The Care of Patients with Kidney Disease and Cancer

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the latest
00:12 --> 00:14information on cancer care by welcoming
00:14 --> 00:17oncologists and specialists who are on the
00:17 --> 00:19forefront of the battle to fight cancer.
00:19 --> 00:21This week, it's a conversation about the
00:21 --> 00:23care of patients with kidney disease
00:23 --> 00:25and cancer with doctor Anushree Shirali.
00:25 --> 00:27Dr. Shirali is an associate professor
00:27 --> 00:29of medicine in the section of nephrology
00:29 --> 00:31at the Yale School of Medicine,
00:31 --> 00:32where Doctor Chagpar is a
00:32 --> 00:34professor of surgical oncology.
00:35 --> 00:37Maybe we could start off by you
00:37 --> 00:39telling us a little bit more about
00:39 --> 00:42yourself and what it is you do.
00:42 --> 00:44I'd be happy to.
00:44 --> 00:47So I am a clinical nephrologist and
00:47 --> 00:51I have been here at Yale since about
00:51 --> 00:532006 when I came for fellowship.
00:53 --> 00:55I spent a few years in an
00:55 --> 00:57immunology lab and then joined
00:57 --> 01:00the clinical faculty back in 2011.
01:00 --> 01:03That's when Smilow was just getting off
01:03 --> 01:06the ground and there was a real need
01:06 --> 01:08for renal specific or kidney
01:08 --> 01:10specific care of cancer patients.
01:10 --> 01:14So I started seeing cancer patients
01:14 --> 01:17who have any sort of kidney issue
01:17 --> 01:19and that in essence is what I do
01:19 --> 01:22now as a clinical practice that
01:22 --> 01:24is centered on onco nephrology.
01:25 --> 01:27So tell us a little bit
01:27 --> 01:29more about onco nephrology,
01:29 --> 01:31are there cancer patients who
01:31 --> 01:35have kidney issues or is that really
01:35 --> 01:37people who have kidney cancer?
01:38 --> 01:40Yeah, so it's a bit more expansive
01:40 --> 01:43than just patients who may have
01:43 --> 01:45cancer of the kidney.
01:45 --> 01:49Onco nephrology is a relatively new sub
01:49 --> 01:52specialty within the field of nephrology,
01:52 --> 01:55it really is about 10 to 15 years old.
01:55 --> 02:00And it involves the care of patients who have
02:00 --> 02:05either active cancer or a history of cancer,
02:05 --> 02:07who then develop kidney disease
02:07 --> 02:08in all of its forms.
02:08 --> 02:12And that could be something like having some
02:12 --> 02:15protein in the urine or blood in the urine.
02:15 --> 02:17Or it could be a change
02:17 --> 02:18in actual kidney function,
02:18 --> 02:20something that we measure by a
02:20 --> 02:22blood marker called creatinine.
02:22 --> 02:24And that change in creatinine could
02:24 --> 02:26happen over a short period of time
02:26 --> 02:29which we call acute kidney injury or it
02:29 --> 02:32could happen over a longer period of time,
02:32 --> 02:33something that we call chronic
02:33 --> 02:34kidney disease.
02:34 --> 02:37And then finally patients who have cancer
02:37 --> 02:40and particularly those who are
02:40 --> 02:42on certain types of active treatment
02:42 --> 02:44can also develop high blood pressure.
02:44 --> 02:46So the job of the onco nephrologist
02:46 --> 02:49is really to take care of patients
02:49 --> 02:51who have all these different
02:51 --> 02:53manifestations of kidney disease.
02:55 --> 02:57That's a really good point because
02:57 --> 03:00we know that people in general
03:00 --> 03:02can get kidney disease whether
03:02 --> 03:05they have hypertension or diabetes
03:05 --> 03:07or various other nephropathies.
03:07 --> 03:09And clearly people who have
03:09 --> 03:11cancer are also people
03:11 --> 03:13so they could get these things too.
03:13 --> 03:16But do people who have cancer and
03:16 --> 03:19are on certain therapies related
03:19 --> 03:22to cancer like chemotherapy or
03:22 --> 03:25people who have gotten radiation
03:25 --> 03:26for various reasons,
03:26 --> 03:28particularly to the abdomen,
03:28 --> 03:31are they at increased risk of
03:31 --> 03:33getting kidney disease and if so,
03:33 --> 03:36can you talk a little bit more about what
03:36 --> 03:38those things are that put them at risk?
03:38 --> 03:41Yes, definitely. And the answer is yes,
03:41 --> 03:45they are indeed at risk specifically from,
03:45 --> 03:47well in certain cases from the cancer itself.
