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Acute Kidney Injury in Cancer Patients And EXPERIMENTAL AND THERAPEUTIC MEDICINE 14: 5671-5677, 2017 Acute kidney injury in cancer patients and impedance cardiography‑assisted renal replacement therapy: Experience from the onconephrology unit of a Chinese tertiary hospital TAO WANG1, YAN ZHANG2, QINGXIA LI3, SHUMIN JIA4, CHANGJIN SHI5, KAI NIU1 and BING LIU1 1Department of Nephrology, Hebei General Hospital, Shijiazhuang, Hebei 050051; 2Department of Dermatology, Hebei Provincial Tumor Hospital, Shijiazhuang, Hebei 050011; 3Department of Oncology; 4Hemodialysis Center, Hebei General Hospital, Shijiazhuang, Hebei 050051; 5Department of Urology, Hebei Provincial Tumor Hospital, Shijiazhuang, Hebei 050011, P.R. China Received April 7, 2017; Accepted July 27, 2017 DOI: 10.3892/etm.2017.5244 Abstract. Acute kidney injury (AKI) in cancer patients improve the safety and efficacy of CRRT in cancer patients with may disrupt anticarcinogenic treatment and greatly increase AKI. In addition, it provided information to bring advances in associated mortality rates. The present study reported on the onconephrology, a novel nephrological subspecialty field. management of cancer patients with AKI and, from the nephro- logic viewpoint, on the significance of fine volume control Introduction during the continuous renal replacement therapy (CRRT). The records of 117 cancer patients with AKI treated over Acute kidney injury (AKI) is a particularly common compli- three years were reviewed and their data were compared with cation in cancer patients and associated with increased those of 120 healthy controls. AKI was defined according to mortality (1). It may occur as a direct or indirect consequence the Kidney Disease: Improving Global Outcomes criteria with of the cancer itself, its treatment or associated complica- serum creatinine levels determined on initial admission and tions (2,3). Among the heterogeneous etiology, nephrotoxic for the diagnosis of AKI. CRRT with concomitant impedance AKI by chemotherapeutic drugs is one of the most frequently cardiography (ICG) monitoring was performed in 79 patients. encountered in malignancies (4), whereas in rare cases, renal On average, AKI manifested as a 1.68±0.38-fold increase in infiltration in chronic myeloid leukemia (CML) has also been serum creatinine within 10.2±5.7 days. The causes of AKI were reported (5). Under these circumstances, renal hypoperfusion diverse, with the major ones being nephrotoxic agents, hypo- further jeopardizes the patients to the development of AKI or tension and obstructive nephropathy. Renal biopsy confirmed more likely exacerbates it to full acute renal failure (ARF) (3). two cases of thrombotic microangiopathy, due to the use of On the other hand, patients with AKI are predisposed to fluid interfon-α and sunitinib malate, respectively, and a third case overload, which may also increase mortality (6). Maintenance of cast nephropathy caused by immunoglobulin D multiple of an appropriate fluid balance is hence considered vital to the myeloma. The patients were generally marantic and had compro- management of AKI in cancer patients, in which AKI usually mised cardiac function compared with the healthy controls. The emerges in the context of multiple organ dysfunction (7). CRRT prescription was discriminatingly optimized by the ICG More recently, it has been shown that the presence of an parameters effecting discreet fluid balance, as the thoracic fluid underlying cancer alone should no longer deny the critically ill content was significantly correlated with the ultrafiltration rate. patients the chance of receiving continuous renal replacement By considering the causative mechanisms and applying subtle therapy (CRRT) or other advanced life-support measures (8,9). ICG-assisted volume control, the present study may thus help to Continuous venovenous hemodiafiltration (CVVHDF) with its dialysis component is thought to be the best option to treat ARF in cancer patients (10). CRRT, however, is not a panacea without concern. For instance, one obvious potential well-recognized hazard is overly aggressive fluid removal Correspondence to: Professor Bing Liu, Department of Nephrology, evoking hypotension, renal hypoperfusion, prerenal azotemia, Hebei General Hospital, 348 West Heping Boulevard, Shijiazhuang, Hebei 050051, P.R. China and de novo renal injury or even ARF (11). An inaccurate E-mail: [email protected] volume assessment, if left unattended, may thus lead to the inappropriate implementation of therapy and the clinical Key words: acute kidney injury, cancer, continuous renal replacement consequence may be costly. Therefore, careful assessment of therapy, hemodynamic monitoring, impedance cardiography the fluid status prior to the initiation of and during CRRT is required. In this regard, impedance cardiography (ICG) is a subtle and non-invasive method of evaluating hemodynamic parameters (12) and ICG‑guided CVVHDF was of bona fide 5672 WANG et al: AKI IN CANCER PATIENTS AND ICG-ASSISTED CRRT value in a previous study by our group on the management of CRRT and ICG. In addition to the symptom-oriented treatments, CML-associated ARF (5). 