Management of a 90-Year-Old Male Patient with Suspected Bladder Cancer and Abnormal Laboratory Values
Today, you should obtain additional laboratory tests to evaluate liver function abnormalities and anemia, refer to nephrology for management of chronic kidney disease, and consider carboplatin-based chemotherapy regimens given the patient's renal impairment.
Priority Laboratory Evaluations
- Obtain liver function tests including lactate dehydrogenase (LDH), alkaline phosphatase, and calcium to evaluate for potential metastatic disease 1
- Order additional imaging studies (CT scan of chest, abdomen, and pelvis) to complete staging evaluation for suspected bladder cancer 1
- Consider bone scan if alkaline phosphatase is elevated or if the patient reports bone pain 1
Management of Abnormal Laboratory Values
Elevated Liver Enzymes
- ALT of 137 U/L and AST of 78 U/L with normal bilirubin suggest non-alcoholic fatty liver disease, consistent with ultrasound findings 1
- Monitor liver function tests closely as they may impact chemotherapy options 1
Chronic Kidney Disease
- Patient has Stage 3B CKD with creatinine of 1.94 mg/dL and eGFR of 35 ml/min 1
- Refer to nephrology for management of CKD as appropriate nephrology referral may help prevent further deterioration of renal function 1
- Consider cystatin C measurement to more accurately assess true renal function, as creatinine may not be reliable in elderly patients with decreased muscle mass 2
Anemia
- Hemoglobin of 11.9 g/dL represents mild anemia in a male patient 3
- Anemia is likely multifactorial due to chronic kidney disease and possibly bladder cancer 4
- Consider iron studies (ferritin, transferrin saturation) to assess iron stores 3
- Erythropoiesis-stimulating agents may be considered after iron status evaluation, but use with caution in cancer patients 5
Treatment Considerations for Bladder Cancer
Staging Considerations
- Complete staging with CT scan of chest, abdomen, and pelvis is essential before finalizing treatment plan 1
- Biopsy results from the urologist will determine definitive treatment approach 1
Treatment Options Based on Renal Function
- Patient's renal impairment (eGFR 35 ml/min) makes him ineligible for cisplatin-based chemotherapy 1
- For patients unfit for cisplatin due to impaired renal function, carboplatin/gemcitabine (CG) is the preferred regimen with a more favorable toxicity profile 1, 6
- Single-agent therapy (gemcitabine or taxane) may be considered if the patient cannot tolerate combination therapy 6
Age and Comorbidity Considerations
- Advanced age (90 years) combined with CKD and anemia requires careful consideration of treatment toxicity versus benefit 6
- Performance status assessment is crucial for determining treatment intensity 1
- Palliative approaches including radiotherapy may be appropriate for symptom control 1, 6
Follow-up Plan
- Schedule follow-up within 1-2 weeks to review results of additional testing and urologist consultation 1
- Monitor renal function, electrolytes, and complete blood count regularly during treatment 1
- Adjust treatment plan based on biopsy results, complete staging, and patient's performance status 1
Common Pitfalls to Avoid
- Don't assume elevated liver enzymes are due to metastatic disease without complete evaluation 1
- Avoid cisplatin-based regimens in patients with impaired renal function as they may worsen kidney function 1, 6
- Don't overlook the importance of addressing anemia, as it can impact quality of life and treatment tolerance 3, 7
- Remember that serum creatinine may underestimate renal impairment in elderly patients with decreased muscle mass 2