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Amyloidosis is a complex group of rare disorders characterized by the deposition of misfolded proteins in the extracellular space of various tissues and organs, leading to progressive organ dysfunction. The kidneys constitute a very common site affected, most notably by immunoglobulin-mediated (light chain, heavy chain, and light and heavy chain amyloidosis), but other types that include serum amyloid A (AA) amyloidosis and leukocyte chemotactic factor 2 amyloidosis, along with mutant proteins in several hereditary forms of amyloidosis such as transthyretin, fibrinogen α-chain, gelsolin, lysozyme, and apolipoproteins AI/AII/AIV/CII/CIII amyloidosis have been incriminated as well. The clinical presentation is variable and can range from minimal proteinuria for leukocyte chemotactic factor 2 amyloidosis to a full-blown nephrotic syndrome for AA amyloidosis. Clinical correlation, genetic analysis, and adequate tissue typing through a kidney biopsy are essential to make the correct diagnosis, especially when a family history of amyloidosis is absent. Except for AA and transthyretin amyloidosis, the treatment is usually purely supportive. Kidney transplantation is an acceptable form of treatment for end-stage kidney disease in all types of non-Ig-mediated renal amyloidosis.

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Allogeneic hematopoietic cell transplantation (HCT) offers cure for some patients with hematological diseases but is associated with significant risk of morbidity and mortality. We investigated the incidence of AKI and its impact on transplant outcomes among 408 patients transplanted at Princess Margaret Hospital Cancer Centre, Toronto, Canada. The overall incidence of AKI at 100 days was 64.2%. Compared to those with no AKI, patients who developed AKI had inferior 2-y overall survival (OS), 44.7% vs. 62.4% (P= 0.0004), higher 2-y transplant related mortality (TRM) 36.8% vs. 18.7% (P= 0.0003), lower 2-y graft-vs-host disease (GVHD)- and relapse-free survival (GRFS), 21.0% vs. 39.8% (P= 0.0002), and higher 100-day grade 3–4 acute GVHD (aGVHD), 12.4% vs. 6.3% (P= 0.01). There was no difference in 2-y incidence of relapse between the AKI and non-AKI groups, 24.2% vs. 24.3% (P= 0.84), 100-day grade 2–4 aGVHD, 27.7% vs. 25.7 (P= 0.41) or 2-y moderate-severe chronic GVHD, 24.0% vs. 21.6% (P= 0.79). Patients who develop AKI within 100 days of HCT have inferior OS and GRFS with higher rates of TRM and grade 3–4 aGVHD. These results highlight the importance of close monitoring of renal function, multidisciplinary collaboration, and implementation of protective strategies throughout HCT to optimize transplant and kidney outcomes.

Immune checkpoint inhibitors (ICIs) are widely used for various malignancies. However, their safety and efficacy in patients with a kidney transplant have not been defined. To delineate this, we conducted a multicenter retrospective study of 69 patients with a kidney transplant receiving ICIs between January 2010 and May 2020. For safety, we assessed the incidence, timing, and risk factors of acute graft rejection. For efficacy, objective response rate and overall survival were assessed in cutaneous squamous cell carcinoma and melanoma, the most common cancers in our cohort, and compared with stage-matched 23 patients with squamous cell carcinoma and 14 with melanoma with a kidney transplant not receiving ICIs. Following ICI treatment, 29 out of 69 (42%) patients developed acute rejection, 19 of whom lost their allograft, compared with an acute rejection rate of 5.4% in the non-ICI cohort. Median time from ICI initiation to rejection was 24 days. Factors associated with a lower risk of rejection were mTOR inhibitor use (odds ratio 0.26; 95% confidence interval, 0.09-0.72) and triple-agent immunosuppression (0.67, 0.48-0.92). The objective response ratio was 36.4% and 40% in the squamous cell carcinoma and melanoma subgroups, respectively. In the squamous cell carcinoma subgroup, overall survival was significantly longer in patients treated with ICIs (median overall survival 19.8 months vs. 10.6 months), whereas in the melanoma subgroup, overall survival did not differ between groups. Thus, ICIs were associated with a high risk of rejection in patients with kidney transplants but may lead to improved cancer outcomes. Prospective studies are needed to determine optimal immunosuppression strategies to improve patient outcomes.