03:47 --> 03:49So I'm thinking here of kidney cancer
03:49 --> 03:51when you have a nephrectomy
03:51 --> 03:53or removal of the kidney that's
03:53 --> 03:55been affected by tumor, you lose
03:55 --> 03:57some kidney function,
03:57 --> 04:01the surgical procedure itself can cause
04:01 --> 04:03certain types of injury to the kidney,
04:03 --> 04:06but yes, other types of therapies
04:06 --> 04:10for any kind of cancer can also cause
04:10 --> 04:12different manifestations of kidney disease,
04:12 --> 04:14particularly acute kidney injury.
04:14 --> 04:15And this is not something
04:15 --> 04:17new within oncology.
04:17 --> 04:19So platinum based drugs for example
04:19 --> 04:22have been around for a very long
04:22 --> 04:24time and we knew early on that
04:24 --> 04:26cisplatin is particularly toxic
04:26 --> 04:28to the kidney,
04:28 --> 04:30a part of the kidney called the
04:30 --> 04:32proximal tubule that's
04:32 --> 04:34really the workhorse of the kidney
04:34 --> 04:38can be damaged with use of cisplatin.
04:38 --> 04:40So that's something that
04:40 --> 04:42we've known for a long time.
04:42 --> 04:44There are other more what
04:44 --> 04:45we call targeted therapies.
04:45 --> 04:48So something that I think about or see
04:48 --> 04:52commonly is the use of inhibitors against
04:52 --> 04:55vascular endothelial growth factor,
04:55 --> 04:56which is a growth factor that
04:56 --> 04:57encourages tumor growth.
04:57 --> 05:01Inhibition of that is obviously of
05:01 --> 05:04importance when you're trying to
05:04 --> 05:06achieve tumor growth suppression.
05:06 --> 05:10But VEGF also happens to play an
05:10 --> 05:13integral role in maintaining the
05:13 --> 05:16vascular architecture of the kidney.
05:16 --> 05:19And so when these drugs first came out,
05:19 --> 05:21we noted that patients were presenting
05:21 --> 05:25with new onset or of high blood pressure
05:25 --> 05:28or if they had pre-existing hypertension
05:28 --> 05:31the control of that blood pressure became
05:31 --> 05:33worse with the use of VEGF inhibitors.
05:33 --> 05:35We then also noted that these patients
05:35 --> 05:37were getting protein in their urine
05:37 --> 05:39and when some of these
05:39 --> 05:42patients ended up getting biopsied,
05:42 --> 05:44we noticed something called
05:44 --> 05:45thrombotic microangiopathy.
05:45 --> 05:48Essentially they were getting in
05:48 --> 05:51their kidneys clots within the
05:51 --> 05:53blood vessels of the kidneys.
05:53 --> 05:57So we know that a variety of
05:57 --> 05:59different treatments for cancer
05:59 --> 06:01can cause
06:01 --> 06:04injury to the kidney itself and the
06:04 --> 06:08prompt diagnosis of these kidney
06:08 --> 06:12injuries can then lead to controlling
06:12 --> 06:13those manifestations better.
06:14 --> 06:16Yeah. So that was the other question.
06:16 --> 06:18Of course which is we
06:18 --> 06:20know that there are a number of side
06:20 --> 06:22effects of cancer therapies and
06:22 --> 06:24sometimes in order to try
06:24 --> 06:26to control the cancer you kind of
06:26 --> 06:29have to bite the bullet on the
06:29 --> 06:31risks associated with those therapies.
06:31 --> 06:35But it is concerning if
06:35 --> 06:38some of those factors are irreversible.
06:38 --> 06:41But what I'm gathering from you is
06:41 --> 06:44that so long as you can diagnose
06:44 --> 06:47it and treat it effectively that
06:47 --> 06:50these can be managed. Is that right?
06:50 --> 06:52Or does this sometimes lead
06:52 --> 06:54to irreversible kidney failure?
06:54 --> 06:56Yeah. So I want to, you know,
06:56 --> 06:58reassure that most of the
06:58 --> 07:00time it is indeed reversible.
07:00 --> 07:02So cisplatin is a great
07:02 --> 07:04example, it can cause an acute
07:04 --> 07:07rise in in the blood creatinine and
07:07 --> 07:10those are the referrals that I
07:10 --> 07:12get pretty quickly and patients often
07:12 --> 07:15you know express a lot of concern.
07:15 --> 07:17I don't want my kidneys to fail.
07:17 --> 07:19I don't want to end up on dialysis.
