Guidelines for treatment of renal injury during cancer chemotherapy 2016

Advances in cancer drug therapy have led to improvements in the outcomes of cancer patients, as well as increasing numbers of patients undergoing anticancer chemotherapy and molecularly targeted drug therapy. One adverse event associated with cancer drug therapy is nephrotoxicity, which impedes effective cancer therapy and diminishes the quality of life of cancer patients. Consequently, onco-nephrology has emerged as a new clinical field concerned with the management of nephrotoxicity in cancer drug therapy, creating expectations for advanced expertise and the accumulation of accurate evidence. However, while patients with renal impairment have heretofore undergone planning regarding administration of cancer drug therapy, procedures for nephropathy prevention, and measures for treatment of drug-induced nephrotoxicity in clinical settings based on tradition, experimental rules, and information from clinical trials, the soundness of the evidence for these practices has been uncertain. Over the past 10 years, estimated glomerular filtration rate (eGFR) has replaced creatinine clearance in the assessment of renal function; in addition, research has revealed the pathologies of and risk factors for chronic kidney disease (CKD) and acute kidney injury (AKI). The objectives of the guidelines presented here are to support improvements in the results of cancer drug therapy and the quality of life of cancer patients through application of these advances in clinical nephrology and the practice of evidence-based treatment. For these guidelines, we have assembled a group of Japanese experts on cancer drug therapy and nephrology to select highly important clinical questions that are frequently encountered in everyday practice. These guidelines ultimately comprise 16 clinical questions in two chapters regarding assessment of renal function and prevention of nephropathy during cancer drug therapy, thereby determining the level of evidence to support clinical assessments and elucidating the nature of current standard treatments. However, in drafting these guidelines, we discovered a number of clinical issues (evidence gaps) regarding cancer drug therapy and renal impairment. For example, 1) there is very little clinical research on cancer drug therapy and nephropathy to begin with; 2) many clinical trials continue to use creatinine clearance to assess renal function; 3) in assessments of renal function in large populations, there is a vast discrepancy between eGFR and measured values of GFR; and 4) it remains unknown whether body surface area corrections of drug doses are appropriate for elderly patients (who have reduced muscle mass) or obese patients. These and other evidence gaps must be resolved for the sake of future research. These guidelines were drafted with reference to the “Minds Treatment Guideline Creation Companion 2014” using the Minds Guideline Creation support tool “GUIDE”. We would like to express our profound gratitude to Doctors Tsuguya Fukui and Takeo Nakayama of Minds for their roles as advisors in the creation of our guidelines. We would also like to take this opportunity to express our appreciation to the many young physicians of the systematic review team for their contributions in drafting structured abstracts. The primary significance of treatment guidelines is their application in daily clinical practice. We would appreciate any criticisms or ideas that would be useful in future revisions of these guidelines. Shigeo Horie, M.D. Professor and Chairman, Department of Urology Juntendo University, Graduate School of Medicine