Protected: Onconephrology in Renal Transplant Patient: A Challenge for the Transplant Nephrologist

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Enrico Sanna1, Ana Maria Manzione1, Silvia Mingozzi1, Luigi Biancone1

1 SC Nefrologia, Dialisi, Trapianto di Rene, Città della Salute e della Scienza di Torino, sede Molinette, Torino, Italia

Corresponding author:
Luigi Biancone
SC Nefrologia, Dialisi, Trapianto di Rene, Città della Salute e della Scienza di Torino, sede Molinette, Torino, Italia
Corso Bramante, 88/90
10126 Torino – Italia
Tel. 011-6336150
email: luigi.biancone@unito.it

 

Abstract

Onconephrology, an emerging field in modern medicine, is gaining importance due to its intricate challenges derived from the mixing field of tumorous and renal diseases. The growing incidence of tumors in transplant patients requires preventive strategies and accurate monitoring. Pre-transplant screening is crucial, focusing on subjects with oncological history. Post-transplant follow-up must be personalized, tailoring screenings for patients with cancer history. Immunosuppressive therapy, although essential to prevent organ rejection, represents a delicate balance between controlling the immune response and cancer risk management.
Immune checkpoint inhibitors emerge as a fascinating potential for cancer therapy, but their use in transplant patients requires caution and further research to carefully evaluate their safety and effectiveness, balancing potential benefits with actual risk of rejection. In summary, onconephrology is a growing field that requires an interdisciplinary approach and constant research, aimed at successfully addressing the complex challenges associated with oncological diseases in renal and transplant patients.

Keywords: Onconephrology, Kidney transplant, Immunosuppressive therapy, Immune check-point inhibitors

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Protected: Renal Side Effects of Novel Molecular Targeted Oncologic Agents

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Roberta Fenoglio1, Simone Cortazzi1, Martina Marchisio1, Gianluca Rabajoli1, Edoardo Terzolo1, Savino Sciascia1 e Dario Roccatello1

1 University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy

Corresponding author:
Roberta Fenoglio
Indirizzo: Nefrologia & Dialisi – CMID, Università di Torino e Ospedale San Giovanni Bosco, Piazza del Donatore di Sangue 3, 10154, Torino, Italia
Telefono: +39 0112402056
Email: roberta.fenoglio@unito.it

 

Abstract

The introduction of innovative therapies has changed the scenario of complications. The delay in the recognition of kidney adverse effects is partly due to the timing of the development of the kidney damage which occurs later than the observation period of registration studies, and partly to the exclusion of patients with known kidney impairment from registration trials.

Renal disease has a significant impact on the management of cancer patients and often leads to discontinuation of therapy. Histological evaluations of kidney disorders induced by targeted/immunotherapy are very limited. Renal biopsy is critical for the management of renal toxicities and should be especially encouraged for patients showing adverse renal effects to novel cancer agents.

We recently examined the histological features of patients treated with new cancer agents who underwent renal biopsy for new onset renal failure and/or urinary abnormalities. The cohort included 42 patients. The most frequently administered therapies were immunotherapy (54.8%) and anti-angiogenic treatments (45.2%). The most common adverse effect was tubular interstitial nephritis in the first group and thrombotic microangiopathy in the second one. Based on histological findings, definitive discontinuation of treatment could be restricted to a very limited number of patients. All of them had anti-VEGF-related TMA. Treatment discontinuation was unneeded in patients treated with ICIs. In patients treated with multidrug therapy, the histological findings made it possible to identify the weight of drug-related specific injury. Based on this data, renal biopsy should be considered in every cancer patient who develops urinary abnormalities or shows a worsening of renal function during treatment with immunotherapy or targeted therapy.

Keywords: Onconephrology, Immune checkpoint, Targeted Therapies, Renal biopsy in oncotherapy, Thrombotic Micro-angiopathy, Interstitial tubular nephritis

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Protected: Chronic Kidney Disease and Cancer: Ethical Choices

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Chiara Lenoci1, Gino Gobber2, Giuliano Brunori3

1 Scuola Specialità in Nefrologia, Università Studi di Verona
2 UOC Cure Palliative, APSS Trento
3 UOC Nefrologia e Dialisi, APSS Trento

Corresponding author:
Giuliano Brunori
U.O.M. Nefrologia e Dialisi
Direttore di Dipartimento Medico Specialistico
Ospedale S. Chiara - Trento
uff.: 0461904405
E-mail: giuliano.brunori@apss.tn.it

 

Abstract

Cancer and chronic kidney disease prevalence both increase with age. As a consequence, physicians are more frequently encountering older people with cancer who need dialysis, or patients on dialysis diagnosed with cancer. Decisions in this context are particularly complex and multifaceted. Informed decisions about dialysis require a personalised care plan that considers the prognosis and treatment options for each condition while also respecting patient preferences. The concept of prognosis should include quality-of-life considerations, functional status, and burden of care. Close collaboration between oncologists, nephrologists, geriatricians and palliativists is crucial to making optimal treatment decisions, and several tools are available for estimating cancer prognosis, prognosis of renal disease, and general age-related prognosis. Decision regarding the initiation or the termination of dialysis in patients with advanced cancer have also ethical implications. This last point is discussed in this article, and we delved into ethical issues with the aim of providing a pathway for the nephrologist to manage an elderly patient with ESRD and cancer.

