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Table 2 Importance of renal biopsy in cancer patients

From: Renal failure during chemotherapy: renal biopsy for assessing subacute nephrotoxicity of pemetrexed

Orientation Clinical situation Importance of renal biopsy Drugs involved
Prerenal failure Weigh loss, dizziness, skin dryness, low blood pressure, tachycardia, oliguria. No biopsy All drugs associated with dehydration, vomiting or diarrhea
Obstructive renal failure Pelvic cancer localization
Suspicion or demonstration of ureteral dilation
No ureteral stenting in presence of peritoneal carcinosis
Oliguria, anuria
Hypogastric pain or in the lumbar fossa
Hematuria with clots
No biopsy All drugs inducing a lysis syndrome or renal stones
Glomerular disease Hypertension, edema
Proteinuria composed mostly with albumin, hematuria without clots
Nephrotic syndrome (plasma albumin below 30 g/L and nephrotic range proteinuria)
Perform immediate renal biopsy - Interferon:
podocytopathy inducing clinically minimal change disease, focal segmental glomerulosclerosis [22]
- Anti-VEGF agents:
hypertrophy of glomerular endothelial cells, widening of the subendothelial space [23, 24]
- Tyrosine kinase inhibitors:
Gefitinib: minimal changes [25, 26]
Sorafenib [27]
- Anthracyclines:
Doxorubicin: focal segmental glomerulosclerosis [28]
Tubular disease Proteinuria composed mostly with low weight proteins
Leukocyturia
No hematuria
Perform delayed renal biopsy if
- If no resolution after 2 to 4 weeks
- If clinical and biological picture is not clearly in favor of tubular disease
- Antimetabolites:
Methotrexate: precipitation on renal tubules and tubule cells apoptosis [29]
Pemetrexed: renal tubular cells apoptosis
- Alkylating agents:
Platinum salts: renal tubular cells apoptosis [3, 18]
Ifosfamide: acute proximal tubular injury inducing Fanconi syndrome, diabetes insipidus [30]
- Hormone therapy:
Androgen deprivation therapy: acute tubular injury [31]
- Anti-EGFR agents:
Cetuximab: hypomagnesemia due to magnesium transport channel alteration in the loop of Henle [32]
- mTOR inhibitors:
Everolimus: antiproliferative effects and induction of tubular cells autophagy [33]
Interstitial disease Cutaneous rash, liver enzymes increase, hypereosinophilia, urinary eosinophils Essential and with no delay - Acute interstitial disease:
bevacizumab [34, 35], sunitinib [36, 37, 38], ifosfamide [39, 40], carboplatin [41], gemcitabin [38], methotrexate [38], interferon [42], Bcg therapy [43,44,45]
- Chronic interstitial disease [24]:
ifosfamide, carboplatin, doxorubicin
Vascular disease Presence of schizocytes, drop in platelet count, undetectable haptoglobin or low level in an inflammatory context
Cutaneous vasculitis
Perform biopsy if platelet level compatible VEGF inhibitors:
bevacizumab [46, 47], sorafenib [48], gemcitabine [12, 13, 49, 50], sirolimus [51], afilbercept [52, 47]
Antitumor antibiotic:
mitomycin C [53]
Interferon [54]
Tyrosine kinase inhibitors:
Imatinib [55, 47]