79 patients accepted CRRT. It was performed with an Aquarius With increasingly complex cancer treatment protocols, machine (Aquarius; Edwards Lifesciences, Maurepas, France) novel antineoplastic drugs and a growing emphasis on AKI in using polysulfone hemofilters (AV 600; Fresenius, Oberursel, cancer patients, onconephrology has evolved into a new field of Germany) through a provisional venous catheter. Substitution nephrology (13). It is an intersection between nephrology and solutions were delivered pre‑filter at a rate of 35 ml/kg/h. The oncology, in which nephrologists are required to be familiar ICG (BioZ, CardioDynamics, CA, USA) was performed as with the epidemiology, etiology and treatment of AKI in cancer previously described (5,12) during CRRT (initiation, for 5 h patients. As such, this concept of onconephrology was put thereafter and cessation) and in the healthy controls. The ultra- into practice and the present study reported on recent clinical filtration was performed in a linear decreasing manner (17) and experience in this novel sub‑specialty field of nephrology. The adjusted according to the ICG data, particularly the thoracic fluid study also focused on three rare cases of biopsy‑confirmed content (TFC). To evaluate the utility of ICG in hemodynamic AKI in patients with various types of malignancy. monitoring during the CRRT, the healthy controls and cancer patients were then stratified according to two ICG parameters, Materials and methods the stroke index (SI) and TFC. This generated a plot of four quadrants with the respective cut-off point for the SI and TFC Subjects. The clinical records of 117 cancer patients with AKI as 35 ml/m2 and 35 kOhm-1. that were either admitted or referred to the onconephrology unit between February 2014 and December 2016 at Hebei Statistical analysis. Statistical analyses were performed with General Hospital, a tertiary medical center in Shijiazhuang the SPSS package (version 19.0; IBM Corp., Armonk, NY, (China), were reviewed. They were found to have irresectable USA). Values are expressed as the mean ± standard deviation. tumors and 93 (79.5%) received chemotherapy. The onset of Significantly skewed data were log‑transformed prior to the AKI was defined by the Kidney Disease: Improving Global analysis. Analysis of variance with Bonferroni's post-hoc test, Outcomes criteria (14). At the first presentation, laboratory Student's t-test and the χ2 test were performed to assess differ- tests were performed according to standard procedures, ences between groups for continuous and categorical variables, followed by electrocardiogram, echocardiography, renal respectively. Correlations were examined using Pearson's test. ultrasound and other auxiliary examinations when deemed P<0.05 was considered to indicate a statistically significant necessary. Patients with overt congestive heart failure were difference. excluded. The estimated glomerular filtration rate (eGFR) was deduced from the modified version of the Modification Results of Diet in Renal Disease (MDRD) equation for Chinese individuals: eGFR=175 x Serum creatinine-1.234 x age-0.197 Epidemiology of AKI in cancer patients. The clinical profiles (x0.79 for females). A total of 120 age-matched ‘healthy’ of the participants were listed in Table I. Comparing with the controls were recruited later during annual health examina- healthy controls, the cancer patients were in worse condition tions. The term ‘healthy’ was introduced for the descriptive with a lower body mass index, hypotension, overt anemia, purpose against the existence of cancer. They went through elevated serum creatinine (Scr), decreased eGFR, hypoalbu- an extensive work-up, including hematological screening minemia and hypolipidemia. However, the Scr and eGFR were tests, urinalysis, chest X-ray and the abovementioned exami- 106.1±37.8 µmol/l and 76.4±22.1 ml/min/1.73 m 2, respectively, nations. These subjects were non-diabetic without edema, in the cancer patients prior to the onset of AKI. On average, free of cardiac and renal diseases, devoid of health prob- the increase of Scr was 1.68±0.38-fold within 10.2±5.7 days. lems requiring immediate medical attention and received Sites of primary malignancy are presented in Table II with voluntary referral ICG testing. Other selection criteria were the digestive, respiratory and hematological systems as the similar to those in a previous study by our group (15).
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