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Dr Ayman Seddik ,M.Sc , MD Ass.Prof. Nephrologist Ain Shams University Nephrology consultant
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Outline What Is Onconephrology
Scope Of Kidney Diseases In Cancer Patient
1. Aki In Cancer Patient
2. Cancer Associated Glomerulopathy
3. Chemotherapy Associated Interstetial Nephritis
4. Hypercalcemia Of Malignancy
5. Tumour Lysis Syndrome
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“Onco- Nephrology”
The field of nephrology that is deals with complications of a cancer.
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Oncology Nephrology
Pharmacy
ONCO
Nephrology
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Potential compartments of drug induced injury
Pre Renal
Post Renal
Intrinsic Renal
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Why is the Kidney Vulnerable to Chemotherapy?
Patient Specific Factors
Kidney Specific Factors
Drug Specific Factors
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Watch out kidney, chemo is here!
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Why is the Nephrologist called TO 7 th floor ?
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Multiple Myeloma
Tubular interstitial Damage
New Glomerular paraneoplastic
disease
Kidney disease e ither pre existing or developing in the course of the
cancer
Radiation Nephropathy
Tumor lysis syndrome
Thrombotic microangiopathy
Fluid and electrolyte disorders
Obstructive Nephropath
y
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1-Renal vasculature
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2- Glomeruli
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3- acute tubular necrosis
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4- Tubulointerstitial nephritis
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Cancers and electrolytes NA , K , CA , MG Hyponatremia, hypernatremia
Hypercalcemia
Hypomagnesemia
Hypokalemia and hyperkalemia
.
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GLOMERULAR DISEASES WITH MALIGNANCY
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Management of newly diagnosed membranous nephropathy.
Jean-François Cambier, and Pierre Ronco CJASN
2012;7:1701-1712
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TMA- TTP/HUS syndrome
Mitomycin C is associated with Hemolytic Uremic Syndrome (HUS) at total cumulative doses above 40-60 mg/m2
HUS usually occurs within 4-8 weeks after the last dose and carries a poor prognosis
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Gemcitabine
Gemcitabine is a nucleoside analog with antineoplastic activity against a variety of solid tumors including pancreatic, non-small cell lung, bladder, ovarian and breast carcinomas
Mild proteinuria and microscopic hematuria may occur in up to 50% of pt treat with Gemcitabine
HUS is a well-described complication with an incidence of 0.31%-0.4%
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Gemcitabine Hemolytic Uremic Syndrome
The presentation is subacute with insidious onset of renal dysfunction, hemolytic anemia, new or worsening hypertension and thrombocytopenia
Unrecognized, progression to fulminant acute renal failure and hypertensive crisis can occur
Useful Lab data: LDH, Haptoglobin, Smear Review, Reticulocyte Count, Creat, Urinalysis
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Definition Potentially fatal metabolic complication that occurs in
some patients with cancer
Can result in potentially life threatening metabolic
and electrolyte abnormalities
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Pathophysiology Involves a complex series of events related to the
liberation of intracellular contents from tumor cells
and inability of the kidneys to excrete and maintain
normal serum composition
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Manifestations Usually occurs within 24-48 hours after initiation of
chemotherapy and may persist for 5-7 days post
therapy
May occur as early as 6 hours post chemotherapy administration
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Tumor Types Non-Hodgkins lymphoma
Burkitt’s
High grade T-cell
Acute Leukemia’s Acute Promyelocytic leukemia
Acute lymphoblastic leukemia
Chronic Lymphoblastic leukemia
Solid tumors Small cell lung cancer
Breast cancer
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Prevention Rasburicase- recombinant urate oxidase-
Reduces the uric acid pool
Reduces existing uric acid
Prevents the accumulation of xanthines and hypoxanthine
Does not require alkalinization
Facilitates phosphorous excretion
Dosing:
IV over 30 minutes
0.2 mg/kg IV QD or BID
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Management Hydration
3 Liters daily
Aggressive hydration starting 1-2 days prior to
chemotherapy and continuing for a few days post
chemotherapy
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Management Diuretics:
Furosemide
Prevents:
Fluid overload
Electrolyte imbalance
Complications of uric acid buildup
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Management Dialysis: Hemodialysis/CVVH/CRRT( Requires
ICU Care)
Used for patients unresponsive to preventive measures and electrolyte corrections
Used to remove uric acid
Used in patients with: Serum potassium > 7 mEq/L
Uric acid >12 mg/dl
Phosphorous > 10 mg/dl
Symptomatic hypocalcemia
Presence of volume overload
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Medication Management Avoid nephrotoxic medications
Avoid agents which block tubular reabsorption of uric acid
Aspirin
Probencid
Thiazide diuretics
Radiographic contrast containing iodine
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TTT MALIGNANCY INDUCED HYPERCALCEMIA
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As a Nurse?
remember that chemotherapy are potentially nephrotoxic drugs
dehydration , radiotherapy , sepsis are aditional risk factors many chemotherapeutic drugs are renally execreted bewaare of dose
reduction in those patients
tumour lysis syndrome occurs in haematologicall malignancies and tumours with high cell burden , keep your patient well hydrated , follow urine ph and uric acid level
know that ckd and esrd patients are at higher risk of cancer than general population.
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Agents known to be nephrotoxic
Cisplatinum Methotrexate Gemcitabine Bisphosphanates Tyrosine Kinase Inhibitors Anti VEGF agents
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Nursing Interventions Monitor weights at least daily
ECG’s
Monitor for altered level of consciousness
Strict I&O
Check pH of urine with each void, goal is to keep pH >7.0
Monitor for signs and symptoms of nausea and vomiting,
administer antiemetics WHEN NEEDED
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