Kidney cancer: After the surgery

August 24, 2022

Estimating Post-Nephrectomy GFR May Guide Treatment Decisions
Natasha Persaud

A low predicted GFR after nephrectomy renders adjuvant systemic treatments unsafe and may prompt clinicians to use neoadjuvant therapies instead, according to investigators. Source: Getty Images
Accurate estimation of future glomerular filtration rate (GFR) could help clinicians decide whether to perform partial or radical nephrectomy for challenging cases of renal cell carcinoma (RCC) or upper tract urothelial carcinoma (UTUC) and whether to use neoadjuvant or adjuvant therapies, according to a new editorial published in Nature Reviews Urology.
“Precision in the measurement of [future] GFR is increasingly needed owing to the potential influence of [future] GFR on decision-making about surgical as well as systemic treatment options for a large number of patients with RCC and UTUC,” Federico Ferraris, MD, of Sanatorio Otamendi in Buenos Aires, Argentina, and colleagues wrote.
The reviewers noted, for example, that a low predicted post-nephrectomy GFR might encourage the use of neoadjuvant therapies, which could downsize the tumor and permit partial nephrectomy.
The reviewers lauded a recent GFR equation that provides accurate estimation of post-nephrectomy GFR based on 5 key clinical points: estimated preoperative GFR; patient age; type of nephrectomy; tumor size; and presence of diabetes mellitus.
Diego Aguilar Palacios, MD, of the Glickman Urological and Kidney Institute, Cleveland Clinic Foundation in Ohio, and colleagues developed the equation using data from 7860 patients with RCC undergoing partial or radical nephrectomy at Veterans Affairs facilities. They analyzed 94,327 first-year postoperative GFR measurements and defined new baseline GFRs as the final GFR within 3 to 12 months after surgery. The simplest equation for new baseline GFR was: 35 + preoperative GFR (× 0.65) – 18 (if radical nephrectomy) – age (× 0.25) + 3 (if tumor size greater than 7 cm) – 2 (if diabetes). The investigators validated the equation using both an internal and external cohort.
“Our study provides a validated equation to accurately predict postoperative new baseline glomerular filtration rate in patients being considered for radical nephrectomy or partial nephrectomy that can be easily implemented in daily clinical practice,” Dr Palacios’ team concluded in The Journal of Urology.
The main limitation of the equation is the use of estimated preoperative GFR rather than measured GFR and may need to be refined.
In their editorial, Dr Ferraris and his coauthors commented, “This equation (or any similar equation with the same characteristics) should be included in future diagnosis and treatment guidelines to generate personalized recommendations for patients with RCC and UTUC about the type of surgery, as well as the potential use and timing of treatment with systemic adjuvant therapies.”
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

References

Ferraris F, Raman JD, Musso CG, Rozanec J. Measuring renal function before kidney surgery – evolving towards precision in medicine. Nat Rev Urol. 2022 Aug;19(8):450-451. doi:10.1038/s41585-022-00613-1
Aguilar Palacios D, Wilson B, Ascha M, et al. New baseline renal function after radical or partial nephrectomy: A simple and accurate predictive model. J Urol. 2021 May;205(5):1310-1320. doi:10.1097/JU.0000000000001549

July 19, 2022

Substantial Discrepancies Found in Estimated vs Measured GFR in Individuals

Estimated glomerular filtration rate (based on creatinine and/or cystatin C) can differ by more than 30% from the measured glomerular filtration rate in individual patients, a study found.

