Renal failure in cancer

Almost a third of patients with oncological diseases and those who fall into the ICU are diagnosed with impaired renal function. Most often, in about 80% of cases, various tubular dysfunctions are observed. In 10% of cases, nephropathy is manifested by severe arthrosis or chronic renal failure, the treatment of which involves renal replacement therapy.

[1], [2]

Causes of kidney failure in cancer

Nephropathy develops due to various operations, extensive blood loss, the use of nephrotoxic drugs and specific causes in cancer diseases:

• Operative intervention in the volume of resection of a single kidney, or nephrectomy - increasing the functional load on the remaining kidney.
• Resection and plastic of the ureters, the bladder leads to a violation of the outflow and absorption of urine from the intestine.
• Resection and plasticization of the inferior vena cava and renal veins due to tumor thrombosis or retroperitoneal tumor provokes thermal ischemia during surgery and / or blood flow disorders in the postoperative period.
• Operative intervention, accompanied by extensive tissue trauma, blood loss and unstable hemodynamics, which requires the use of catecholamines intraoperatively and in the early postoperative period, promotes the development of nephropathy.
• The use of nephrotoxic drugs (antibiotics, dextrans, etc.). Nephropathy manifests itself in an increase in the level of creatinine and urea (by a factor of 1.5-2), a decrease in the rate of diuresis to 25-35 ml / h. Less often observed a moderate increase in the level of K +, not exceeding 5.5-6 mmol / l.
• Specific causes of nephropathy in tumorous diseases are most often associated with obstruction of the urinary tract tumor or large vessels of the kidneys, nephrotoxic action of antitumor drugs and maintenance drugs, electrolyte and purine metabolism disorders during the antitumor treatment, replacement of renal parenchyma with tumor tissue, radiation damage to the kidneys.

Possible causes of renal failure associated with the presence of a tumor disease

	Causes associated with a tumor	Causes associated with antitumor treatment
Prerenal	Hypovolemia and critical hypotension (bleeding, extrarenal fluid loss during vomiting or diarrhea, extravasation of fluid in case of polyserositis, etc.) Obstruction of the kidneys of the kidney by the tumor node or tumor thrombus of the renal veins	Complications of the postoperative period leading to shock development Severe sepsis, extrarenal fluid loss during vomiting or diarrhea Thrombotic microangiopathy Hepatorenal thrombosis
Renal	Tubulointerstitsialnye nephritis (with hypercalcemia and hyperuricemia) Infiltration of kidney tumor (cancer of kidney lymphoma, leukemia) Glomerulonephritis Amyloidosis	Nephrectomy or resection of a single functioning kidney Nephrotoxic effect of chemotherapy drugs (cisplatin, methotrexate, etc.), ancillary drugs (amphotericin B, aminoglycosides, bisphosphonates of hyperosmolar radiopaque agents) Urinary acid nephropathy in the syndrome of rapid tumor decay
Emergency services	Obstruction of the urinary tract by tumor (retroperitoneal and pelvic tumors of bladder prostate cancer) Bladder tamponade with bleeding from the tumor High intra-abdominal pressure (ascites)	Nephrolithiasis due to hypercalcemia, hyperuricemia Tamponade of the bladder

In the role of the causes of the development of acute renal failure, the same factors usually occur, as in nephropathy, but more effective. Acute tubular necrosis underlies most of the cases of arthritis, in particular in 80% of the cases occurring in the intensive care units. The cause of acute renal failure in 50% of cases is ischemic, and in 35% toxic kidney damage. The main cause of acute tubular necrosis in sepsis is marked renal hypoperfusion.

[3], [4], [5], [6],

How does kidney failure develop in cancer?

The pathophysiological basis of acute renal failure in cancer is local hemodynamic and ischemic disorders, as well as toxic damage to the tubular cells. In accordance with these disorders, the glomerular filtration rate decreases as a result of intracellular vasoconstriction with a decrease in glomerular filtration pressure, tubular obstruction, transtubular leakage of the filtrate, and interstitial inflammation.

With tubular necrosis, as a rule, after 2-3 weeks, the renal function is restored, the levels of urea and creatinine progressively decrease the clinical picture.