Sustained low efficiency dialysis (SLED) has emerged as an alternative to continuous renal replacement therapy (CRRT) for the treatment of acute kidney injury (AKI) in critically ill patients. However, there is limited information on the short- and long-term outcomes of SLED compared to CRRT.

Recent advances in the fields of hematology and oncology over the past decades are truly astounding. Higher response rates have increased the overall and progression free survival, and for certain cancers, have brought the possibility of a cure within reach. While this represents great news for many cancer patients, their longer survival is creating new challenges. Cancer patients can now live long enough to develop chronic kidney disease (CKD), receive long term dialysis, and even a kidney transplantation. There are important and significant knowledge gaps in the care of the cancer patient with CKD or end stage renal disease (ESRD). The subspecialty of Onco-Nephrology was created with the goal of optimizing the care of cancer patients with CKD or ESRD by (1) identifying crucial knowledge gaps in the proper care of these patients by (2) engaging in basic science and clinical research independently and in partnership with cancer specialists to attenuate these gaps, and (3) by educating future onco-nephrologists.

Hyponatremia is the most common electrolyte disorder in patients with cancer and is associated with significant morbidity and mortality. Innovation in cancer therapies has led to substantial improvement in cancer outcomes, but also to new therapy-related toxicities, including electrolyte disturbance. Improvement in clinicians understanding of hyponatremia may mitigate adverse outcomes and improve quality of life in cancer patients. In this case-illustrated review, we discuss the mechanisms underlying drug-induced hyponatremia both in “classical” antineoplastic drugs and novel cancer therapies. Via these clinical cases, we describe hyponatremia caused by conventional chemotherapies (e.g. platinum compounds, vinca alkaloid, and alkylating agents) as well as hyponatremia related to tyrosine kinase inhibitors and other targeted therapies. We also focus on checkpoint inhibitors-induced hyponatremia, as these agents are increasingly used for a wide variety of malignancies. Lastly, we summarize therapy-related hyponatremia among recipients of newer treatments for multiple myeloma.

The current treatment paradigm for muscle-invasive bladder cancer (MIBC) consists of cisplatin-based neoadjuvant chemotherapy followed by local definitive therapy, or local definitive therapy alone for cisplatin-ineligible patients. Given that MIBC has a high propensity for distant relapse and is a chemotherapy-sensitive disease, under-utilization of chemotherapy is associated with suboptimal cure rates. Cisplatin eligibility criteria are defined for patients with metastatic bladder cancer by the Galsky criteria, which include creatinine clearance =60?ml/min. However, consensus is still lacking regarding cisplatin eligibility criteria in the neoadjuvant, curative MIBC setting, which continues to represent a substantial barrier to the standardization of patient care and clinical trial design. Jiang and colleagues accordingly suggest an algorithm for assessing cisplatin eligibility in patients with MIBC. Instead of relying on an absolute renal function threshold, their algorithm emphasizes a multidisciplinary and patient-centred approach. They also propose mitigation strategies to minimize the risk of cisplatin-induced nephrotoxicity in selected patients with impaired renal function. This new framework is aimed at reducing the inappropriate exclusion of some patients from cisplatin-based neoadjuvant chemotherapy (which leads to under-treatment) and harmonizing clinical trial design, which could lead to improved overall outcomes in patients with MIBC.

