Importance of monitoring renal function in patients with cancer

doi:10.1016/j.ctrv.2011.05.001

Cancer Treatment Reviews

Volume 38, Issue 3, May 2012, Pages 235-240

https://doi.org/10.1016/j.ctrv.2011.05.001 Get rights and content

Abstract

Monitoring renal function in patients with solid tumors and hematologic malignancies is vital to the safe administration of therapeutic agents. Renal impairment is frequent in elderly patients (i.e., age ⩾ 65) with cancer, despite normal serum creatinine levels in most patients. Because serum creatinine levels do not accurately reflect clearance rates, renal function should be estimated by calculation (either Cockcroft-Gault or abbreviated Modification of Diet in Renal Disease [aMDRD] equations) or by measuring creatinine clearance using a 24-h urine collection. Additionally, patients with cancer often have preexisting comorbidities or other risk factors that increase the probability of renal impairment before receiving potentially nephrotoxic therapies. Patient age, preexisting renal dysfunction, and chronic comorbidities (e.g., diabetes, kidney disease, hypertension, and cardiac insufficiency) all contribute to the risk of renal impairment. Furthermore, both cancer and its therapies may lead to renal impairment. A number of cancer therapy agents are nephrotoxic, including chemotherapy agents, molecular targeted agents, pain management agents, radiopharmaceuticals, contrast agents used in radiology, and antiresorptive agents, and contrast agents used in radiology are nephrotoxic as well. Undetected decreases in clearance rates by the kidneys can greatly increase exposure to treatment agents, possibly decreasing the safety of treatment and exacerbating renal impairment. In conclusion, all cancer patients, not only those receiving potentially nephrotoxic agents, require renal monitoring.

Section snippets

High incidence of renal complications in patients with cancer

Monitoring renal function in patients with solid tumors and hematologic malignancies is vital to the safe administration and follow-up of therapeutic agents.[1], [2] Measuring serum creatinine levels to assess renal function may be insufficient because there is often a discrepancy between serum creatinine levels and the actual creatinine clearance rate.³ This is a common pitfall for renal monitoring when treating patients, especially if treating patients across a broad range of ages. In

Risk factors for renal impairment in patients with cancer

Patients with cancer often have preexisting comorbidities or other risk factors that increase the probability of renal impairment before receiving potentially nephrotoxic therapies. Patient age, preexisting kidney disease, and chronic comorbidities (e.g., diabetes, hypertension, and cardiac insufficiency) contribute to the risk of renal impairment (Table 2)⁵ Chronic kidney disease is common in the elderly population in general, regardless of the presence of cancer.¹³ An estimated 44% of

Renal effects of agents used in the cancer setting

A number of cancer therapy agents are cleared through the kidney and may affect renal function, including chemotherapy agents, molecular targeted agents, pain management agents, radiopharmaceuticals, and bone-targeted therapies. Many of these agents (Table 3)[20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35] can be nephrotoxic or lack specificity. Additionally, in patients with renal impairment, decreased renal clearance rates can lead to increased

Monitoring renal function

Both cancer and its therapies may lead to renal impairment. Undetected decreases in clearance rates by the kidneys can greatly increase exposure to treatment agents, possibly decreasing the safety of treatment and exacerbating renal dysfunction (Fig. 1).[3], [4], [40] Stage 3 kidney disease is defined as a moderate decrease in GFR (30–59 mL/min).⁴ At this level of renal impairment, drugs cleared by the kidney remain in the body for a longer duration than in those with normal renal function.³

The need for monitoring renal function during antiresorptive therapy in patients with advanced cancer

All cancer patients need renal monitoring, including those receiving antiresorptive therapies such as bisphosphonates (BPs) or denosumab, a fully humanized monoclonal antibody against the receptor activator of nuclear factor kappa B ligand (RANKL). Patients receiving BPs require monitoring of renal function because BPs are cleared through the kidneys.⁴² However, patients receiving molecular targeted therapies, including monoclonal antibodies such as denosumab, could also require renal

International clinical practice guidelines for monitoring renal function during cancer therapy

The International Society of Geriatric Oncology (SIOG) has several recommendations regarding renal monitoring in elderly patients with cancer (Table 5).[36], [42], [59] Assessing hydration status and renal function in all elderly cancer patients before administering drug therapy is recommended by SIOG.³⁶ Adequate hydration during cancer therapy is important for minimizing nephrotoxicity,[29], [34], [36] and assessing renal function is necessary for adjustment of cancer drug dosing.[3], [59]

Conclusions

Monitoring renal function in patients with cancer is critical for the safe administration of therapeutic agents because this patient population has a high prevalence of renal impairment. Serum creatinine levels are not a sufficient measure of renal function because they do not accurately reflect clearance rates; thus, renal function should be assessed using CrCl. Additionally, patients with cancer often have preexisting comorbidities or other risk factors that increase the probability of renal

Conflict of interest statement

Dr. Aapro has conducted studies and is a consultant on bisphosphonates for Amgen, Bayer-Schering, Novartis, and Roche.

Dr. Launay-Vacher has no conflict of interest related to this manuscript.

Acknowledgments

Financial support for medical editorial assistance was provided by Novartis Pharmaceuticals. We thank Duprane Young, PhD, ProEd Communications, Inc.®, for her medical editorial assistance with this manuscript.

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Complications of TreatmentImportance of monitoring renal function in patients with cancer

Abstract

Section snippets

High incidence of renal complications in patients with cancer

Risk factors for renal impairment in patients with cancer

Renal effects of agents used in the cancer setting

Monitoring renal function

The need for monitoring renal function during antiresorptive therapy in patients with advanced cancer

International clinical practice guidelines for monitoring renal function during cancer therapy

Conclusions

Conflict of interest statement

Acknowledgments

Clin Genitourin Cancer

Crit Rev Oncol Hematol

Semin Nephrol

Ann Oncol

Blood

Am J Kidney Dis

J Pain

Ann Oncol

Eur J Cancer

Lancet

Bone

Eur J Cancer

Chemotherapy in the elderly: pharmacologic considerations

Cancer Control

Chemotherapy-associated renal dysfunction

Nat Rev Nephrol

Prevalence of renal insufficiency in cancer patients and implications for anticancer drug management: the Renal Insufficiency and Anticancer Medications (IRMA) study

Cancer

National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification

Ann Intern Med

A new equation to estimate glomerular filtration rate

Ann Intern Med

Lung cancer and renal insufficiency: prevalence and anticancer drug issues

Lung

Prevalence of renal insufficiency in breast cancer patients and related pharmacological issues

Breast Cancer Res Treat

Prevalence of renal insufficiency in cancer patients: Data from the IRMA-2 study

J Clin Oncol

Renal impairment in patients with multiple myeloma: a consensus statement on behalf of the international myeloma working group

J Clin Oncol

Incidence and outcome of patients starting renal replacement therapy for end-stage renal disease due to multiple myeloma or light-chain deposit disease: an ERA-EDTA Registry study

Nephrol Dial Transplant

Prevalence of CKD and comorbid illness in elderly patients in the United States: results from the Kidney Early Evaluation Program (KEEP)

Am J Kidney Dis

Incidence of renal insufficiency in cancer patients and evaluation of information available on the use of anticancer drugs in renally impaired patients

Med Sci Monit

Cancer burden in the aged: an epidemiologic and demographic overview

Cancer

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Complications of Treatment
Importance of monitoring renal function in patients with cancer