07:19 --> 07:21But in general the way we manage it is
07:21 --> 07:23quite conservatively.
07:23 --> 07:26You know usually there'll be a break
07:26 --> 07:29i chemotherapy they'll be just
07:29 --> 07:32supportive care and then
07:32 --> 07:34in the period of time, usually within weeks,
07:34 --> 07:37I've never had, you know,
07:37 --> 07:40injury last for several months,
07:40 --> 07:43but usually within a matter of a few weeks,
07:43 --> 07:45the kidney function will then return,
07:45 --> 07:47usually to normal.
07:47 --> 07:49Sometimes people will have a
07:49 --> 07:52creatinine that ends up being a bit
07:52 --> 07:54over what their baseline values are,
07:54 --> 07:56but in general, you know,
07:56 --> 07:59even if they have residual kidney disease,
07:59 --> 08:01it's very mild and it's very manageable.
08:05 --> 08:08So if people have already had
08:08 --> 08:10pre-existing kidney disease,
08:10 --> 08:13so let's say somebody has hypertension
08:13 --> 08:15and they're already starting to have
08:15 --> 08:18the first signs of kidney disease
08:18 --> 08:21and then they end up getting cancer,
08:21 --> 08:23are you often involved in
08:23 --> 08:26kind of helping to guide therapy?
08:26 --> 08:29I mean, should those patients avoid some
08:29 --> 08:32of the more nephrotoxic chemotherapies or
08:32 --> 08:34is this something where it's kind of like,
08:34 --> 08:38you know what we'll manage your cancer
08:40 --> 08:42and we'll kind of deal with whatever
08:42 --> 08:44we need to deal with on the back end?
08:46 --> 08:48The answer sort of depends on
08:48 --> 08:50what are the different choices for
08:50 --> 08:52therapy of that particular cancer
08:52 --> 08:55and that of course will depend
08:55 --> 08:57on what organ type is affected,
08:57 --> 08:59how advanced is the malignancy
08:59 --> 09:03and then it also depends on how bad is
09:03 --> 09:06the pre-existing kidney disease and
09:06 --> 09:08I definitely do see those patients
09:08 --> 09:11even before treatment is started
09:11 --> 09:14mostly so that the oncologists and
09:14 --> 09:17I can partner in potentially
09:17 --> 09:21modifying the types of treatment.
09:21 --> 09:22So for example,
09:22 --> 09:25many of these chemotherapies are
09:25 --> 09:27actually cleared by the kidney.
09:27 --> 09:29So it's not just that you worry
09:29 --> 09:31about the drugs that are going to be
09:31 --> 09:33toxic to the kidney and if someone
09:33 --> 09:35has pre-existing kidney disease
09:35 --> 09:37then their kidney disease gets worse
09:37 --> 09:39and that ends up being an issue.
09:39 --> 09:42But that even the therapies that
09:42 --> 09:44are not particularly nephrotoxic,
09:44 --> 09:47so toxic to the kidney are
09:47 --> 09:50metabolically cleared by the kidney.
09:50 --> 09:52And so what you then worry about
09:52 --> 09:54is that these chemotherapies could
09:54 --> 09:56build up and cause toxicity in
09:56 --> 09:59other organs if you have
09:59 --> 10:01preexisting kidney disease and you
10:01 --> 10:03can't quite clear the chemotherapy
10:03 --> 10:06that's being given to you.
10:06 --> 10:07And so we do have some guidelines
10:07 --> 10:09depending on the drug and how much
10:09 --> 10:11experience we have on it about
10:11 --> 10:13a dose reduction if you have
10:13 --> 10:15pre-existing kidney disease,
10:15 --> 10:18I've also had my own dialysis
10:18 --> 10:21patients develop cancer and that's
10:21 --> 10:23a particularly challenging thing
10:23 --> 10:25because you're dealing with their
10:25 --> 10:26dialysis treatments and you're
10:27 --> 10:28dealing with having to definitely
10:28 --> 10:30modify chemotherapy in order to
10:30 --> 10:32dose things safely and effectively
10:32 --> 10:34for the particular cancer.
10:35 --> 10:38Yeah. I mean, and it sounds like
10:38 --> 10:41certainly things can get a little bit
10:41 --> 10:44tricky when you're dealing with somebody
10:44 --> 10:47who has pre-existing kidney issues.
