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Drowning the kidneys: from fluid overload to physiology-guided fluid management in onco-hematology.

Acute kidney injury (AKI) is a frequent complication in patients with cancer. Although AKI in oncology is often multifactorial, it is frequently attributed to nephrotoxicity or intrinsic tubular injury. However, its hemodynamic mechanisms remain underrecognized. Accumulating evidence from critical care and cardiorenal medicine indicates that fluid overload, venous congestion, and increased intra-abdominal pressure are major drivers of kidney dysfunction and adverse outcomes in patients with cancer. These mechanisms are particularly relevant in onco-hematology, where protocol-driven hydration,

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… Oliguria may indicate reduced GFR but is often influenced by neurohormonal activation, VC, increased IAP, pain, stress, or vasopressor therapy. Conversely, transient increases in urine output following fluid administration may create false reassurance despite ongoing kidney stress [ 7 , 32 ]. …

Emergency Care

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Persistent lactic acidosis in ALK-positive anaplastic large cell lymphoma: a case report and literature review.

Lactic acidosis is common in the ICU, but malignancy-associated type B lactic acidosis mediated by the clinical Warburg effect (CWE) is uncommon and easily missed when infection or organ dysfunction dominates the presentation. We report a 35-year-old man with a month of fever and progressive dyspnea who presented with persistent hyperlactatemia (peak 15.46 mmol/L) and markedly elevated LDH despite stable hemodynamics. Imaging revealed generalized lymphadenopathy, multifocal osteolytic lesions, and bilateral pleural effusions; infectious studies were unrevealing apart from chronic hepatitis B.

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… Additionally, on June 10, in response to acute kidney injury (manifested by oliguria) and refractory metabolic acidosis (pH 7.313, bicarbonate 14.5 mmol/L), continuous renal replacement therapy (CRRT) was commenced (continuous venovenous hemodiafiltration [CVVHDF] mode with bicarbonate replacement fluid …

Chemotherapy plus therapeutic plasmapheresis with 4% human albumin solution in multiple myeloma patients with acute kidney injury: a prospective, open-label, proof-of-concept study.

As no unified treatment protocol or evidence yet exists for plasmapheresis without plasma, this study explored the outcomes of using 4% human albumin (ALB) solution as a replacement solution in patients undergoing plasma exchange for multiple myeloma (MM) patients with acute kidney injury (AKI). This study was prospectively registered (ChiCTR2000030640 and NCT05251896). Bortezomib-based chemotherapy plus therapeutic plasmapheresis (TPP) with 4% human ALB solution was assessed for three years in patients with MM aged >18 years, with AKI according to the Kidney Disease Improving Global Outcomes

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… Non-interventional follow-up versus fluid bolus in RESPONSE to oliguria in hemodynamically stable critically ill patients: a randomized controlled pilot trial . Crit Care . 2022 ; 26 ( 1 ): 401 . doi: 10.1186/s13054-022-04283-8 . 36550559 PMC9773608 27 Little RJA , Rubin DB. …

Treatment of acute kidney injury in cancer patients.

Acute kidney injury (AKI), either of pre-renal, renal or post-renal origin, is an important complication in cancer patients, resulting in worse prognosis, withdrawal from effective oncological treatments, longer hospitalizations and increased costs. The aim of this article is to provide a literature review of general and cause-specific treatment strategies for AKI, providing a helpful guide for clinical practice. We propose to classify AKI as patient-related, cancer-related and treatment-related in order to optimize therapeutic interventions. In the setting of patient-related causes, proper as

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… Finally, renal replacement therapy (RRT) may be required in the setting of severe hypercalcaemia and AKI with oliguria. Treatment-related AKI The decision to temporarily or permanently discontinue oncological treatment depends on several nephrological and oncological factors. …

Acute kidney injury in the patient with cancer.

Dramatic advances in the care of patients with cancer have led to significant improvement in outcomes and survival. However, renal manifestations of the underlying cancer as well as the effects of anti-neoplastic therapies leave patients with significant morbidity and chronic kidney disease risks. The most common renal manifestations associated with cancer include acute kidney injury (AKI) in the setting of multiple myeloma, tumor lysis syndrome, post-hematopoietic stem cell therapy, and AKI associated with chemotherapy. Knowledge of specific risk factors, modification of risk and careful atte

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… Hepatic SOS is characterized by painful hepatomegaly, jaundice, oliguria, and ascites and mimics hepatorenal syndrome. Hypervolemia in these cases is usually diuretic resistant, and spontaneous recovery is rare. …

Phase IIB, Randomized, Double-Blind, Placebo-Controlled Clinical Trial of Intravenous Defibrotide for the Prevention and Treatment of Respiratory Distress and Cytokine Release Syndrome in COVID-19.