In individual patients, an estimated glomerular filtration rate (eGFR) based on serum creatinine and/or cystatin C often differs substantially from measured GFR (mGFR), investigators reported in the Annals of Internal Medicine.
The individual-level difference between mGFR and eGFR is large, according to Tariq Shafi, MBBS, MHS, of The University of Mississippi Medical Center in Jackson, Mississippi, and colleagues. “Clinicians need to recognize that the eGFR is not an mGFR replacement and consider eGFR’s inaccuracy while managing individual patients.”
In analyses of data from 3223 participants across 4 studies, the investigators found that only 37% of eGFR results based on creatinine (eGFRCR) fell within 10% of mGFR. For example, at an eGFRCR of 45 mL/min/1.73 m2, 15% of the participants had an mGFR outside of the range of 30-60 mL/min/1.73 m2, 30% had an mGFR outside the range of 35-45 mL/min/1.73 m2, and 57% had an mGFR outside the range of 40-50 mL/min/1.73 m2. Such discrepancies between measured and estimated GFR were observed regardless of an individual’s race, age, or sex.
The agreement in chronic kidney disease (CKD) staging between mGFR and eGFRCR was only 58% overall, Dr Shafi’s team reported. Among the 42% of patients who were misclassified, 22% were reclassified to a lower CKD stage and 20% to a higher stage. For 39%, the misclassification was by 1 CKD stage.
The eGFR equations incorporating cystatin C did not improve the probability of large errors and CKD stage misclassification. The investigators pointed out that non-GFR factors influence the serum concentration of creatinine and/or cystatin C, such as obesity, muscle mass, meat consumption, and fasting.
Findings Poised to Change Clinical Practice
The clinical implications of these findings are far-reaching. Underestimating GFR may exclude patients from receiving optimal therapies and overestimating GFR may leave patients vulnerable to drug adverse effects such as hyperkalemia from mineralocorticoid antagonists and toxicity from chemotherapy, Dr Shafi’s team pointed out.
In an interview with Renal & Urology News, Christine A. White, MD, MSc, of Queen’s University in Kingston, Ontario, Canada, who was not involved in the study, said the research by Dr Shafi and colleagues “exposes the substantial discrepancy that often exists between estimated GFR using creatinine or cystatin C and measured GFR in individuals. This discrepancy is not captured by the traditionally reported metric of overall population bias where individual positive and negative biases negate each other, leading to an erroneous impression of unbiased GFR estimation at the individual level.
“The discrepancy,” she continued, “has not been well appreciated by clinicians assessing patients’ kidney function who then make work-up and treatment decisions according to eGFR, nor is it explicitly addressed in many society clinical practice guidelines.”
Dr White said the study authors appropriately recommend that the uncertainty of eGFR be reported by laboratories alongside eGFR results and that GFR measurement should become more widespread. Dr White will be conducting a session on GFR measurement techniques at the American Society of Nephrology’s Kidney Week in November 2022.
“There are many ways to measure GFR using either renal or plasma clearance of a variety of exogenous markers with different sampling strategies,” she said. Few comparative studies have evaluated various protocols against the gold standard renal inulin clearance, which is no longer commercially available, she noted.
“Available studies indicate that GFR measurement protocols should be tailored according to specific patient characteristics such as level of eGFR and presence of edema,” Dr White said.
Iohexol has several advantages over other tracers, she explained. It is non-radioactive, inexpensive, and already in use worldwide as a contrast media, so it is “poised to become a preferred tracer.”
According to Dr White, “Studies such as this one may galvanize the development of GFR measurement protocols that are both accurate and logistically and economically feasible across the spectrum of GFR and clinical presentations.”
The study authors noted that advances in nonradiolabeled GFR measurement techniques have made it a “highly feasible” and safe outpatient procedure. Race, sex, age, and socioeconomic factors should not cause errors, although results may vary due to normal physiology and measurement errors, such as incomplete bladder emptying. It should be a “priority” and made “widely available,” they wrote.
The 4 cohorts in this study included GENOA (Genetic Epidemiology Network of Arteriopathy), ALTOLD (Assessing Long Term Outcomes in Living Kidney Donors), ECAC (Epidemiology of Coronary Artery Calcification), and CRIC (Chronic Renal Insufficiency Cohort). Overall, 58% of participants were White, 32% Black, 7% Hispanic, and 3% another race. The GFR was directly measured using urinary clearance of nonradiolabeled iothalamate in GENOA and ECAC, radiolabeled iothalamate in CRIC, and plasma clearance of iohexol in ALTOLD.
The investigators calculated eGFRCR using the Chronic Kidney Disease Epidemiology (CKD-EPI) 2021 race-free equation, which is valid only in adults, and the European Kidney Function Consortium (EKFC) equation, which is valid in individuals aged 2 years or older. They calculated the eGFR from serum cystatin C (eGFRCYS) and from serum creatinine and serum cystatin C combined (eGFRCR-CYS) using the CKD-EPI 2012 and 2021 equations, respectively.
Reference
Shafi T, Zhu X, Lirette ST, et al. Quantifying individual-level inaccuracy in glomerular filtration rate estimation: a cross-sectional study. Ann Intern Med. Published online July 4, 2022. doi:10.7326/M22-0610

July 14, 2022
Cardiovascular Outcomes Worsen With Declining Kidney Function

Jody A. Charnow

Intensive vs conservative management of chronic coronary disease is significantly associated with an increased risk for stroke and procedural myocardial infarction across stages of chronic kidney disease, according to investigators. Source: Getty Images
The risk for death or nonfatal myocardial infarction among patients with chronic coronary disease increases with declining kidney function, according to a recent study.

