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Case history

image A 76-year-old man with castrate-refractory metastatic prostate cancer receiving palliative chemotherapy with docetaxel (75 mg/m2 once every 3 weeks) was admitted with a 2 day history of vomiting and diarrhoea after his second cycle of chemotherapy. He had a history of hypertension and hypercholesterolaemia and was taking 2.5 mg ramipril once daily and 20 mg simvastatin at night.

The following details were noted: weight 68 kg; temperature 37.2°C; pulse 105 beats/min; BP 92/60 mmHg; Na+ 136 mmol/l; K+ 6.5 mmol/l; urea 22 mmol/l; creatinine 245 μmol/l. Two weeks earlier, serum creatinine had been 89 μmol/l.

What is the definition of acute kidney injury (AKI)?

What are the potential difficulties in estimating kidney function in patients with cancer?

What are the risk factors for AKI and how can it be prevented?

What were the possible causes of AKI in this patient?

What is the initial management of AKI?

What is the prognosis of AKI?

What is the definition of AKI?

AKI is a common complication in cancer patients and occurs in up to 30% during the course of their disease.1 AKI may be considered a spectrum of injury, with even relatively minor rises in serum creatinine being associated with increased morbidity and mortality.2 Recent definitions have been based on rises in serum creatinine or decreased urine output and have been harmonized by the international guideline organization Kidney Disease: Improving Global Outcomes.3

AKI is present when one of the following criteria is met:

  • Serum creatinine rises by ≥26 μmol/l within 48 h.

  • Serum creatinine rises ≥1.5-fold from the known baseline value, or the rise is presumed to have occurred within 1 week.

  • Urine output is <0.5 ml/kg for >6 h consecutively.

Baseline serum creatinine should be the lowest creatinine value recorded within 3 months of the event.

What are the potential difficulties in estimating kidney function in patients with cancer?

This man, like many patients with metastatic cancer, might have had reduced muscle mass (sarcopenia) as a consequence of cancer cachexia and/or treatment. Reduced muscle mass will result in a relatively low baseline creatinine level, giving the potential to overestimate kidney function and thus potentially fail to recognize the presence of chronic kidney disease (CKD) and increased risk of AKI. The severity of AKI may also be underestimated because of the limit to which serum creatinine can rise. It is important to recognize these factors when making decisions on chemotherapy and dosing, imaging modalities (specifically the use of iodinated contrast) and the prescription of supportive medications dependent on kidney metabolism and excretion.

What are the risk factors for AKI and how can it be prevented?

The prevention of AKI is an important part of care for all patients with cancer. It is essential that risk ...

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