INTRODUCTION: Endothelial dysfunction is key in COVID-19 pathogenesis. This randomized, double-blind phase IIb trial investigated continuous intravenous infusion of defibrotide in patients hospitalized with SARS-CoV-2 infection and respiratory failure. METHODS: One-hundred and fifty patients were randomized (2:1) to defibrotide or placebo, stratified by disease severity (WHO COVID-19 severity scale 4/5 vs. 6). The primary endpoint was clinical improvement time (days from first improvement through Day 30). RESULTS: Median clinical improvement time was not significantly different with defibrot

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… Four deaths were due to metabolic coma, necrotizing pneumonia, refractory shock with oliguria and metabolic acidosis, and distributive septic shock (each 1, 2.6%); all occurred in the defibrotide arm and were not considered treatment‐related. …

Current Challenges in Chimeric Antigen Receptor T-cell Therapy in Patients With B-cell Lymphoid Malignancies.

Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapy based on genetically engineered T cells derived from patients. The introduction of CAR T-cell therapy has changed the treatment paradigm of patients with B-cell lymphoid malignancies. However, challenging issues including managing life-threatening toxicities related to CAR T-cell infusion and resistance to CAR T-cell therapy, leading to progression or relapse, remain. This review summarizes the issues with currently approved CAR T-cell therapies for patients with relapsed or refractory B-cell lymphoid malignancies, inc

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… in case of rapidly increasing and high serum ferritin levels (>5,000 ng/mL) with cytopenia in the context of fever, especially if accompanied by any of the following: 1) Common Terminology Criteria for Adverse Events (CTCAE) grade ≥3 increase in serum bilirubin, AST, or ALT levels; 2) CTCAE grade ≥3 oliguria …

Acute kidney injury in critically ill cancer patients: an update.

Patients with cancer represent a growing group among actual ICU admissions (up to 20 %). Due to their increased susceptibility to infectious and noninfectious complications related to the underlying cancer itself or its treatment, these patients frequently develop acute kidney injury (AKI). A wide variety of definitions for AKI are still used in the cancer literature, despite existing guidelines on definitions and staging of AKI. Alternative diagnostic investigations such as Cystatin C and urinary biomarkers are discussed briefly. This review summarizes the literature between 2010 and 2015 on

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… Prevention of TLS All patients who are at risk for the TLS should receive intravenous hydration to rapidly improve renal perfusion and glomerular filtration and to minimize acidosis and oliguria (an ominous sign). …

Oral ixazomib, lenalidomide, and dexamethasone for transplant-ineligible patients with newly diagnosed multiple myeloma.

Continuous lenalidomide-dexamethasone (Rd)-based regimens are among the standards of care in transplant-ineligible newly diagnosed multiple myeloma (NDMM) patients. The oral proteasome inhibitor ixazomib is suitable for continuous dosing, with predictable, manageable toxicities. In the double-blind, placebo-controlled TOURMALINE-MM2 trial, transplant-ineligible NDMM patients were randomized to ixazomib 4 mg (n = 351) or placebo (n = 354) plus Rd. After 18 cycles, dexamethasone was discontinued and treatment was continued using reduced-dose ixazomib (3 mg) and lenalidomide (10 mg) until progres

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… “Acute renal failure” included the preferred terms of blood creatinine increased, acute kidney injury, renal failure, renal impairment, creatinine renal clearance decreased, oliguria, azotemia, nephritis, glomerular filtration rate decreased, proteinuria, renal tubular disorder. …

Recommended Treatment for Antibody-mediated Rejection After Kidney Transplantation: The 2019 Expert Consensus From the Transplantion Society Working Group.

With the development of modern solid-phase assays to detect anti-HLA antibodies and a more precise histological classification, the diagnosis of antibody-mediated rejection (AMR) has become more common and is a major cause of kidney graft loss. Currently, there are no approved therapies and treatment guidelines are based on low-level evidence. The number of prospective randomized trials for the treatment of AMR is small, and the lack of an accepted common standard for care has been an impediment to the development of new therapies. To help alleviate this, The Transplantation Society convened a

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… known preformed DSA, as early posttransplant AMR occurs in up to 40% of patients with preformed DSA and a positive flow cytometric crossmatch. 38 , 39 This aggressive form of active AMR typically presents with an abrupt increase in DSA accompanied by allograft dysfunction (increased creatinine and oliguria …

Recognition and management of early complications in CAR-T cell therapy and virus-specific T-lymphocyte therapy: a practical clinical reference.

BACKGROUND: Cellular immunotherapies-including chimeric antigen receptor T-cell (CAR-T) therapies and adoptive transfer of virus-specific T lymphocytes (VSTs) - have transformed the treatment of refractory hematological malignancies and post-transplant infectious complications. Eight products are currently authorized by the European Medicines Agency, encompassing seven autologous CAR-T products targeting CD19 or BCMA and tabelecleucel (Ebvallo), the first approved allogeneic off-the-shelf EBV-specific T-cell product for EBV-positive post-transplant lymphoproliferative disease. Despite their cl

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… seizures not responding to first-line anticonvulsants IEC-HS with multiorgan dysfunction Requirement for mechanical ventilation New cardiac dysfunction (arrhythmia, myocarditis, cardiogenic shock) Relative criteria requiring intermediate care: Grade 2 CRS with significant respiratory compromise or oliguria …

Patterns of Glomerular Injury: Histopathological Classification and Clinical Correlation.