The bidirectional relationship between cancer and chronic kidney disease (CKD) is complex. Patients with cancer, particularly those with hematological malignancies such as multiple myeloma and lymphoma, are at increased risk of developing acute kidney injury and CKD. On the other hand, emerging evidence from large observational registry analyses have consistently shown that cancer risk is increased by at least 2- to 3-fold in kidney transplant recipients, and the observed increased risk occurs not only in those who have received kidney transplants but also in those on dialysis and with mild- to moderate-stage CKD. The interactions between cancer and CKD have raised major therapeutic and clinical challenges in the management of these patients. Given the magnitude of the problem and uncertainties, and current controversies within the existing evidence, Kidney Disease: Improving Global Outcomes (KDIGO) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology to identify key management issues in nephrology relevant to patients with malignancy. This report covers the discussed controversies in kidney disease in hematological malignancies, as well as cancer after kidney transplantation. An overview of future research priorities is also discussed.

The association between kidney disease and cancer is multifaceted and complex. Persons with chronic kidney disease (CKD) have an increased incidence of cancer, and both cancer and cancer treatments can cause impaired kidney function. Renal issues in the setting of malignancy can worsen patient outcomes and diminish the adequacy of anticancer treatments. In addition, the oncology treatment landscape is changing rapidly, and data on tolerability of novel therapies in patients with CKD are often lacking. Caring for oncology patients has become more specialized and interdisciplinary, currently requiring collaboration among specialists in nephrology, medical oncology, critical care, clinical pharmacology/pharmacy, and palliative care, in addition to surgeons and urologists. To identify key management issues in nephrology relevant to patients with malignancy, KDIGO (Kidney Disease: Improving Global Outcomes) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology in December 2018. This report covers issues related to kidney impairment and solid organ malignancies as well as management and treatment of kidney cancer. Knowledge gaps, areas of controversy, and research priorities are described.

Surveillance blood work is routinely performed in maintenance hemodialysis (HD) recipients. Although more frequent blood testing may confer better outcomes, there is little evidence to support any particular monitoring interval.

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of cancer and are now the backbone of therapy for several malignancies. However, ICIs can cause a spectrum of renal immune-related adverse events including acute kidney injury (AKI), most commonly manifesting as acute interstitial nephritis (AIN), although glomerular disease and electrolyte disturbances have also been reported. In this position statement by the American Society of Onco-nephrology (ASON), we summarize the incidence and risk factors for ICI-AKI, pathophysiological mechanisms, and clinicopathologic features of ICI-AKI. We also discuss novel diagnostic approaches and promising biomarkers for ICI-AKI. From expert panel consensus, we provide clinical practice points for the initial assessment and diagnosis of ICI-AKI, management and immunosuppressive therapy, and consideration for rechallenge with ICI following AKI episodes. In addition, we explore ICI use in special populations, such as kidney transplant recipients, and propose key areas of focus for future research and clinical investigation.

Tribal communities have a long history of association living in close contact with nature as herdsmen, and their mode of use of natural products as food and medicine dates reverse to ancient time. Usually, the folklore knowledge transfers from one generation to next generation by the way of living and the mode of usage of available resources. There is less known information on taxonomy, ethnic traditional knowledge, nutrient contents and chemistry of Lepidium didymumL., a leafy wild edible Himalayan culinary herb. The authors have documented such folklore knowledge for the first time from two Himalayan nomadic and pastoral communities—Gujjars and Bakarwals, from seven regions (Patnitop, Sanasar, Kud, Batote, Bani, Nathatop and Mantalai) of Jammu and Kashmir, India. Investigations were carried out using snowball technique from 167 people both the male and the female, aged 17–68 years. As per knowledge investigated, L. didymumis commonly used as seasonal cooked vegetable, local medicine, fodder for animals, salad, chapati making and traditional dish Wazwanpreparation. The field data analysis shows high use value of this species. The plant prefers to grow in subtropical and temperate climate and has high nutritive values due to the presence of high glucose, unsaturated fatty acids, proteins, vitamins and minerals. This finding will lead to the formulation of new nutraceutical products as value addition from wild edible plants for people residing in the high-altitude regions of Jammu and Kashmir and elsewhere in the world.