In addition, the study demonstrated that invasive management of chronic coronary disease was significantly associated with an increased risk for stroke and procedural myocardial infarction as well as improved angina-related quality of life (QOL).

The findings are from a study of 5956 participants in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) and ISCHEMIA-Chronic Kidney Disease (CKD) trials. The primary clinical outcome was a composite of death or nonfatal myocardial infarction. The primary QoL outcome was the Seattle Angina Questionnaire (SAQ)-7 summary score. The median follow-up duration was 3.1 years.

The 3-year cumulative incidence of the primary clinical outcome were 9.5%, 10.7%, 18.2%, 34.2%, and 38.0% for patients with CKD stage 1, 2, 3, 4, and 5, respectively, Sripal Bangalore, MD, MHA, of the New York University Grossman School of Medicine in New York City, and colleagues reported in JAMA Cardiology.

Overall, the 3-year cumulative incidence of stroke was 2.2% with invasive management compared with 1.2% with conservative management, according to the investigators. The 3-year cumulative incidence of stroke was significantly higher among patients with stage 4 CKD (5.7% vs 0.7%) and stage 5 CKD or dialysis (6.8% vs 2.1%).

Results also showed that the 3-year cumulative incidence of procedural myocardial infarction was significantly higher with intensive vs conservative management (2.6% vs 1.0%), but the 3-year cumulative incidence of non-procedural myocardial infarction was significantly lower with intensive management (5.5% vs 8.0%).
The increased risks of stroke and procedural myocardial infarction associated with invasive management were consistent across CKD stages, according to investigators.

Invasive management was significantly associated with improved angina-related QOL in patients with CKD stages 1-3, but not in those with CKD stages 4-5. Among patients with stages 1, 2, and 3 CKD, the SAQ-7 QOL summary scores were 79.8, 80.1, and 81.1, respectively, in the intensive management group and 76.0, 76.8, 76.4 in the conservative treatment group, Dr Bangalore’s team reported.

“The study reinforces the evidence that cardiovascular rather than end-stage kidney disease is the leading cause of death in this high-risk population,” the authors wrote. “This finding challenges the practice of excluding patients with CKD from cardiovascular clinical trials owing to a misconception that most deaths will likely be noncardiovascular and hence nonmodifiable with cardiovascular therapies.”

Reference
Bangalore S, Hochman JS, Stgevens SR, et al. Clinical and quality-of-life outcomes following invasive vs conservative treatment of patients with chronic coronary disease across the spectrum of kidney function. JAMA Cardiol. Published online June 29, 2022. doi:10.1001/jamacardio.2022.1763

July 6, 2022

New Insight Into Surgical Treatment of Metastatic Renal Cell Carcinoma

Major complications within 30 days of metastasectomy for metastatic renal cell carcinoma occur in 8.4% of cases, a much lower rate than population-based registry data suggest, according to investigators

Studies presented at the 37th Annual European Association of Urology Congress in Amsterdam, The Netherlands, may provide insight into the surgical management of metastatic renal cell carcinoma (mRCC).