10:47 --> 10:50But one of the questions that might come up,
10:50 --> 10:53I mean, there are people who either have
10:53 --> 10:58donated a kidney or have lost a kidney
10:58 --> 11:03for whatever reason, either a benign
11:03 --> 11:06or perhaps a due to a trauma
11:06 --> 11:09have had either a partial or total
11:09 --> 11:11nephrectomy and after that
11:11 --> 11:14oftentimes they're told don't worry,
11:14 --> 11:18you have two kidneys you can you can live
11:18 --> 11:24quite happily on one, if they then get cancer,
11:24 --> 11:26does that cause an impediment
11:26 --> 11:29or is it that, you know,
11:29 --> 11:32so long as that one kidney is functioning,
11:32 --> 11:33they're still OK?
11:34 --> 11:35Yeah. So in a sense,
11:35 --> 11:37you're absolutely right.
11:37 --> 11:38When people have a nephrectomy,
11:38 --> 11:40whether it's traumatic or
11:40 --> 11:41sometimes it's congenital, right?
11:41 --> 11:43You're just born with one kidney.
11:43 --> 11:46That is the advice we give them that
11:46 --> 11:49you should be OK because your other
11:49 --> 11:52remnant kidney does start taking
11:52 --> 11:55over for the other kidney that
11:55 --> 11:57quote UN quote should be there,
11:57 --> 11:59and that is true.
11:59 --> 12:02You should be maintaining your
12:02 --> 12:04overall kidney function whether
12:04 --> 12:06you have one or two kidneys.
12:06 --> 12:09Having said that, that remaining
12:09 --> 12:12kidney remains in a sense
12:12 --> 12:15more susceptible because you're only working
12:15 --> 12:18with a certain amount of kidney reserve.
12:18 --> 12:21So yes, if the patients I think about
12:21 --> 12:23sometimes are the ones who have kidney
12:23 --> 12:25cancers and have had to have a nephrectomy.
12:25 --> 12:27And then end up being on some
12:27 --> 12:30sort of systemic treatment
12:30 --> 12:32that is potentially nephrotoxic.
12:32 --> 12:34And so there I do worry a little
12:34 --> 12:36bit more because you're working
12:36 --> 12:38with less kidney reserve.
12:38 --> 12:41And so if we are using potentially
12:41 --> 12:42nephrotoxic therapies that we
12:42 --> 12:45just have to monitor very closely.
12:46 --> 12:49Yeah. And it sounds like,
12:49 --> 12:51um, particularly for people
12:51 --> 12:53with kidney cancer is
12:53 --> 12:56that really more so for people
12:56 --> 12:59who have had kidney cancer that have
12:59 --> 13:02had a nephrectomy or is that for
13:02 --> 13:05anybody who's got a single kidney
13:05 --> 13:08who's getting nephrotoxic drugs?
13:08 --> 13:08Yeah, I would
13:08 --> 13:09say it's not
13:09 --> 13:12particularly specific to
13:12 --> 13:14people with kidney cancer.
13:14 --> 13:15I really think it's
13:15 --> 13:17for anybody who's had
13:17 --> 13:19a nephrectomy for any reason,
13:19 --> 13:21whether it's congenital or
13:21 --> 13:23related to trauma.
13:24 --> 13:27Fantastic. Well, we are gonna take
13:27 --> 13:29a short break for a medical minute,
13:29 --> 13:31but on the other side,
13:31 --> 13:33hopefully we'll talk more about
13:33 --> 13:35kidney cancer and the whole area
13:35 --> 13:38of onco nephrology with my guest,
13:38 --> 13:39doctor Anushree Shirali.
13:40 --> 13:42Funding for Yale Cancer Answers comes
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13:44 --> 13:46their Center for Gastrointestinal
13:46 --> 13:48Cancers provides patients with a
13:48 --> 13:49comprehensive multidisciplinary
13:49 --> 13:53approach to the treatment of GI cancers.
13:53 --> 13:57SmilowCancerhospital.org
13:57 --> 14:00The American Cancer Society estimates that
14:00 --> 14:02over 200,000 cases of Melanoma will be
14:02 --> 14:05diagnosed in the United States this year,
14:05 --> 14:08with over 1000 patients in Connecticut alone.
14:08 --> 14:10While Melanoma accounts for only
14:10 --> 14:13about 1% of skin cancer cases,
14:13 --> 14:16it causes the most skin cancer deaths,
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14:17 --> 14:20it is easily treated and highly curable.
14:20 --> 14:22Clinical trials are currently
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14:25 --> 14:28Yale Cancer Center and Smilow Cancer.
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14:48 --> 14:51You're listening to Connecticut public radio.
14:53 --> 14:55Welcome back to Yale Cancer Answers.
14:55 --> 14:57This is doctor Anees Chagpar
14:57 --> 14:59and I'm joined tonight by my guest,
14:59 --> 15:00doctor Anushree Shirali.