Glomerular diseases represent a diverse group of conditions that significantly contribute to chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide. Understanding the histopathological patterns of glomerular injury is essential for accurate diagnosis, prognosis, and targeted therapy. This comprehensive review explores the morphologic, immunopathologic, and clinical characteristics of major glomerular disorders, including minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, immunoglobulin A nephropathy, lupus nephritis, and others. Histological

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… Oliguria and rising creatinine reflect decreased filtration due to active inflammation [ 55 ]. It indicates glomerular capillary wall damage and immune complex deposition with complement activation [ 55 ]. …

Preventive strategies for acute kidney injury in cancer patients.

Acute kidney injury (AKI) is a common complication of cancer that occurs in up to 50% of neoplastic patients during the natural history of their disease; furthermore, it has a huge impact on key outcomes such as overall prognosis, length of hospitalization and costs. AKI in cancer patients has different causes, either patient-, tumour- or treatment-related. Patient-related risk factors for AKI are the same as in the general population, whereas tumour-related risk factors are represented by compression, obstruction, direct kidney infiltration from the tumour as well by precipitation, aggregatio

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… As HSCT-associated SOS often present hepatorenal syndrome with painful hepatomegaly, jaundice, oliguria and ascites, preventive and treatment strategies include prostaglandin E, pentoxiphylline and low-dose heparin [ 63 ]. …

Liver Disease Associated with Non-Hepatitis Viruses

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… Patients suffer from nausea, vomiting, or epigastric pain, and develop jaundice and oliguria. Bleeding can occur from the mouth, nose, eyes or stomach. Serum aspartate transferase (AST) levels usually exceed those of alanine transferase (ALT). …

Cancer Therapy-Induced Encephalitis.

Encephalitis associated with cancer therapies is a rare but serious complication that can significantly impact patients' quality of life and it requires prompt identification and management. Over the past two decades, immunotherapy-particularly immune checkpoint inhibitors-has become a cornerstone of cancer treatment, with up to half of metastatic cancer patients in economically developed countries now receiving these therapies. The widespread adoption of immunotherapy has led to improved survival rates and long-term remissions, even in patients with advanced metastatic disease. However, as im

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… Clinically, CRS resembles septic shock and is characterized by high fever, tachycardia, hypotension, myalgia, respiratory failure, vascular leakage, coagulopathy (disseminated intravascular coagulation, or DIC), and oliguria, which can lead to multiple organ failure in severe cases [ 45 , 61 , 62 ]. …

Chemotherapy-Associated Thrombotic Microangiopathy.

Thrombotic microangiopathy (TMA) is a syndrome of microangiopathic hemolytic anemia and thrombocytopenia with end-organ dysfunction. Although the advent of plasma exchange, immunosuppression, and complement inhibition has improved morbidity and mortality for primary TMAs, the management of secondary TMAs, particularly drug-induced TMA, remains less clear. TMA related to cancer drugs disrupts the antineoplastic treatment course, increasing the risk of cancer progression. Chemotherapeutic agents such as mitomycin-C, gemcitabine, and platinum-based drugs as well as targeted therapies such as anti

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… within days due to TMA Iams, 2013 21 | 1 | 57 y/o F, ER/PR/HER2 + breast ca, AKI, dyspnea, ↓hgb, ↓plt, ↓hapto, ↑LDH | 4 mo | Docetaxel, etoposide | No | D/c + TPE +CS | CR in 8 days | PR (8 days), CR (5 mo) | Alive at 9 wk Oxaliplatin | Saad, 2022 22 | 1 | 73 y/o F, met colon ca, jaundice, hematuria, oliguria …

A comprehensive update of extracutaneous involvement of mycosis fungoides: A narrative review of literature.

Mycosis fungoides, the most prevalent subtype of cutaneous T-cell lymphoma, primarily targets areas of the skin that of not exposed to sunlight. Nevertheless, it can involve extracutaneous tissues at any disease stage, especially during its advanced phases. Research suggests that all extracutaneous organs might be susceptible, though such cases are more commonly reported in autopsy studies and less so in clinical setting. The most recent comprehensive review of such extracutaneous manifestations in mycosis fungoides occurred almost a decade ago. With the aim of enhancing clinicians' understand

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… Renal involvement in MF has been documented with manifestations such as proteinuria, oliguria, acute renal failure, hypotension, and azotemia. …

Intestinal/Multivisceral Transplantation

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… In the face of low renal reserve, whole blood tacrolimus concentrations over 20 ng/mL are associated with elevated serum creatinine, blood urea nitrogen (BUN), and oliguria [ 90 ]. …

42nd International Symposium on Intensive Care & Emergency Medicine

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