Walid Sabry
Renal toxicity varies depending on the drug and requires special follow-up protocols. Clinical challenges include the difficulty of diagnosis and the decision to continue or stop treatment. Coping strategies include early diagnosis, continuous monitoring, and dose adjustment. The success of cancer treatment is measured by the ability to protect the patient from kidney complications.
Clinical pharmacist and member of the Friends of Health Society, Dr. Laila Al-Aali said that recent years have witnessed an unprecedented therapeutic revolution in the world of oncology, explaining that immunotherapy, targeted therapies, and CAR-T cells have given patients greater chances of recovery and survival. However, this boom came loaded with new challenges, most notably acute or chronic kidney injury, which has become an important complication affecting treatment decisions and patient outcomes.
She added that studies indicate that between 11% and 22% of cancer patients suffer from some form of acute kidney failure, and this percentage increases in intensive care units or in patients with hematological tumors, stressing that the risk of kidney injury is not limited to loss of organic function, but rather extends to depriving the patient of completing treatment, or excluding him from advanced drug protocols, which increases the possibility of death and complications.
Al-Aali continued, explaining that kidney injury resulting from medications varies depending on the drug and the mechanism of its effect, noting that platinum medications such as cisplatin, carboplatin, and oxaliplatin cause acute tubular injury, proximal tubule morbidity, and thrombotic microvascular syndrome, in addition to salt loss and magnesium deficiency.
She pointed out that methotrexate may lead to crystalline nephropathy and tubular obstruction, which makes adequate hydration and monitoring of drug concentrations necessary, while gemcitabine is often associated with thrombotic microvascular syndrome, which is a difficult condition to treat and requires early diagnosis.
She added that pemetrexed and ifosfamide cause proximal tubulopathy, and ifosfamide may lead to hemorrhagic cystitis, which requires the use of a prophylactic agent such as mesna, while cyclophosphamide causes hemorrhagic cysttoxicity and hyponatremia.
She explained that nitrosurea, such as streptozocin, causes chronic kidney infections, uric acid stones, and even diabetes insipidus, while other drugs such as mitomycin C, melphalan, and terabectedin are associated with special syndromes such as thrombotic microvascular syndrome, antidiuretic hormone secretion syndrome, or myolysis, stressing that this large discrepancy confirms that dealing with each drug must be done according to its own follow-up and prevention protocols.
Al-Aali said that the clinical challenges are multiple, explaining that diagnosis is difficult. Because it is difficult to differentiate between kidney injury resulting from the drug, and that resulting from ischemia, infection, or obstruction of the urinary tract, indicating that toxicity often appears late, which increases the difficulty of early intervention.
She added that the decision to continue or stop also represents a challenge, as stopping treatment may deprive the patient of the opportunity to control the tumor, while continuing despite the toxicity may lead to permanent kidney failure, noting that prevention is limited. With the exception of some measures such as hydration with cisplatin or the use of Mesna with cyclophosphamide and ifosfamide, most other toxicities do not have proven preventive measures.
Al-Aali stressed that early diagnosis and continuous monitoring are essential, and this includes assessing kidney function before starting each treatment protocol, monitoring creatinine, glomerular filtration rate, and electrolytes periodically, and using new biomarkers for early detection of kidney injury before function deteriorates.
She added that pharmacological and supportive prevention is important, such as intravenous hydration protocols before and after cisplatin administration, the use of mesna to prevent hemorrhagic cystitis with cyclophosphamide and ifosfamide, and the correction of electrolyte disorders such as magnesium deficiency with platinum.
She added that dose adjustment or drug replacement may be necessary by re-evaluating drug doses according to kidney function and creatinine clearance, and searching for less toxic alternatives when possible.
She pointed out that cooperation between specialties is also essential, within the renal oncology team, which includes oncologists, nephrologists, and clinical pharmacists, to determine the best options for each case, and to develop joint protocols to determine when treatment should be stopped. When can it be resumed after kidney function improves?
Al-Aali stressed that patient education is an integral part of the strategy, and includes encouraging patients to drink fluids regularly when there are no contraindications, and alerting them to early symptoms such as decreased urine, color changes, or bladder pain.
She concluded by emphasizing that kidney injury due to cancer medications is not a secondary event that can be overlooked, but rather a pivotal factor that may change the course of the treatment plan, explaining that confronting this problem requires a multi-dimensional strategy that includes careful monitoring, preventive interventions, dose adjustment, and effective cooperation among members of the medical team.
She added that success in treating cancer is not measured only by the ability of the drug to eliminate the tumor, but also by our ability to protect the patient from the treatment itself becoming a cause of complications that may rob him of the chance of recovery, stressing that with the development of research and the use of accurate biomarkers, the future could become safer for cancer patients, as the tumor is treated, without the kidneys being a victim in this battle.