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Kidney-related adverse drug effects from chemotherapeutic agents can cause acute kidney injury that may influence cancer treatment and patient outcomes. Many current chemotherapy drugs are associated with acute kidney injury, including methotrexate which causes dose-dependent tubular injury. In this review, we will focus on the manifestations of kidney disease secondary to methotrexate and discuss management strategies. In particular, we will review the use of high-flux hemodialysis versus glucarpidase for reducing toxic serum levels of methotrexate.

Background: Extraction or sample preparation is the first step in any research related to natural products and the objectives of the research could be seriously jeopardized if the extract prepared is not the true representative of the original crude material. The work reports a microwave assisted extraction model for the rapid extraction of phenolics and flavonoid bioactives from the leaves of Taraxacum officinale which is an edible plant with profound ethobotanical significance. The work aims to showcase new technological ventures to the nutraceutical industries for large scale production of such components which are greatly used as dietary supplements. Methods: The process optimization of the proposed method has been carried out using Taguchi L9 orthogonal array approach and total phenolics content (μg/gm dried extract in terms of chlorogenic acid equivalent) was used as the performance evaluation parameter. SEM reports and test of integrity of biological activity has also been reported. Results: Eight phenolic/flavonoid bioactives were identified using HPTLC. The final optimum conditions for rapid microwave assisted extraction of phenolics were reported as 160 W microwave power, 6 min irradiation time, 50 °C temperature and 2 min soak time. Results in terms of yield of total phenolics were very superior compared to 36 hours of conventional Soxhlet and maceration extraction. SEM images clearly indicated cellular ruptures, thus facilitating easy exit of bioactives from inside the cell to the external bulk solvent. Conclusions: The work basically attempts to encourage researchers in adapting to green technologies so that science, industry and environment can progress in tandem.

To determine whether patients with severe acute kidney injury who receive dialysis (AKI-D) experience better outcomes at centres that care for more patients with AKI-D.

Genetic diversity is essential for survival and adaptation of high altitude plants such as those of Tanacetumgenus, which are constantly exposed to environmental stress. We collected flowering shoots of ten accessions of Tanacetum gracileHook.f. & Thomson (Asteraceae) (Tg 1–Tg 10), from different regions of cold desert of Western Himalaya. Chemical profile of the constituents, as inferred from GC–MS, exhibited considerable variability. Percentage yield of essential oil ranged from 0.2 to 0.75% (dry-weight basis) amongst different accessions. Tg 1 and Tg 6 were found to produce high yields of camphor (46%) and lavandulol (41%), respectively. Alpha-phellendrene, alpha-bisabool, p-cymene and chamazulene were the main oil components in other accessions. Genetic variability among the accessions was studied using RAPD markers as well as by sequencing and analyzing nuclear 18S rDNA, and plastid rbcLand matKloci. The polymorphic information content (PIC) of RAPD markers ranged from 0.18 to 0.5 and the analysis clustered the accessions into two major clades. The present study emphasized the importance of survey, collection, and conservation of naturally existing chemotypes of medicinal and aromatic plants, considering their potential use in aroma and pharmaceutical industry.

While the short-term implications of acute kidney injury (AKI) have been known for many years, far less attention has been paid to the health of AKI survivors. This was perhaps fueled by a prevailing wisdom that if a patient was fortunate enough to survive the primary illness associated with AKI, the prognosis for future health was auspicious. More recently, this dogma was challenged by data suggesting that after an episode of AKI, patients remain at risk of experiencing multiple adverse health outcomes. Greater recognition and appreciation of the risks faced by AKI survivors have led to the development of quality improvement initiatives that are supposed to enrich this vulnerable population.