Findings from one of the studies suggest that cytoreductive partial nephrectomy (PN) may be an acceptable alternative to cytoreductive radical nephrectomy (RN) for selected patients. In another study, a team found that robotic radiosurgery, a subspecialty of stereotactic body radiotherapy, is safe and effective for lung metastases. In a third study, investigators characterized perioperative morbidities associated with surgical metastasectomy.
The cytoreductive study included 55 and 54 patients undergoing cytoreductive PN and RN, respectively. A key inclusion criterion was remaining functional renal parenchymal volume greater than 50%. That volume was 79.0% (range 67.5%-85.8%) in the PN group vs 60.5% (range 52.0%-69.0%) in the RN group.
The PN group had significantly longer 5-year survival compared with RN group (32.1 vs 15.5 months). PN vs RN was significantly associated with a 38% decreased risk for death, presenting author Iurii Vitruk, MD, of the National Cancer Institute in Kiev, Ukraine, reported.
“Kidney preservation in [the] metastatic setting can play a role in reducing potential adverse systemic therapy events and decreasing risks of concomitant pathology deterioration within selected patients,” he said. The indication for cytoreductive PN is remaining functional parenchymal volume over 65.7%, according to Dr Vitruk.
In terms of IMDC risk group classification, 85.4% of the PN group and 98.2% of the RN group had favorable- or intermediate-risk disease.
The robotic radiosurgery (RSS) study was a retrospective single-center analysis that included 50 patients with RCC-associated lung metastases. Of these, 49 patients had clear cell and 1 had papillary RCC. The patients had a median age of 64 years at the time of RSS. Of the 50 patients, 32 (64%) had oligometastatic disease at the time of RRS and 21 (42%) received systemic therapy during RRS.
The median overall survival (OS) and progression-free survival (PFS) were 35 months and 13 months, respectively, Severin Rodler, MD, of Klinikum der Universität München in Munich, Germany, reported on behalf of his team. Only 1 patient experienced local recurrence at the treated site, and this was observed 13 months after RRS. Investigators observed adverse events in 6 (11.8%) patients, and all were grade 1 or 2.
“Robotic radiosurgery is safe and effective local treatment option for patients with metastatic RCC with high local tumor control rates,” Dr Rodler said.”
The impact on OS and PFS remains unclear, he said, but it seems to be promising considering that the patients had progressive disease at the time of RRS.
The study of perioperative morbidity resulting from surgical metastasectomy examined 30-day complications after the procedure at 2 high-volume surgical centers: Mayo Clinic in Rochester, Minnesota, and University Hospitals Leuven in Leuven, Belgium. The study included 740 surgical metastasectomies in 522 patients. The 30-day rate of major complications was 8.4%, first author Eduard Roussel, MD, of University Hospitals Leuven, reported. The rate is much lower than reflected in population-based registry data, which show an incidence of high-grade postoperative morbidity as high as 25%, he said.
Multivariable analysis demonstrated that each 10-year increase in age was significantly associated with 1.5-fold increased odds of major complications, Dr Roussel reported. Patients with multiple sites of metastasis vs a single site had significant 2.4-fold increased odds for major complications. Pancreatic metastasis significantly increased the odds of major complications 5.7-fold.
“Along with increasing age and comorbidity, patients who harbor multiple sites of disease and also those who have pancreatic metastases are at the highest risk of experiencing high-grade postoperative morbidity following these procedures,” he said.
Dr Roussel also observed, “Patients who harbor pancreatic metastases are generally considered good candidates for metastasectomy from a survival point of view, but the increased risk for perioperative morbidity provides a surgical counterargument to offer metastasectomy to these patients, and especially if they are less fit.”

References
Vitruk I, Semko S, Voylenko O, et al. Oncological results of cytoreductive partial nephrectomy in mRCC patients. Presented at: EAU 2022, July 1-4, 2022, Amsterdam, The Netherlands. Abstract A0372.
Rodler S, Schott M, Casuscelli J, et al. Robotic radiosurgery for the treatment of lung metastases of renal cell carcinoma. Presented at: EAU 2022, July 1-4, 2022, Amsterdam, The Netherlands. Abstract A0376.
Roussel E, Lyon TD, Sharma V, et al. Perioperative morbidity of surgical metastasectomy for renal cell carcinoma: An international multicenter study. Presented at: EAU 2022, July 1-4, 2022, Amsterdam, The Netherlands. Abstract A0373.

Here's what I have experienced as far as stages of cancer. I don't mean the cancer itself, I mean how one experiences it.....

1. Stage 1: You get diagnosed. Anger, disbelief, fear, depression.

2. Stage 2: You get it taken out. Relief, joy, optimism.

3. Stage 3: First 6 month scan. Anxiety, then relief (if you are NED).

4. Stage 4: One year scan. Anxiety, relief, you forget about it for a while.

5. Stage 5: 18 month scan. Anxiety, relief, then you realize this is it for the rest of your life. Now more than ever every day counts. Not one day goes by that you don't remember it. Days are precious. Not so much fear of it returning, but putting yourself first, maybe for the first time, not in a selfish way, in a healthy way.