The clinical picture of acute renal failure manifests itself in an increase in the level of creatinine and urea (more than 2-3 times), an increase in the level of potassium in the blood (more than 6 mmol / l), a decrease in the rate of diuresis (less than 25 ml / h).

Classification

Renal function disorders that develop in the postoperative period are classified into two large groups that determine further diagnostic and therapeutic tactics in the ICU - nephropathy and acute renal failure in cancer.

[7], [8], [9]

Diagnosis of kidney failure in cancer

Diagnostics is facilitated not only by the results of clinical and instrumental examinations, but also by data obtained as a result of the collection of anamnesis and analysis of previous treatment.

Diagnostic tactics for nephropathy includes:

• carrying out a biochemical blood test (level of urea and creatinine),
• analysis of the acid-base state of the blood (pH and electrolyte level),
• general urine analysis,
• determination of creatinine clearance (as a dynamic indicator and for the calculation of drug doses),
• Ultrasonography of the kidneys (with evaluation of the state of renal blood flow, parenchyma and bowel-and-pelvis system),
• bacteriological examination of urine (to exclude exacerbation of chronic pyelonephritis).

[10], [11],

Indications for consultation of other specialists

Adequate assessment of the cause of acute renal failure, the volume of additional examination and effective treatment require concerted work of intensive care specialists, nephrologists (determining the volume of nephrological benefit and providing replacement renal therapy) and oncologists. However, less than half of cases of severe arthritis are associated with specific (tumor) causes, in 60-70% of cases of acute renal failure develops due to shock and severe sepsis.

Treatment of renal failure in cancer

The main condition for successful treatment of nephropathy and arthritis in operated patients is the elimination or minimization of the maximum possible number of causes contributing to their development. Considering the tactics of treatment of acute renal failure, it is necessary to pay attention to the rate of increase in creatinine and potassium, the total amount of urine and the availability of clinical data of volumetric overload of the patient, that is, the threat of AL.

Non-drug treatment

Intensive treatment of acute renal failure, in addition to conservative methods used in nephropathy, includes extracorporeal detoxification. The choice of methods for extracorporeal detoxification, its duration and multiplicity depends on the clinical situation:

• isolated OPN - HD,
• ARF in the PON, against sepsis, with the addition of ARDS - GDF,
• prevalence of patient overload with liquid (including AL threat) - isolated UV.

The choice between prolonged or discrete regimens of extracorporeal detoxification is determined primarily by the severity of acute renal failure, as well as by the state of hemostasis systems (hypocoagulation, thrombocytopenia) and hemodynamics (need for catecholamines, cardiac rhythm disturbances).

Medication

The main aspects of nephropathy correction in intensive care:

• Maintaining adequate renal blood flow is sufficient bcc, epidural blockade.
• Improvement of rheological properties of blood (disaggregants, low molecular weight heparins).
• The appointment of specific solutions of amino acids and enteral nutrition ("-nefro", "-renal").
• Ingestion of lactulose preparations, if possible.
• Stimulation of diuresis according to indications (furosemide or osmotic diuretics).

The appointment of dopamine in the so-called "renal dose" (1-3 μg / kg hmin) does not lead to a decrease in the level of creatinine, but in most elderly patients with atherosclerosis of renal vessels causes an increase in the rate of diuresis (increases the water excretory function), which is important in infusion therapy.

Correction of MIH, such as hypotension, respiratory and hepatic insufficiency, pancreatitis, anemia (less than 8-8.5 g / dL), as organ dysfunction aggravates nephropathy and leads to the development of arthritis.

Sanitation of extrarenal and renal foci of infection.

The appointment of nephrotoxic drugs only in case of emergency.

Prognosis of renal failure in cancer

The duration of nephropathy usually does not exceed 5-7 days, the further development of the clinical situation leads either to its resolution or to the development of acute renal failure. According to the French multicentre study, OPN is diagnosed in 48% of septic patients with a mortality rate of 73% in this group. Sepsis remains one of the main causes of ARF development, despite significant achievements in intensive care, the mortality rate of patients with this pathology has not changed over the past decades, remaining very high.