15:00 --> 15:02We're talking about the
15:02 --> 15:04field of onco nephrology,
15:04 --> 15:08which is really how cancer intersects
15:08 --> 15:11with nephrology, or kidney disease.
15:11 --> 15:13And this isn't specifically
15:13 --> 15:14just for kidney cancers,
15:14 --> 15:18it can be for any cancer where
15:18 --> 15:22therapies may have nephrotoxic
15:22 --> 15:23side effects.
15:23 --> 15:24So doctor Shirali,
15:24 --> 15:25before the break,
15:25 --> 15:28we were talking about some of the
15:28 --> 15:31chemotherapies that can be nephrotoxic.
15:31 --> 15:33And you mentioned, for example,
15:33 --> 15:37platinum agents these days we are
15:37 --> 15:40using a lot more immunotherapies.
15:40 --> 15:43Can you talk a little bit more
15:43 --> 15:44about the effects potentially
15:44 --> 15:46of immunotherapies on the kidney
15:46 --> 15:49and what can be done about that?
15:49 --> 15:51Sure. So, yeah, absolutely.
15:51 --> 15:53So you know immunotherapy as
15:53 --> 15:56I'm sure the audience knows
15:56 --> 15:58is really becoming the mainstay treatment
15:58 --> 16:01for a variety of different cancers,
16:01 --> 16:03not just kidney cancer, but lung cancer,
16:03 --> 16:05Melanoma and others.
16:05 --> 16:08So it's really an exciting time
16:08 --> 16:10I think for the field of oncology
16:10 --> 16:13and for patients who are looking
16:13 --> 16:15for treatment of their tumors.
16:15 --> 16:17Unfortunately the same drugs can
16:17 --> 16:21have immune side effects on things
16:21 --> 16:23other than their particular
16:23 --> 16:25tumor and so
16:25 --> 16:29we knew early on at Yale when
16:29 --> 16:31patients were enrolled in clinical
16:31 --> 16:33trials for some of the immunotherapies.
16:33 --> 16:35And what we noticed,
16:35 --> 16:36I had several referrals for
16:36 --> 16:38patients who had a elevation in
16:38 --> 16:40their creatinine all of a sudden.
16:40 --> 16:43And when we biopsied their kidneys,
16:43 --> 16:45we found something that we call
16:45 --> 16:47acute interstitial nephritis.
16:47 --> 16:50It's essentially a fancy term
16:50 --> 16:52for infiltration of the kidney
16:52 --> 16:54with a variety of immune cells.
16:54 --> 16:56And the way I sort of explain it to
16:56 --> 16:59patients is that you can think about
16:59 --> 17:00it as a hypersensitive sensitivity
17:00 --> 17:03or allergic reaction in the kidney.
17:03 --> 17:05And we see the acute interstitial nephritis
17:05 --> 17:08with other drugs or NSAIDs or Advil,
17:08 --> 17:11ibuprofen or what we commonly tell patients
17:11 --> 17:13who are on them can sometimes develop
17:13 --> 17:14kidney injury and if we biopsy,
17:14 --> 17:17we'll sometimes see acute interstitial
17:17 --> 17:19nephritis and it's really thought to
17:19 --> 17:21be in hypersensitivity reaction in
17:21 --> 17:23the kidney with the immunotherapy,
17:23 --> 17:24we don't quite
17:24 --> 17:26know what the mechanism here is,
17:26 --> 17:28we hypothesize that it's
17:28 --> 17:30general immune activation against
17:30 --> 17:32the cancer and then maybe there's
17:33 --> 17:35some sort of cross reactive antigen
17:35 --> 17:37in the kidney that these immune
17:37 --> 17:38cells then respond to.
17:38 --> 17:43But the presentation can be quite dramatic.
17:43 --> 17:45I've had patients with
17:45 --> 17:48very high creatinine where their kidney
17:48 --> 17:50function can go quite low,
17:50 --> 17:53but it also tends to be a very
17:53 --> 17:54steroid responsive side effect.
17:54 --> 17:56What happens in the kidney with
17:56 --> 17:59immunotherapy, so in general,
18:01 --> 18:02you would stop the immunotherapy
18:02 --> 18:05and you would treat somebody with
18:05 --> 18:07steroids and you'd see pretty
18:07 --> 18:11quick resolution in the
18:11 --> 18:14elevation of their serum creatinine.
18:16 --> 18:17It's not uncommon,
18:17 --> 18:19but it doesn't happen in all patients either.