June 17, 2022

Race-Free eGFR Equation Based on Creatinine, Cystatin C Preferable
Natasha Persaud

The 2021 race-free equation including both creatinine and cystatin C appropriately shows higher risk for kidney failure and early death among Black than non-Black individuals.

Among equations for estimating glomerular filtration rate (eGFR) developed by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), the 2021 race-free eGFR equation including both creatinine and cystatin C (eGFRcr-cys) is preferable to the 2021 creatinine-only equation refit without the race coefficient (eGFRcr) for documenting racial disparities in the risk for kidney failure and death, investigators reported in JAMA.
The 2021 race-free eGFRcr-cys appropriately shows the racial gaps that were previously observed with the conventional 2009 creatinine-based equation including the race coefficient. The 2021 race-free eGFRcr inappropriately diminishes these racial gaps. Other equations also appeared suboptimal.

Josef Coresh, MD, PhD, of Johns Hopkins Bloomberg School of Public Health and the Chronic Kidney Disease Prognosis Consortium Data Coordinating Center, Baltimore, Maryland, and colleagues analyzed 62,011 adults from 5 general population and 3 chronic kidney disease (CKD) cohorts from 1988 to 2018. Of these, 20,773 individuals were Black and 41,238 were non-Black race.
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Both 2021 equations documented a greater burden of CKD in the Black population. The prevalence ratio of CKD (eGFR less than 60 mL/min/1.73 m2) among Black vs non-Black patients was 1.2 using eGFRcr-cys and 1.8 using race-free eGFRcr.

During a mean 13 years, kidney failure requiring renal replacement therapy (KFRT) occurred in 8% vs 4% of Black and non-Black patients, respectively; death occurred in 34% vs 39%, respectively. At an eGFR of 60 mL/min/1.73 m2, the 5-year absolute risk difference of KFRT among Black vs non-Black patients was 1.3% using race-free eGFRcr-cys compared with 0.37% using race-free eGFRcr.

At an eGFR of 60 mL/min/1.73 m2, the hazard ratios for all-cause and cardiovascular mortality using the eGFRcr-cys were 1.1 and 1.3, respectively — significantly higher for Black than non-Black individuals. Mortality risks did not differ significantly between race groups using the 2021 eGFRcr.

“These findings offer compelling evidence that the new 2021 eGFRcr-cys [based on age and sex] consistently estimates greater prevalence of decreased kidney function for Black individuals compared with non-Black individuals,” L. Ebony Boulware, MD, MPH, and colleagues from Duke University School of Medicine in Durham, North Carolina, commented in an accompanying editorial. “The equation also appropriately quantifies racial disparities in kidney disease risk and mortality across the spectrum of kidney dysfunction, a crucial prerequisite for efforts to intervene on and track improvements in kidney health equity.”

References
Gutiérrez OM, Sang Y, Grams ME, et al. Association of estimated GFR calculated using race-free equations with kidney failure and mortality by Black vs Non-Black race. JAMA. Published online June 6, 2022. doi:10.1001/jama.2022.8801

It ain’t over till the fat lady sings, in this case the kidney surgeon. Scan is clear but, there always is a “but”, the tumor poked into the renal vein which means high risk, but the cell type is low risk so all the projections on risk are out the window.

Another 6 month scan over today. Make no mistake about it, no one really knows what it is like other than other kidney cancer survivors. What keeps playing over in my head is "your're cured!" and "see you in six months". It's like saying a ball is square or an apple is a banana. Could one call it a lie? In my case the chances of a return are low given the cancer cell type. So it's a game of roll the dice or flip the coin. What are the chances? Let's say 1 in 100. Is anything other than 0 in 100 peaceful? There's still that "1" hanging out there.

Home » News » Nephrology » Chronic Kidney Disease (CKD)
Publish DateMay 3, 2022

Exercise May Slow Kidney Function Decline in Older Adults

Natasha Persaud
In a study of older adults, an exercise intervention decreased the odds of rapid eGFR decline by a significant 21%.
Moderate-intensity physical activity can slow decline in estimated glomerular filtration rate (eGFR) in sedentary older adults, a new study finds.