Oncologic immunotherapies use a patient's immune response to eliminate tumor cells by modulation of immune checkpoints, including programmed cell death 1 (PD-1) and cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4) proteins. Immune-mediated sequelae, including interstitial nephritis, have been reported; however, glomerular disease appears rare. We describe 2 cases of nephrotic syndrome in patients treated with these agents. Patient 1 received the anti–PD-1 antibody pembrolizumab for Hodgkin lymphoma. Following his second dose, he developed nephrotic syndrome and acute kidney injury. Biopsy showed diffuse foot-process effacement consistent with minimal change disease and findings of acute tubular injury. Pembrolizumab therapy cessation and corticosteroid treatment yielded improvement in proteinuria and acute kidney injury. Patient 2 received the CTLA-4 antibody ipilimumab for melanoma. He developed nephrotic syndrome with biopsy changes consistent with minimal change disease. Ipilimumab therapy was stopped and proteinuria resolved following corticosteroid treatment. Ipilimumab rechallenge caused relapse of nephrotic-range proteinuria. These cases suggest an association between therapeutic immune activation and the development of nephrotic syndrome. Given the increasing prevalence of oncologic immunotherapies, monitoring patients for renal sequelae is warranted.

The field of therapeutics in autosomal dominant polycystic kidney disease (ADPKD) has seen a significant expansion recently, as major clinical trials have provided promising evidence in favor of new disease-modifying drugs. Though these trials are encouraging, limitations are noticeable in the form of methodological issues that restrict the interpretation of results. In this review, we discuss the methodological pitfalls of high-profile clinical interventional trials for ADPKD which have been published since 2009. Issues in study design, patient selection and follow-up, analyses and reporting of results are presented. From this review, we highlight a number of suggestions for future improvement including designs to enrich a more homogeneous patient population (i.e. based on their age-adjusted total kidney volume and/or underlying mutation class) at high-risk for disease progression, appropriate study duration and patient sample size that are matched to the disease severity of the study patients, and the use of baseline characteristics (i.e. renal function, TKV, and the proportion of PKD1and PKD2patients) of the analyzed patients as a quality control measure to assess any potential imbalance in randomization. Furthermore, the recognition that TKV change is not a linear trait is important in both the study design and interpretation. Implementing these lessons learned from the published trials will greatly enhance the robustness and validity of future clinical trials in ADPKD.

Over the last few decades, the life expectancy of solid organ transplant recipients (SOTRs) has improved significantly. With SOTRs living longer, more recipients are dying from cancer. There is a reported 2- to 3-fold increased risk of cancer-specific mortality in SOTRs compared with the general population. Cancer in an SOTR can be de novo, recurrent, or donor-derived. Cancer screening in this population is crucial, as early detection and treatment may improve outcomes. In the absence of randomized controlled trials dedicated to SOTRs, clinicians rely on clinical practice guidelines from regional and national transplant societies; however, these may vary considerably across jurisdictions and transplanted organ. At present, no widely accepted consensus exists for cancer screening protocols in SOTRs, particularly with regard to screening for malignancy related to transplanted organ. Some SOTRs may be at higher risk of malignancies within the allograft. This is particularly the case in lung and liver recipients, though less common in kidney recipients who are at increased risk of developing renal cell cancer in their native kidneys. This increased risk has not been uniformly incorporated into screening recommendations for SOTRs. In this review, we summarize the cancer screening recommendations for SOTRs from various transplant organizations based on transplanted organ. This review also discusses the complexity and controversies surrounding screening of cancer in the allograft and future avenues to improve cancer detection in this context. More studies specific to SOTRs are required to form generalizable and evidence-based cancer screening guidelines, particularly with respect to cancer screening in the allograft.

Cisplatin is a highly effective chemotherapeutic agent that has been used for more than 50 years for a variety of cancers; however, its use is limited by toxicity, including nephrotoxicity. In this in-depth review, we discuss the incidence of cisplatin-associated acute kidney injury, as well as common risk factors for its development. Cisplatin accumulates in the kidney tubules and causes AKI through various mechanisms, including DNA damage, oxidative stress, and apoptosis. We also discuss the spectrum of nephrotoxicity, including acute and chronic impairment of kidney function, electrolyte disturbances, and thrombotic microangiopathy. We discuss the limited options for the diagnosis, prevention, and management of these complications, along with factors that may impact future therapy with or without cisplatin. We conclude with directions for future research in this expanding and important area.