18:19 --> 18:23So in the studies as well as the
18:23 --> 18:25postmarketing data that we have,
18:25 --> 18:27it's about a 2 to 4% incidence
18:27 --> 18:30rate among all patients who are
18:30 --> 18:32being treated with immunotherapy.
18:32 --> 18:34So something that we encounter,
18:34 --> 18:36but something that's also treatable.
18:37 --> 18:39And so how often should patients who
18:39 --> 18:43are on chemotherapy or on an immune
18:43 --> 18:45checkpoint inhibitor have their creatinine checked?
18:45 --> 18:47I mean is that something
18:47 --> 18:50that is routinely done or is it
18:50 --> 18:51something that patients
18:51 --> 18:55should advocate for?
18:55 --> 18:56Yeah. So I think in
18:56 --> 18:59general because so much of
18:59 --> 19:01chemotherapy and immunotherapy is,
19:01 --> 19:03is protocol driven,
19:03 --> 19:05you know it's sort of built into when
19:05 --> 19:06they come in for their treatment.
19:06 --> 19:09So before you're going to
19:09 --> 19:11be infused with your particular
19:11 --> 19:14chemotherapy or immunotherapy you'll
19:14 --> 19:17have a visit with your oncologist.
19:17 --> 19:19Or another provider and you'll
19:19 --> 19:22have all of your labs drawn that
19:22 --> 19:24morning and the serum creatinine.
19:24 --> 19:27So that's what we check to see
19:27 --> 19:29how someone's kidneys are functioning
19:29 --> 19:32is part of the basic metabolic panel
19:32 --> 19:34that's ordered with these labs.
19:34 --> 19:37And you had mentioned that many times
19:37 --> 19:40the kidney side effects of chemotherapies
19:40 --> 19:43or immunotherapies tend to be acute.
19:43 --> 19:45Are there long term side
19:45 --> 19:46effects that might hurt
19:46 --> 19:48your kidneys down the road,
19:48 --> 19:53so you know 10-15 years later you end
19:53 --> 19:57up with a kidney issues that may be
19:57 --> 19:59related to your earlier therapy.
20:00 --> 20:02Yeah, so that's a great question and I
20:02 --> 20:05think the answer to that is, yes,
20:05 --> 20:08particularly when you look at the age
20:08 --> 20:11group of patients being treated.
20:11 --> 20:13So the best example I can give you
20:13 --> 20:15from my own clinical experience
20:15 --> 20:16when I see patients in our
20:16 --> 20:19Onco Nephrology clinic is patients who
20:19 --> 20:23have had childhood cancer of some sort and
20:23 --> 20:25they're treated with nephrotoxic agents.
20:25 --> 20:27So Ifosfamide
20:27 --> 20:29is the particular chemotherapy
20:29 --> 20:32that I'm thinking of and it is
20:32 --> 20:34particularly nephrotoxic and that
20:34 --> 20:36nephrotoxicity is very dose dependent.
20:36 --> 20:40And so there's now pretty large
20:40 --> 20:43repository of literature that suggests
20:43 --> 20:47that if you get cumulative dosing over
20:47 --> 20:50a lifetime of over a
20:50 --> 20:52certain amount of ifosfamide,
20:52 --> 20:54the chances of getting chronic
20:54 --> 20:56kidney disease later on in life that
20:56 --> 20:58is directly tied to that cancer
20:58 --> 21:01or to that chemotherapy is higher.
21:01 --> 21:03And as you mentioned before, right,
21:03 --> 21:04that cancer patients aren't just
21:04 --> 21:06patients who have cancer, right?
21:06 --> 21:09They have their people who can get
21:09 --> 21:11diabetes and hypertension later on.
21:11 --> 21:13So when I get referrals for chronic
21:13 --> 21:15kidney disease in patients who
21:15 --> 21:17have had a history of cancer,
21:17 --> 21:18you know the most
21:18 --> 21:20important thing I underscore
21:20 --> 21:22is that whatever's happened
21:22 --> 21:23with your kidney has happened.
21:23 --> 21:25We can't undo that,
21:25 --> 21:28and thankfully your cancer is at Bay.
21:28 --> 21:31But what we now need to do is control
21:31 --> 21:34risk factors that could make your
21:34 --> 21:36existing kidney disease worse.
21:36 --> 21:38So essentially you have another insult
21:38 --> 21:40that can make your pre-existing
21:40 --> 21:41kidney disease worse.
21:41 --> 21:44And so that's really control of your diet.
21:44 --> 21:46So if you happen to have high
21:46 --> 21:48blood pressure taking your meds.
