Report of sequential interventions at a tertiary cancer centre to reduce acute kidney injury rates following concurrent cisplatin with radiotherapy for head and neck cancer

Abstract

Introduction: Standard of care Cisplatin chemoradiation (CRT) for head and neck cancer cancers (HNC) improves outcomes, but has associated risk of acute kidney injury (AKI). Various interventions have been proposed to reduce this risk. We report the effects of sequential changes in practice at a tertiary oncology centre introduced to reduce the incidence of AKI and reviewed in a repeated assessment cycle. Materials and Methods: AKI rates was assessed for three patient cohorts receiving concurrent cisplatin with radiotherapy from April 2016 to February 2020. AKI Stage 1 was defined as a rise in creatinine more than 1.5 times baseline or >26 umol/l in 48 hr, Stage 2 as doubled and Stage 3 as triple baseline creatinine. All patients received cisplatin 100 mg/m2 in 1L NaCL on D1 and D22 of a six week radiotherapy course. This was given overnight with 1L Nacl pre-hydration and 2L NaCl post cisplatin administration. Initially patients had a baseline nuclear medicine GFR (if <60 ml/min cisplatin was omitted) and then renal function checked prior to cycle 2 cisplatin, unless concerns about fluid intake. From cohort 2 all patients were mandated to undergo weekly blood tests during treatment regardless of symptoms or oral intake and a pre-chemotherapy review was initiated including recording of stopping all nephrotoxic medications prior to treatment. For cohort 3 mannitol 10% 120 ml added to the chemotherapy regime which otherwise remained unchanged. Results: A total of 136, 39 and 50 patients were audited in cohort 1,2 and 3 respectively. Patient and disease characteristics were well matched in each group. The number of patients suffering any AKI during treatment fell from 38% to 26% over the period, despite increased frequency of monitoring. AKI stage I fell from 27% to 18% and severe AKI stage III incidence fell from 5% to 0%. Admission rates for management of AKI dropped by almost two thirds, from 34% to 18%, and then 12% in each successive cohort. Conclusions: This study has demonstrated that the sequential adoption of simple evidence based interventions to reduce the incidence of AKI during CTRT with cisplatin can have a significant benefit to patient outcomes, reducing treatment related nephrotoxicity and requirement for inpatient management. Despite this one in four patients continues to suffer AKI during therapy highlighting the need for meticulous management of this patient group.