Patients with chronic kidney disease (CKD) may be at increased risk for cancer. CKD may also be associated with worse cancer outcomes. This study examined cancer incidence and mortality across the spectrum of CKD.

Dialysis-requiring acute kidney injury (AKI) is common among critically ill patients, but little is known about trends in the incidence and outcomes of this condition over time.

On-pump total arterial grafting is associated with improved long-term outcomes compared to conventional grafting using left internal thoracic artery and saphenous vein grafts, but there are no data to confirm the same for off-pump total arterial grafting. We assessed the impact of off-pump total arterial grafting on medium-term outcomes. From September 1998 to September 2008, 580 consecutive patients who had off-pump multivessel arterial grafting only were compared with a control group of 806 patients undergoing off-pump coronary artery bypass with internal thoracic artery and saphenous vein grafts, performed by the same surgeon. Perioperative data were collected prospectively. Medium-term univariate and risk-adjusted comparisons between the 2 groups were carried out. After adjusting for clinical covariates, total arterial grafting did not emerge as a significant independent predictor of medium-term mortality, readmission to hospital, or the composite outcome of death and readmission. At medium-term follow-up, off-pump total arterial grafting, despite being a safe and effective myocardial revascularization strategy, offered no mortality or morbidity benefits.

AbstractTwo distinct chemotypes of Artemisia dracunculuswere found in Kashmir. The oils from these two distinct chemotypes were analysed by GC and GC-MS. The chemical constituents of local variety were α-pinene (0.7%), myrecene (1.2 %), limonene (3.5 %), Z-(β)-ocimene (12.7 %), E-(β)-ocimene (4.6 %), α-terpinolene (2.7 %), 5-phenyl-l,3-Pentadiyne (5.1 %), methyl eugenol (0.7 %), capillene (60.2 %), elemicin (2.3 %), bicyclogermacrene (0.5 %), iso-elemicin (2.1 %) and germacrene-B (0.6 %). The major chemical constituents found in exotic variety are α-pinene (1.4 %), β-pinene (0.3 %), myrecene (0.1 %), p-cymene (0.2 %), limonene (2.8 %), Z-(β)-ocimene (1.6 %), E-(β)-ocimene (1.0 %), γ-terpinene (0.3 %) linalool (1.2 %), β-thujone (0.4 %),camphor (0.4 %), methyl chavicol (71.3 %), iso-menthol (0.1 %), bornyl acetate (0.7 %), carvacraol (7.7 %), α-terpinyl acetate (0.2 %), hexyl hexanoate (0.5 %), α-copaene (2.2 %), β-caryophyllene (0.2 %). The chemical constituents of the volatile oil are similar to French Tarragon.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether, for patients undergoing coronary artery bypass grafting at higher risk of stroke, the single cross-clamp (SC) technique is of benefit in reducing the incidence of stroke. Using the reported search 458 papers were identified. Six randomised controlled trials (RCTs), of which one was a duplicate publication, represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. We conclude that current best available evidence, from six RCTs randomising 490 patients, suggests that there is no benefit of SC technique over multiple cross-clamp (MC) technique in terms of reduction in the incidence of stroke (SC=2/206 vs. MC=7/284; P=ns) although there is some advantage of SC technique in causing less neuropsychological deficits and release of serum S-100 protein, a surrogate marker of cerebral injury.

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) offers cure for some patients with hematological diseases but is associated with significant risk of morbidity and mortality. Acute kidney injury (AKI) represents an important cause of post-transplant complications, often multifactorial in the unique setting of allo-HSCT. However, to date, there is limited information on the overall impact of AKI in this patient population. To address this, we retrospectively reviewed the effect of AKI on transplant outcomes at Princess Margaret Cancer Centre (PMCC).

Madsen: Jazz Pharmaceuticals: Honoraria. Pelletier:Celgene: Honoraria; International Kidney and Monoclonal Gammopathy: Membership on an entity's Board of Directors or advisory committees. Mattsson:Jazz Pharmaceuticals: Honoraria; ITB: Honoraria; Takeda: Membership on an entity's Board of Directors or advisory committees; Mallinkrodt: Honoraria; Gilead: Honoraria.

