Malignancy-related Renal Disease and Procalcitonin

Malignancy Related Renal Disease

  • Malignancy can cause a variety of renal diseases. Always think about the most common causes, including pre-renal azotemia.
  1. Pre-renal Disease

    a. Volume depletion (very common): chemotherapy related vomiting, diarrhea : Hypercalcemia of malignancy can exacerbate hypovolemia : IL-2 may cause a capillary leak syndrome, leading to reduced effective circulating volume : NSAIDs used to treat cancer pain can lead to reduced effective circulating volume as well.

    b. In post-hematopoietic stem cell transplantation, hepatorenal like syndrome may occur due to hepatic sinusoidal obstruction syndrome.  Check out this cohort study in Annals Internal Med à PMID 8420443

  2. Intrarenal Disease

    a. Glomerular Diseases
    – Paraneoplastic phenomenon: deposition of tumor antigens within the glomeruli, inducing antibody accumulation and complement activation
    – Membranous nephropathy: associated with solid tumors (breast, lung, colon being most common)
    – Minimal change disease: Hodgkin lymphoma, other lymphoproliferative disorders.
    : one proposed mechanism is the secretion of glomerular toxic lymphokines by abnormal T cells.
    – Amyloidosis and light chain deposition
    – Proliferative/crescentic glomerulonephritis: associated with solid tumors as well as lymphomas, although etiology is not clear.

    b. Tubulointerstitial diseases
    – Chemo-induced: Think, cisplatin and ifosfamide! These can cause severe tubular damage resulting in AKI and electrolyte disorders.
    – Myeloma cast nephropathy: tubular injury and tubular obstruction can occur by casts containing light chains.
    – Tumor lysis syndrome: tubular obstruction with uric acid crystals or intrarenal deposition of calcium.
    – Tumor infiltration: Presence of large kidneys without hydronephrosis on imaging

    c. Vascular Disease
    Renal Thrombotic Microangiopathy:  Microvascular thrombosis due to abnormalities of arterioles and capillaries.
    : Underlying adenocarcinoma may be directly responsible
    : anti-tumor therapy is a common cause of TMA (cyclophosphamide, mitomycin, gemcitabine)

  3. Obstructive Disease

    a. Intratubular obstruction: discussed above under tubulointerstitial disease; intratubular obstruction from uric acid crystals, light chain casts, or drug crystallization

    b. Extrarenal obstruction: ureteric obstruction, especially common with GI, urologic, or gynecologic cancers

Procalcitonin to Diagnose Infection in Cancer Patients

  • Thank you, Lily for asking the question regarding the utility of using procalcitonin in our patient with metastatic SCC, in whom we were concerned about infection! And thank you, Harry for directing us to 2 particular papers that discuss 1) role of procalcitonin in sepsis diagnosis; and 2) its specific utility in cancer patients.
  • What is the role of procalcitonin in sepsis diagnosis?
    – Procalcitonin, although more expensive, is more accurate than CRP testing for detecting sepsis.
    – However, it is non-specific and can be raised in non-infectious conditions as well (trauma, surgery, burns, cardiogenic shock, small cell lung cancer, medullary C cell carcinoma of thyroid)
    – Values of procalcitonin are important!
    < 0.5 ng/mL: low likelihood of sepsis
    0.5 – 2.0 ng/mL: intermediate likelihood of sepsis
    > 2.0 ng/mL: significantly increased risk of sepsis
    – In a recent meta-analysis, sensitivity and specificity of procalcitonin in discriminating sepsis from non-infectious causes were 77% and 79% respectively.
    Reference: McLean et al., Investigating sepsis with biomarkers, BMJ 2015;350:h254
  • Utility of procalcitonin in management of cancer patients with infection?
    Reference: Durnas et al., Utility of blood procalcitonin concentration in the management of cancer patients with infection (PMCID: PMC4731001)
    – Studies have shown that patients with metastatic cancer have elevated procalcitonin levels in the absence of infection
    – However, in cancer patients who have a confirmed diagnosis of infection, serial measurements of procalcitonin may be useful in following-up an infectious course.
  • Big picture: Utility of procalcitonin to diagnose infections has been a controversial topic for both infectious disease and critical care physicians. A very elevated level has a high predictive value, but an elevated procalcitonin must always be interpreted with the patient’s clinical context in mind.

 

Evernote Link:  https://www.evernote.com/shard/s338/sh/c6ea4fbf-1aa1-4978-9a10-de7014d420a1/608d55a93fe9940edcc0dc1a354facec

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