21:48 --> 21:50Controlling your salt if you have diabetes,
21:50 --> 21:51controlling your sugar,
21:51 --> 21:53taking your diabetes meds.
21:53 --> 21:55So really,
21:55 --> 21:57same kind of advice I'd give to
21:57 --> 21:58patients with chronic kidney disease
21:58 --> 22:00who don't have a history of cancer.
22:00 --> 22:03And so is it really that
22:03 --> 22:06you're trying to minimize
22:06 --> 22:08any additional injury or is
22:08 --> 22:10there a way to reverse the injury
22:10 --> 22:12that's already happened?
22:12 --> 22:15The kidney is a
22:15 --> 22:16really remarkable organ.
22:16 --> 22:18It can really withstand a
22:18 --> 22:20variety of insults.
22:20 --> 22:23And so the example I give to people is,
22:23 --> 22:25let's say you are sick with
22:25 --> 22:27something and you have vomiting and
22:27 --> 22:28diarrhea for several days, right?
22:28 --> 22:30All of us will not end up even though
22:30 --> 22:32you're having a huge amount of volume loss,
22:32 --> 22:34but all of us don't end up
22:34 --> 22:36getting kidney disease from that.
22:36 --> 22:37And that's because the kidneys
22:37 --> 22:38very remarkable.
22:38 --> 22:40It's got a variety of different
22:40 --> 22:41mechanisms to withstand what's
22:41 --> 22:43happening to the rest of the body
22:43 --> 22:45when you have an acute illness.
22:45 --> 22:48Sometimes, though, if an illness is extended.
22:51 --> 22:53you're definitely getting a toxic
22:53 --> 22:55agent that you can't be off of,
22:55 --> 22:58that insult and that injury is
22:58 --> 23:01ongoing and the kidney reaches a point
23:01 --> 23:04where it can try to defend itself,
23:04 --> 23:06but it has reached a point
23:06 --> 23:08where the kidney injury sets in.
23:08 --> 23:10So in those cases,
23:10 --> 23:13I sort of liken it to someone
23:13 --> 23:14getting a cut on their skin.
23:14 --> 23:16It depends on what the cut is,
23:16 --> 23:18like, how deep it is.
23:18 --> 23:20Sometimes that cut will heal and you'll
23:20 --> 23:22look at it and you'll never know
23:22 --> 23:23there was a cut there.
23:23 --> 23:23Other times though,
23:23 --> 23:25if the cut on the skin is deeper
23:25 --> 23:27or it's a particular kind of cut,
23:27 --> 23:29you'll end up seeing a scar.
23:29 --> 23:31So the kidney
23:31 --> 23:34to use that analogy can
23:34 --> 23:36get a cut and that
23:36 --> 23:38cut can either heal or if it's
23:38 --> 23:40a severe cut then you'll end up
23:40 --> 23:42with scarring in the kidney.
23:43 --> 23:47Now we had talked earlier about
23:47 --> 23:51the fact that
23:51 --> 23:55some of the toxicities associated with
23:55 --> 23:57chemotherapy and immunotherapy etcetera,
23:57 --> 23:59that are used for any kind of
23:59 --> 24:01cancer can affect the kidney.
24:03 --> 24:06For people who have had kidney cancer,
24:06 --> 24:09are those side effects worse?
24:09 --> 24:11In other words, is the kidney that
24:11 --> 24:15has had the kidney cancer
24:15 --> 24:17more susceptible to injury or
24:17 --> 24:20does that not really play a role?
24:20 --> 24:21Yeah. So I don't
24:21 --> 24:22think there's any great literature
24:22 --> 24:24that suggests that
24:24 --> 24:27having kidney cancer puts you at
24:27 --> 24:30more risk for having kidney side
24:30 --> 24:32effects from a particular treatment.
24:32 --> 24:36And frankly we don't know why
24:36 --> 24:38certain people get injury with
24:38 --> 24:41cisplatin for example or why 2 to 4%
24:41 --> 24:45get kidney injury from immunotherapy.
24:45 --> 24:49Why don't the other 97 to 99%, right,
24:49 --> 24:51why don't they get it.
24:51 --> 24:54So I don't think we really understand
24:54 --> 24:57completely the mechanisms of why
24:57 --> 25:00particular patients get a particular
25:00 --> 25:02nephrotoxicity from a specific drug.
25:02 --> 25:05Whether that's chemotherapy or immunotherapy.
25:06 --> 25:07I wouldn't say that patients with kidney
25:08 --> 25:10cancer are more susceptible to side effects.