Between January 1995 and December 1999, 942 patients (452 males and 490 females) aged 1 to 51 years underwent definitive surgery under perfusionless hypothermia for correction of congenital heart defects, predominantly uncomplicated ventricular or atrial septal defects (80%). Hypothermia of 24°C to 28°C was achieved in 15 to 45 minutes (mean, 25.7 ± 1.2 minutes) by application of crushed ice over the body and head. Aortic crossclamp time ranged from 10 to 76 minutes (mean, 26.1 ± 0.25 minutes). Cardiac restoration time ranged from 1 to 10 minutes (mean, 2.1 ± 0.08 minutes). Eight patients (0.85%) died postoperatively: 4 from acute cardiac insufficiency, 2 as a consequence of technical faults, 1 from persistent pulmonary hypertension, and 1 had sudden cardiac arrest. None of the surviving patients showed any gross neurological deficit. Perfusionless hypothermic cardiac surgery, when applied appropriately, is safe and simple, and might still have a place in treating a selected group of patients with uncomplicated congenital heart defects.

Conventional chemotherapies remain the mainstay of treatment for many malignancies. Kidney complications of these therapies are not infrequent and may have serious implications for future kidney function, cancer treatment options, eligibility for clinical trials, and overall survival. Kidney adverse effects may include acute kidney injury (AKI) (via tubular injury, tubulointerstitial nephritis, glomerular disease and thrombotic microangiopathy), long-term kidney function loss and chronic kidney disease (CKD), and electrolyte disturbances. In this review, we summarize the kidney complications of conventional forms of chemotherapy and, where possible, provide estimates of incidence, identify risk factors and strategies for kidney risk mitigation. Also, we provide recommendations regarding kidney dose modifications, recognizing that these adjustments may be limited by available supporting pharmacokinetic and clinical outcomes data. We discuss management strategies for kidney adverse effects associated with these therapies with drug-specific recommendations. We specifically focus on frequently used anticancer agents with established kidney complications, including platinum-based chemotherapies (cisplatin, carboplatin, oxaliplatin), cyclophosphamide, gemcitabine, ifosfamide, methotrexate and pemetrexed, among others.

BACKGROUND: Evidence-based, guideline-recommended practices improve multiple outcomes in patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), but are incompletely implemented in actual practice. Admission order sets with evidence-based diagnostic and therapeutic guidance have enabled quality improvement and guideline implementation in other conditions.OBJECTIVE: To characterize the magnitude of care gaps and the effect of order sets on quality of care in patients with AECOPD.METHODS: The authors prospectively designed a standardized chart review protocol to document process of care and health care utilization before and after implementation of AECOPD order sets at an academic hospital in Toronto, Ontario.RESULTS: A total of 243 total AECOPD admissions and multiple important care gaps were identified. There were 74 admissions in the pre-order set period (January to June 2009) and 169 in the order set period (October 2009 to September 2010). The order set was used in 78 of 169 (46.2%) admissions. In the order set period, we observed improvements in respiratory therapy educational referrals (five of 74 [6.8%] versus 48 of 169 [28.4%]; P<0.01); venous thromboembolism prophylaxis prescriptions (when indicated) (15 of 68 [22.1%] versus 100 of 134 [74.6%]; P<0.01); systemic steroid prescriptions (55 of 74 (74.3%) versus 151 of 169 [89.4%]; P<0.01]); and appropriate antibiotic prescriptions (nine of 24 [37.5%] versus 61 of 88 [69.3%]; P<0.01). The mean (± SD) length of stay also decreased from 6.5±7.7 days before order sets to 4.1±5.0 days with order sets (P=0.017).CONCLUSIONS: Care gaps in inpatient AECOPD management were large and evidence-based order sets may improve guideline adherence at the point of care. Randomized trials including patient outcomes are required to further evaluate this knowledge translation intervention.