Pharmacotherapy considerations in patients who develop acute kidney injury during anti-cancer therapy

ABSTRACT

Introduction

Acute kidney injury (AKI) frequently develops in patients receiving cancer therapy and requires a wide differential diagnosis due to possible role of unique cancer and drug-related factors, in addition to common pre- and post-renal causes. Rapid development of new molecular targeted anti-cancer drugs and immunotherapies has opened unprecedented possibilities of treatment at the price of an increased spectrum of renal side effects.

Areas covered

The present review aims at providing a state-of-the-art picture of AKI in cancer patient (PubMed and Embase libraries were searched from inception to January 2024), with a focus on differential diagnosis and management of diverse clinical settings. Reports of parenchymal AKI due to glomerular, microvascular, tubular and interstitial damage have been constantly increasing. Complex electrolyte and acid-base disorders can coexist. The role of renal biopsy and possible therapeutic approaches are also discussed.

Expert opinion

Onconephrology has become an important subspecialty of clinical nephrology, requiring constantly updated skills and a high degree of interdisciplinary integration to tackle diagnostic challenges and even therapeutic and ethical dilemmas. Integrated onconephrological guidelines and availability of biomarkers may provide new tools for management of this unique type of patients in the near future.

KEYWORDS:

• Acute kidney injury
• cancer chemotherapy
• chronic kidney disease
• immune checkpoint inhibitors
• onconephrology
• renal immune-related adverse effect
• targeted anti-cancer drugs

Article highlights

• Patients with cancer are at risk for acute kidney disease (AKI) due to malignancy and treatment-related factors.

• Increasing use of new immunotherapeutic drugs such as immune checkpoint-inhibitors (ICI) is determining a parallel increase in immune-related adverse events (irAE), including AKI.

• Referral to a nephrologist experienced in this field is mandatory, especially in case of persistent AKI or in more severe or atypical forms, also to assess indication to renal biopsy.

• Close cooperation between nephrologist and oncologist is necessary to find a balance between measures required to treat kidney complication (including permanent withdrawal of offending drug) and need to continue an effective anti-cancer therapy.

• New diagnostic and prognostic biomarkers and integrated onco-nephrological guidelines could help us in making these decisions in the near future.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.