In the LIFE (Lifestyle Interventions and Independence For Elders) trial, investigators randomly assigned 1199 adults aged 70 to 89 years with mobility limitations to moderate-intensity physical activity or a health education workshop. Of the cohort, two-thirds had an eGFR less than 60 mL/min/1.73 m2, using cystatin C as the filtration marker. The activity component targeted 30 minutes of walking daily as well as 10 minutes of lower-extremity strength training, 10 minutes of balance training, and large-muscle flexibility exercises. This analysis was an ancillary study of the original trial.
Over 2 years, the physical activity and exercise intervention led to mean 0.96 mL/min/1.73 m2 less decline in eGFR compared with a health education workshop, Michael G. Shlipak, MD, MPH, of San Francisco VA Health Care System in California, and colleagues reported in JAMA Internal Medicine.

Patients with the highest quartile of step count (3470 steps/d or more) had an approximately 2 mL/min/1.73 m2 slower decline in eGFR and, in a fully adjusted model, a significant 38% decreased odds of rapid decline compared with patients with the lowest quartile of step count (1567 steps/d or less).

Of the 1199 older adults, 29.1% experienced rapidly declining kidney function (defined as 6.7% per year), including 25.9% of the physical activity group and 32.2% of the health education group. The exercise intervention decreased the odds of rapid eGFR decline by a significant 21% compared with the control group. The effect appeared stronger among patients without cardiovascular disease.
“Clinicians should consider prescribing physical activity and moderate-intensity exercise for older adults to slow the rate of decline of kidney function,” according to Dr Shlipak’s team. They cautioned that exercise sessions need to be individualized.
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference

Shlipak MG, Sheshadri A, Hsu FC, et al. Effect of structured, moderate exercise on kidney function decline in sedentary older adults: an ancillary analysis of the LIFE study randomized clinical trial. JAMA Intern Med. Published online May 2, 2022. doi:10.1001/jamainternmed.2022.1449

4/22/22

Kidney Cancer Metastases Effectively Treated With Robotic Radiosurgery

Robotic radiosurgery (RRS) was safe and effective for treating metastases of renal cell carcinoma (RCC) in a study that involved a highly selected group of patients, according to a presentation at IKCS Europe 2022.
Long-term outcomes appeared favorable, investigators concluded.
The study cohort included 50 patients with lung metastases, 44 with visceral metastases, and 16 with lymph node metastases who underwent image-guided RRS. Indications for treatment included oligometastatic disease defined as 5 or fewer lesions and oligoprogressive disease or limited systemic treatment options. At the time of the procedure, patients had a median age of 64 years. Of the 110 patients, 102 presented with clear cell RCC, 1 had papillary type 1, 3 had papillary type 2, and 3 had chromophobe histology, and 1 patient had a RCC with TFE3 translocation.
Recurrent disease developed in 3 patients. The median progression-free survival was 13.0, 17.2, and 22.5 months for patients with lung, visceral, and lymph node metastases, respectively, investigator Severin Rodler, MD, of Klinikum der Universität München in Munich, Germany, reported. The median overall survival was 35.0, 65.7, and 36.8 months, respectively.
Adverse events (AEs) were limited to grade 1 or 2, although 1 patient experienced a grade 4 stroke and thrombosis. The most frequent AE was fatigue (8 patients), followed by pneumonitis (2 patients).

Reference
Schott M, Casuscelli J, Graser A, et al. Image-guided robotic radiosurgery for the treatment of metastases of renal cell carcinoma. Presented at IKCS Europe in Antwerp, Belgium. April 22-24, 2022. Poster 15.

Association of Medical Financial Hardship and Mortality Among Cancer Survivors in the United States
K Robin Yabroff, PhD, MBA, Xuesong Han, PhD, Weishan Song, MS, Jingxuan Zhao, MS, Leticia Nogueira, PhD, Craig E Pollack, MD, MPH, Ahmedin Jemal, DVM, PhD, Zhiyuan Zheng, PhD
JNCI: Journal of the National Cancer Institute, djac044, https://doi.org/10.1093/jnci/djac044

