
• Consider periprocedural IV saline and/or oral hydration depending on GFR level, although evidence for this practice is mixed 1
• Be aware that patients undergoing CT within 45 days after completing chemotherapy may have a higher risk of contrast-induced nephropathy 1

Monitoring and Early Detection

• Assess kidney function, acid-base balance, and electrolytes at diagnosis of cancer and regularly during treatment 1
• For patients developing AKI, add spot urine protein-to-creatinine ratio to standard assessments 1
• Use the CKD-EPI equation for estimating GFR in cancer patients, as it is the most accurate and least biased estimator 1
• Be aware that some agents (e.g., ALK inhibitors like crizotinib and CDK4/6 inhibitors like abemaciclib) may cause non-injurious increases in serum creatinine due to inhibition of creatinine secretion 1

Management of Specific Nephrotoxicities

Acute Tubular Injury (ATI)

• Provide supportive care with focus on fluid management 2
• Remove or reduce the dose of the nephrotoxic agent 2, 4
• Monitor for acid-base or electrolyte disturbances even without changes in kidney function 2

Acute Interstitial Nephritis (AIN)

• Discontinue the offending agent as the primary intervention 2
• Consider corticosteroid therapy, especially for drug-induced cases 2
• For immune checkpoint inhibitor-related AIN, high-dose methylprednisolone (1 mg/kg) is recommended 2

Electrolyte Disorders

• Monitor for hypomagnesemia, particularly with epidermal growth factor inhibitors like cetuximab 1
• Address salt wasting and other tubulopathies with appropriate electrolyte replacement 1

Special Considerations for Different Agent Classes

Targeted Cancer Agents

• Anti-angiogenesis drugs: Monitor for new or worsened hypertension, proteinuria, and TMA 1
• B-Raf and ALK inhibitors: Watch for AKI (ATI and AIN) 1
• Proteasome inhibitors: Monitor for TMA 1

Cancer Immunotherapies

• Immune checkpoint inhibitors: Monitor for AKI (primarily due to AIN) and proteinuria 1
• Interferon: Watch for various types of glomerulonephritis and TMA 1
• High-dose interleukin-2: Monitor for cytokine storm syndrome and capillary leak syndrome with prerenal AKI 1

Anemia Management in Chemotherapy Nephropathy

• Target hemoglobin levels of 9.0-11.5 g/dl for CKD patients with malignancy 1
• Use nephrologic doses of erythropoietin-stimulating agents (ESAs) for cancer patients with CKD 1
• Be aware that ESA treatment in cancer patients may have implications for mortality and overall survival 1

Pitfalls and Caveats

• Do not withhold beneficial diagnostic studies due to exaggerated fear of radiocontrast nephropathy 1
• Recognize that some agents cause non-injurious increases in serum creatinine that should not be confused with genuine renal toxicity 1
• Consider temporary discontinuation of ACE inhibitors and ARBs during cancer treatment to reduce AKI risk 1
• Nephrotoxicity should be included in the surveillance of patients treated with immunotherapy and reported in drug registries 1