New Onco-Nephrology Curriculum Available Online

Developed in collaboration with other onco-nephrology experts, the ASN Onco-Nephrology Forum (ONF) series of 19 chapters covers most of the important onco-nephrology topics (Table 1). The chapters include Take Home Points and Board style questions to highlight important issues. The goal is to provide ASN members—including veteran nephrologists, newly minted nephro-clinicians, fellowship trainees, and other interested healthcare providers—the building blocks upon which further information can be added as the field advances. The ONF hopes the curriculum provides the initial framework to achieve this goal.

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It should come as no surprise that cancer is associated with significant morbidity and mortality. Cancer is the second leading cause of death today (1). Both acute kidney injury (AKI) and chronic kidney disease (CKD) are highly prevalent in cancer patients, particularly those with renal cell cancer, liver cancer, multiple myeloma, leukemias, and lymphomas (4,5). Kidney disease frequently occurs in 5 major cancers: prostate, breast, gynecologic, lung, and colorectal (6).

In addition, mortality is higher in cancer patients with AKI/CKD. Possible explanations for this increased mortality include the association of AKI development with cessation of effective chemotherapeutic regimens, the presence of pre-existing CKD limiting the use of otherwise curative anti-cancer regimens, or both. The combination of cancer and kidney disease has led to the recognition that nephrology and oncology are intricately linked and require our full attention as a growing area of specialization (Figure 1). Thus, “onco-nephrology” was born and has steadily grown in many medical centers, hospitals, and clinics.

Figure 1.

Cancer, AKI, and CKD are linked by various exposures and pathways

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Abbreviations: AKI, acute kidney injury; CKD, chronic kidney disease; ESRD, end stage renal disease

What exactly is onco-nephrology? It is a rapidly growing subspecialty area of nephrology that recognizes that kidney disease in cancer patients has become an important source of nephrology consultations over the past 10 to 15 years. Nephrologists have traditionally treated cancer patients with various forms of kidney disease. However, oncology patients now make up a significant number of the patients nephrologists see for kidney-related problems in the outpatient clinic, on the inpatient floors, and in the medical ICU.

The increase in cancer patients with kidney disease is in part related to the high incidence rates for many malignancies, as well as the overall reduction in cancer death rates owing to more effective chemotherapeutic agents that include biologics and stem cell therapies. These improved therapies have led to an increase in the number of cancer survivors who develop and survive with AKI and/or CKD due to their malignancy and/or its associated treatment.

Kidney injury from cancer occurs via several different mechanisms. Cancer can directly injure the kidneys through tumor infiltration or production of nephrotoxic (paraneoplastic) substances. Also, the growing number of therapeutic agents that extend patient lives can cause various types of AKI or CKD along with serious electrolyte and acid–base abnormalities.

Although typical AKI and electrolyte/acid–base disturbances can be handled by the practicing clinical nephrologist, it has become increasingly clear that many of the renal issues are more complex and highly specialized. For example, many nephrologists were not trained in the era of bone marrow/hematopoietic stem cell transplant, which can lead to a number of unusual and complicated forms of kidney injury.

In addition, the number of anti-cancer drugs with various types of nephrotoxicity has increased dramatically, and their entry into clinical practice continues at a fast pace. Patients may develop multi-organ illness requiring ICU-level care and renal replacement therapy. Certain malignancies are more likely to cause this severe form of multi-organ dysfunction and may be associated with higher mortality rates.

When this type of critical illness occurs in the setting of advanced malignancy, it also raises questions about the appropriateness of aggressive care and the role of palliation. Thus, care for oncology patients has become more specialized and complicated, requiring collaboration among nephrologists, oncologists, intensivists, and palliative care specialists.

The remarkable advances made in cancer management present both new opportunities and complex challenges for the oncology and nephrology communities. It is essential for nephrologists to be informed and actively involved in certain facets of cancer care.

Nephrologists need a better understanding of the rapidly evolving field of cancer biology and its therapy in order to become valuable members of the cancer care team, and to provide the best nephrology care possible. Developing expertise in the practice of onco-nephrology will enable nephrologists to be well prepared to provide care for the unique renal complications that develop in patients with cancer.

References

1. Hoybert DL, Xu J. Deaths: Preliminary data for 2011. National Vital Statistics Report 2012; 61:6. www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf

2. Age-adjusted SEER Incidence Rates, 2007–2011 (Table 2.7). SEER Cancer Statistics Review (CSR) 1975–2011. Surveillance, Epidemiology, and End Results Program. National Cancer Institute. http://seer.cancer.gov/csr/1975_2011/browse_csr.php?sectionSEL=2&pageSEL=sect_02_table.07.html

3. Percent of Medicare patients aged 66+, (a) with at least one AKI hospitalization, and (b) with an AKI hospitalization that had dialysis by year, 2003–2012 (Figure 5.1). Chapter 5: Acute Kidney Injury. USRDS 2012. www.usrds.org/2014/view/v1_05.aspx

4. Christiansen CF, et al. Incidence of acute kidney injury in cancer patients: a Danish population-based cohort study. Eur J Intern Med 2011; 22:399–406.

5. Schmid M, et al. Predictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma. Urol Cancer 2014; 32:1285–91.

6. Janus N, et al. Cancer and renal insufficiency results of the BIRMA study. Br J Cancer 2010; 103:1815–21.