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Systemic anticancer treatment (SAT) for metastatic renal cell carcinoma (mRCC) is associated with a variety of adverse events including hemorrhagic disorders and infections. A substantial number of patients with mRCC develop chronic kidney disease, which can progress to end-stage kidney disease (ESKD) and subsequently require renal replacement therapy, including chronic hemodialysis (HD). It is currently not clear how often patients with mRCC and ESKD who are treated with SAT develop life-threatening bleeding and infections.
We retrospectively identified all patients with mRCC and ESKD who received SAT with VEGFR inhibitors, immune check-point inhibitors, or mTOR inhibitors, alone or in combinations, at the Institute of Oncology Ljubljana in Slovenia between December 2009 and October 2023. Data on the frequency and severity of bleeding and infections was collected from the electronic health records.
We identified 33 patients with mRCC and ESKD who were treated with SAT. Their median (Q3-Q1) age was 71 (65-76) years and 25 (75.8%) of them were men. While 21 patients (63.6%) were already on HD before starting SAT, 12 patients (36.4%) developed ESKD subsequently. Of these patients, eight (66.7%) had GFR ≤30 ml/min/1.73 m2 and four (33.3%) had GFR >30 ml/min/1.73 m2 at the start of the SAT. Overall, eight patients (24.2%) experienced an episode of bleeding before the start of the SAT, including three patients who had gastrointestinal bleeding (GIB). Grade 4 epistaxis was seen in three patients, including a patient who developed hemorrhagic shock during the first-line treatment with sunitinib. Two patients experienced a grade 4 anal hemorrhage, one of which was due to hemorrhoids during the first-line therapy with sunitinib. Two patients underwent an urgent nephrectomy during pazopanib or sunitinib treatment respectively. Overall, in five patients (15.2%) grade 4 GIB was observed during or after the SAT. The cumulative incidence of grade 3/4 bleeding was 0.55 (18 events/33 patients), while the cumulative incidence of all-grade bleeding was 1.2 (41 events/33 patients). Overall, 10 patients (30.3%) experienced grade 4 infections during SAT. Of these patients, six developed sepsis, and one, who was on HD and received the first-line treatment with sunitinib, developed septic shock.
Serious bleeding and infections are common complications in patients with mRCC and ESKD who are treated with SAT. Clinicians should bear in mind these potentially life-threatening complications when deciding on the selection and duration of SAT. Due to the considerable challenges associated with the management of these patients, they should be treated in dedicated onco-nephrology services.