AKI in critically ill cancer patients: do
we need more studies? : No !
Michaël DARMON
Medical-Surgical ICU
Bekele Afessa Research Day, March 28th 2017, Paris
University
Hospital
Third meetingSaint-Etienne
of the CarIng for CrItIcally
Ill ImmunocompromIzed
PatIents
Saint-Etienne
, France–
MultInatIonal Network
The Nine-I Network
Conflict of interests
• Research grants: MSD
• Research support: Astute Medical
• Speaker Fees : MSD, Astellas, Bristol-Myers Squibb
• Grant to organize educational meetings: MSD, Astellas, Jazz
Pharmaceutical
• Advisory board: Sanofi
Conflict of interests
Conflict of interests
Framework
• More research dedicated to AKI in critically-ill cancer patients?
• Are any the potential objectives specific ?
• Research agenda regarding AKI in the next decade
• Conclusion
Framework
• More research dedicated to AKI in critically-ill cancer patients?
• Are any the potential objectives specific ?
• Research agenda regarding AKI in the next decade
• Conclusion
What do we know
• Acute Kidney Injury in CICP is frequent
Darmon et al. Nephrol Dial Transplant 2015
Prevalence and consequences of AKI
Schetz et al. Intensive Care Med 2015
What do we know
• Acute Kidney Injury in CICP is frequent
• Risk factors of AKI in this setting are the same than in general ICU
population
Risk factors of AKI
Nisula et al.
Soares et al.
Darmon et al.
Sepsis
Sepsis
Shock / severity
Shock/hypovolemia
Shock
Nephrotoxic agents
Nephrotoxic agents
Nephrotoxic agents
Older age
Cardiac arrest
Tumor lysis syndrome
Tumor lysis syndrome
Rhabdomyolysis
Myeloma
Myeloma
Diuretics (?)
Rhabdomyolysis
Comorbidities
Prevalence in the studied population
Myeloma : 3 to 12%
TLS: 3 to 9%
Nisula et al. Intensive Care Med 2013
Soares et al. J Clin Oncol 2006
Darmon et al. Nephrol Dial Transplant 2015
What do we know
• Acute Kidney Injury in CICP is frequent
• Risk factors of AKI in this setting are the same than in general ICU
population
• AKI in CICP is associated with grim short term prognosis
Prevalence and consequences of AKI
Nisula et al. Intensive Care Med 2013
Darmon et al. Nephrol Dial Transplant 2015
What do we know
• Acute Kidney Injury in CICP is frequent
• Risk factors of AKI in this setting are the same than in general ICU
population
• AKI in CICP is associated with grim short term prognosis
• AKI in CICP is associated with morbidity and long term outcome
Risk of hospital readmission
Multicentre data registry – Boston – 62,096 Critically-ill patients
Admission 1997-2010
Adjusted risk of readmission (OR; 95%CI)
R class AKI:
1.39 (95%CI 1.28-1.51)
I class AKI:
1.47 (95%CI 1.31-1.64)
F class AKI:
1.43 (95%CI 1.26-1.62)
Horkan et al. Crit Care Med 2015
Chronic renal dysfunction following AKI
5351 Patients with AKI (ICD 9 definition - 15,917 controls)
728 progressors toward CKD stage 4 (13.6%)
Chawla et al. Kidney international 2012
Long-term mortality following AKI
Single centre cohort study - 2010 ICU Patients
AKI defined according to the serum creatinine criteria of KDIGO classification
10-years survival in AKI patients: 28%
Overall mortality
Mortality in day-28 survivors
Linder et al. Am J Respir Crit Care Med 2014
Framework
• More research dedicated to AKI in critically-ill cancer patients?
• Potential objectives of research in field of AKI
• Research agenda on AKI for the next decade
• Conclusion
Research on AKI specific to CICP?
• Identification of high risk patients (TLS at the era of targeted th.)
• Early detection / diagnosis of AKI (High grade malignancy)
• Reshaping the diagnostic tree of AKI (Specific diagnosis of AKI)
• Preventing / mitigating renal injury (TLS, Cast nephropathy)
• Optimal management (optimal timing of RRT in TLS patients)
• Mitigating long term consequences of AKI
– Renal reserve (Allogeneic stem cell transplantation)
– Renal function (Allo-SCT, long term renal function, risk of CKD…)
– Other organs (including remission)
Framework
• More research dedicated to AKI in critically-ill cancer patients?
• Potential objectives of research in field of AKI
• Research agenda on AKI for the next decade
• Conclusion
Framework
• More research dedicated to AKI in critically-ill cancer patients?
• Are any the potential objectives specific ?
• Research agenda regarding AKI in the next decade
• Conclusion
Conclusion
• A lot remain to be done to improve outcome of AKI patients
• Cancer patients is a subgroup with few specificities
• Research purposes are similar to the general ICU population
• Next steps ?
– Large studies (observational / RCTs) with preplanned stratification
– Research on diseases/syndromes: TLS, Myeloma, sepsis, rhabdomyolysis…
– Meanwhile: advocating early ICU admission of high risk patients
Thank you for your attention