Keywords: Chronic Kidney Disease, Cancer, Dialysis, Ethic, Onconephrology

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Protected: Management of Chemotherapy in Patients Subjected in Chronic Dialysis Treatment

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Pirovano Marta1, Re Sartò Giulia Vanessa1, Cosmai Laura1

1 Ambulatorio di Onconefrologia, UOC Nefrologia Dialisi ASST Fatebenefratelli Sacco

Corresponding author:
Laura Cosmai
ASST Fatebenefratelli Sacco – via G.B Grassi, 74
e-mail: lacos@iol.it

 

Abstract

The incidence of tumors is increased in patients with chronic renal failure and even more in patients on dialysis. Dialysis can affect both therapy and prognosis of oncological patients. It increases both cancer-related and non-cancer-related mortality rates and is the main cause of a suboptimal use of therapies. In patients with renal impairment, the dosage of many chemotherapies should be reduced but, due to the lack of real knowledge of the pharmacokinetic and pharmacodynamic properties of these drugs in dialysis, dosage adjustments are often done empirically and most often avoided.

Although many papers are available in the literature regarding chemotherapy in dialysis, there is a lack of consensus regarding drug dosages and administration schedules. Furthermore, guidelines are absent due to the lack of “evidence” for most of these patients, usually excluded from experimental treatments.

Specific onconephrologic trials are therefore mandatory to decide how much, how, and when to use chemotherapy in patients on dialysis and thereby ensure adequate treatment for these patients.

Keywords: onconephrology, dialysis, cancer, chemotherapy

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Protected: Cancer and the Kidney: A Deadly Embrace

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Dario Roccatello1, Simone Cortazzi1, Francesca Bertinetto1, Alessandra La Rosa1, Lorenzo Nescis1, Savino Sciascia1 e Roberta Fenoglio1

1 University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy

Corresponding author:
Dario Roccatello
Nefrologia & Dialisi – CMID, Università di Torino e Ospedale San Giovanni Bosco, Piazza del Donatore di Sangue 3, 10154, Torino, Italia
Telefono: +39 0112402056
Email: dario.roccatello@unito.it

 

Abstract

A deadly embrace occurs between cancer and chronic kidney disease.   The estimation of kidney function in cancer patients is of utmost interest due to its direct impact on chemotherapy dosing, selection, and eligibility for chemotherapeutics. Overestimating kidney function (determined as estimated glomerular filtration rate -eGFR) can lead to overdosing and drug toxicity, while underestimating kidney function can prevent patients from receiving novel therapies. Notably, the current measures of eGFR are not validated in transplanted patients yet.

The field of onconephrology ranges from nephrotoxicity of existing and novel therapeutics, paraproteinemias, and cancer-associated electrolyte imbalance, fluid and acid-base disturbances, the effects of the destruction of cancer cells, and acute and/or chronic kidney injuries. Recently, the therapeutic armamentarium has been enriched with new agents that interfere with specific proteins involved in oncogenesis. These are the so-called target therapies, which although acquired as “targeted” therapies do not have absolute specificity and selectivity and tend to inhibit multiple targets, often involving the kidney. Renal biopsy may be critical in managing these adverse effects. Moreover, primary hematological and oncological disorders can have significant kidney implications in the form of glomerular or nonglomerular diseases presenting with proteinuria, hematuria, hypertension, and kidney function decline, specifically including cast nephropathy or systemic light chain amyloidosis, and paraneoplastic glomerulopathies that occur as a result of occult malignancy, such as Membranous Nephropathy and Minimal Change disease.

Keywords: Onconephrology, Target Therapies, Renal biopsy in onconephrology, Cancer and kidney

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Protected: Ten Years of Onconephrology

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Laura Cosmai

Ambulatorio di Onconefrologia, UOC Nefrologia e Dialisi, ASST Fatebenefratelli Sacco, Milano

Corresponding author:
Laura Cosmai
ASST Fatebenefratelli Sacco – via G.B Grassi, 74
E-mail: lacos@iol.it

 

Abstract

Onconephrology is a subspecialty of Nephrology with the aim of fully dealing with the complex and bidirectional relationship between the tumor and the kidneys.
In a world where Nephrologists still too often consider Oncological patients as “lost” and in which Oncologists are afraid to administer oncological therapies to patients with renal failure due to the absence of Literature data, Onconephrology was created with the aim of guaranteeing patients with renal disease the same treatment opportunities as the general population.
Over the years this subspecialty has developed and more nephrologists, experts in the field, daily support oncologists in clinical-therapeutic decisions by dealing with cases of renal toxicity from oncological therapy, managing treatments in patients with renal failure and dealing with all those conditions associated with both oncological and renal pathology in terms of prevention and treatment.
In this paper we will retrace the history of Onconephrology by analyzing what are the results achieved and what are the objectives for the future. 

Keywords: onconephrology, history of onconephrology, oncological therapies

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