25:10 --> 25:13It's more that if they already have
25:13 --> 25:16compromised kidney function so perhaps
25:16 --> 25:18they've had pre-existing kidney
25:18 --> 25:21disease or they have had a nephrectomy,
25:21 --> 25:24then potentially if they get nephrotoxicity
25:24 --> 25:27from a particular agent for example,
25:27 --> 25:29then I am a little bit more
25:29 --> 25:31nervous that they have less renal
25:31 --> 25:32reserve to withstand that.
25:33 --> 25:35And what about the reverse?
25:35 --> 25:40So if you have had a chemotherapy or an
25:40 --> 25:44immunotherapy with a nephrotoxic drug,
25:44 --> 25:46are you more susceptible for developing
25:46 --> 25:48kidney cancer down the line?
25:48 --> 25:50In other words, that toxicity,
25:50 --> 25:53that scar from that cut,
25:53 --> 25:56does that increase your risk of
25:56 --> 25:58kidney cancer down the line?
25:58 --> 25:58So I wouldn't
25:58 --> 26:00say there's
26:00 --> 26:01kidney cancer in particular.
26:01 --> 26:03There are some very muddy data
26:03 --> 26:05that suggests that patients
26:05 --> 26:08with chronic kidney disease may
26:08 --> 26:11be at generally at higher risk
26:11 --> 26:14for getting cancer of any kind.
26:14 --> 26:16And there's some theories on that
26:16 --> 26:19because kidney disease can lead to some
26:19 --> 26:22relative suppression of the immune system.
26:22 --> 26:24And so you're not getting surveillance
26:24 --> 26:26of cancer that's floating around,
26:26 --> 26:27but it's not
26:27 --> 26:29very clean data.
26:30 --> 26:32I wouldn't say that having kidney
26:32 --> 26:35disease makes one at higher risk
26:35 --> 26:37in particular for kidney cancer.
26:38 --> 26:41You had mentioned that
26:41 --> 26:44particularly for people who may have
26:44 --> 26:46been treated in childhood for childhood
26:46 --> 26:48cancers with nephrotoxic drugs,
26:48 --> 26:51that there's a risk for developing
26:51 --> 26:54kidney disease years down the line.
26:54 --> 26:57Can you talk a little bit about some
26:57 --> 27:00of the symptoms and and signs that
27:00 --> 27:02people should watch for that might
27:02 --> 27:05lead them to believe that they have
27:05 --> 27:07kidney disease because presumably they
27:07 --> 27:10wouldn't be getting routine blood work?
27:10 --> 27:14That's a great question.
27:14 --> 27:16And you know oftentimes we'll get referrals
27:16 --> 27:19for patients who have been
27:19 --> 27:22diagnosed based on their lab testing with
27:22 --> 27:25chronic kidney disease and they'll say,
27:25 --> 27:27but I don't feel anything and that
27:27 --> 27:29is actually quite true that kidney
27:29 --> 27:31disease for the most part unless
27:31 --> 27:33it becomes very advanced
27:33 --> 27:34is relatively asymptomatic.
27:34 --> 27:37So most of the times the diagnosis
27:37 --> 27:40for kidney disease is really based on
27:40 --> 27:41routine lab testing.
27:41 --> 27:43So, so that's a great point
27:43 --> 27:45that you're right that
27:45 --> 27:47if you had childhood cancer,
27:47 --> 27:49you may not necessarily in your early
27:49 --> 27:5120s be getting blood work done.
27:54 --> 27:56So you're right,
27:56 --> 27:58a lot of times the way patients
27:58 --> 28:00will present is that
28:00 --> 28:03perhaps they'll have some sort of insurance
28:03 --> 28:05company lab screening and that will
28:05 --> 28:08incidentally pick up a kidney disease.
28:08 --> 28:10But in general the symptoms of
28:10 --> 28:13and signs of kidney disease don't show
28:13 --> 28:15up until they're very advanced and
28:15 --> 28:17they tend to be pretty nonspecific.
28:17 --> 28:19So patients will complain of
28:19 --> 28:21I don't feel like eating very much.
28:21 --> 28:23I've lost some weight.
28:23 --> 28:24Food taste different to me.
28:24 --> 28:25I have nausea.
28:25 --> 28:27So nothing that I think would
28:27 --> 28:29immediately clue patients in
28:29 --> 28:31that they have kidney disease.
28:31 --> 28:33Doctor Anushree Shirali is an
28:33 --> 28:35associate professor of medicine
28:35 --> 28:36in the section of nephrology
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:45and past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

The Care of Patients with Kidney Disease and Cancer with guest Dr. Anushree Shirali February 26, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095