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Case history

image A 77-year-old man presented with a 1 week history of haematuria. His past medical history included hypertension, type 2 diabetes, mild mitral regurgitation, hiatus hernia, diverticulosis and hypercholesterolaemia. His drug history included bendroflumethiazide, ramipril, metformin and simvastatin. He lived alone and was independent in his activities of daily living. Investigations revealed a muscle-invasive bladder cancer with pelvic nodal metastases.

The oncologist requested isotopic measurement of the patient's glomerular filtration rate (GFR) and recommended full-dose palliative chemotherapy with gemcitabine and cisplatin. Serum creatinine was 77 µmol/l and isotope GFR was 65 ml/min.

Following cycle 1, the patient developed dizziness on standing, grade 2 vomiting and grade 2 fatigue. He was admitted to hospital and his vital signs were: temperature 37.0°C, pulse 115 bpm, BP 96/55 mmHg. His blood tests revealed: Na 140 mmol/l, K 5.7 mmol/l, urea 16.2 mmol/l, creatinine 252 µmol/l. White blood cell count, C-reactive protein and calcium were normal. Serum glucose was 10 mmol/l.

The management of his acute kidney injury involved fluid resuscitation, antiemetics, and stopping bendroflumethiazide, ramipril and metformin. A bedside bladder scan performed on admission excluded post-renal acute kidney injury from urinary retention. Urine analysis excluded infection. Ultrasonography of the kidneys was performed within 24 h and also ruled out upper urinary tract obstruction.

His acute kidney injury improved with conservative measures; a repeat isotope GFR was 55 ml/min. The cause was ascribed to dehydration secondary to chemotherapy-related vomiting and an element of cisplatin-related nephrotoxicity, all exacerbated by his medications. Post-discharge performance status (PS) was 1.

The oncologist discussed the risks and benefits of further palliative chemotherapy. In light of his renal impairment he was offered gemcitabine/carboplatin, instead of continuing with gemcitabine/cisplatin, and a reassessment CT scan after his next treatment. He decided to proceed with the chemotherapy but to retain the option to stop his treatment if the fatigue had a significant impact on his quality of life.

How should this patient be managed?

What were the goals of cancer treatment in this patient?

Are there challenges specific to older patients?

What could be done to reduce his risk of acute kidney injury as he underwent cancer treatment?

What is the evidence base for his treatment options?

How should this patient be managed?

The patient should be admitted to an acute oncology unit, where initial investigations should include: immediate bedside bladder scan to exclude post-renal acute kidney injury, urinalysis (for infection and presence of protein and/or blood), arterial/venous blood gases to exclude metabolic acidosis, and an ECG if the patient is hyperkalaemic. NICE guidelines recommend that renal ultrasound is performed within 24 h if no cause of acute kidney injury is identified or if renal tract obstruction is a possibility.1 In this patient's case, the bladder tumour put him at risk of renal obstruction; therefore, renal ultrasound was performed. Prompt fluid replacement may reverse acute kidney injury secondary to hypovolaemia and/or limit kidney injury due to acute ...

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