Published:
20 April 2022

Abstract
Background
Cancer survivors frequently experience medical financial hardship in the United States. Little is known, however, about long-term health consequences. This study examines the associations of financial hardship and mortality in a large nationally representative sample of cancer survivors.
Methods
We identified cancer survivors aged 18-64 years (n = 14 917) and 65-79 years (n = 10 391) from the 1997-2014 National Health Interview Survey and its linked mortality files with vital status through December 31, 2015. Medical financial hardship was measured as problems affording care or delaying or forgoing any care because of cost in the past 12 months. Risk of mortality was estimated with separate weighted Cox proportional hazards models by age group with age as the timescale, controlling for the effects of sociodemographic characteristics. Health insurance coverage was added sequentially to multivariable models.
Results
Among cancer survivors aged 18-64 years and 65-79 years, 29.6% and 11.0%, respectively, reported financial hardship in the past 12 months. Survivors with hardship had higher adjusted mortality risk than their counterparts in both age groups: 18-64 years (hazard ratio [HR] = 1.17, 95% confidence interval [CI] = 1.04 to 1.30) and 65-79 years (HR = 1.14, 95% CI = 1.02 to 1.28). Further adjustment for health insurance reduced the magnitude of association of hardship and mortality among survivors aged 18-64 years (HR = 1.09, 95% CI = 0.97 to 1.24). Adjustment for supplemental Medicare coverage had little effect among survivors aged 65-79 years (HR = 1.15, 95% CI = 1.02 to 1.29).
Conclusion
Medical financial hardship was associated with mortality risk among cancer survivors in the United States.

Association of Medical Financial Hardship and Mortality Among Cancer Survivors in the United States AbstractBackground. Cancer survivors frequently experience medical financial hardship in the United States. Little is known, however, about long-term health con

April 4, 2022

Cancer Is Associated With Increased Kidney Failure Risk
Natasha Persaud

Among patients with chronic kidney disease, those with vs without cancer had a significant 1.4-fold increased risk for kidney failure requiring renal replacement therapy, according to a recent study.
Patients with cancer have a higher risk for kidney failure requiring replacement therapy (KFRT), and that risk differs by cancer type, a new study finds.

Using the Korean National Health Insurance Service database, investigators examined KFRT risk among 824,365 Korean patients with cancer compared with 1,648,730 patients without cancer matched by age, sex, estimated glomerular filtration rate (eGFR), diabetes status, and hypertension status.

KFRT was required for 1.07 patients with cancer compared with 0.51 patients without cancer per 1000 person-years, Soo Wan Kim, MD, PhD, Chonnam National University Medical School, Korea, and colleagues reported in the American Journal of Kidney Diseases. Cancer was significantly associated with a 2.3-fold increased risk for KFRT, in a fully adjusted model. Among patients with chronic kidney disease (CKD), those with vs without cancer had a significant 1.4-fold increased risk for KFRT. Among patients with proteinuria, cancer was associated with a significant 1.3-fold increased risk for KFRT.

“The presence of kidney failure has significant influence on the treatment options available to patients with cancer, including certain chemotherapeutic agents, hematopoietic stem cell transplant, and surgery, and affects overall cancer-related survival,” Dr Kim’s team wrote. “Therefore, it is crucial for nephrologists and oncologists to be aware of the risk of KFRT in patients with cancer so better preventive strategies can be developed.”
Across 23 types of cancer, KFRT risk was higher among patients with hematologic malignancies than for patients with solid cancers. Multiple myeloma was significantly associated with a 19-fold increased risk for KFRT compared with no cancer (29.1 cases per 1000 person-years). Among the solid cancers, kidney, liver, ovary, cervix, bladder, uterus, and esophagus cancer were associated with a 4.9-, 3.9-, 3.9-, 3.9-, 3.3-, 2.9, and 2.1-fold higher risk of KFRT, respectively, compared with no cancer. Dr Kim’s team observed that “patients with these cancers require greater kidney failure prevention efforts and closer surveillance.”

No greater risk for KFRT was observed with cancers of the pancreas, lung, skin, oral cavity, larynx, and nerves.
The investigators adjusted models for age, sex, smoking, alcohol, exercise, low income, body mass index, proteinuria, diabetes, hypertension, dyslipidemia, ischemic heart disease, stroke, peripheral artery disease, and CKD.

Nephrotoxicity from anticancer therapy, electrolyte/metabolic disturbances, contrast medium-associated acute kidney injury, nephrectomy, and obstructive nephropathy due to cancer invasion or lymphadenopathy are some well-known the risk factors for kidney injury in patients with cancer, the investigators noted.
Reference

Kim CS, Kim B, Suh SH, et al. Risk of kidney failure in patients with cancer: a South Korean population-based cohort study. Am J Kidney Dis. 79(4):507-517. doi:10.1053/j.ajkd.2021.06.024