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Chronic kidney disease, end-stage renal disease, and bone marrow transplant

Introduction Hematopoietic stem cell transplantation (HSCT) is commonly used as a treatment for malignant and nonmalignant diseases. Over the past decade, there has been more focus on the chronic complications post-HSCT, in particular chronic kidney disease (CKD), which is associated with high mortality in this population, especially in patients who progress to end-stage renal disease (ESRD) requiring dialysis. Although the HSCT may be curative of the…

Graft-versus-host disease

Introduction Since 1957, when the first bone marrow transplantation was performed by Thomas et al., hematopoietic stem cell transplantation (HSCT) has been used for the treatment of several hematologic and autoimmune disorders. With the discovery of the human leukocyte antigen (HLA) system in 1958 and the subsequent better understanding of histocompatibility, allogeneic and autologous stem cell transplantations became standard practice. In the 1970s the number of…

Thrombotic microangiopathy

Introduction Hematopoietic stem cell transplantation (HSCT) is a potentially curative therapy for patients with hematologic malignancies, bone marrow failure syndromes, immunodeficiency states, and metabolic disorders. Thrombotic microangiopathy (TMA) is a well-recognized potentially lethal complication of HSCT. It is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and multiple organ dysfunction. The etiologies of this syndrome are diverse, and it requires a high degree of clinical suspicion for diagnosis.…

Sinusoidal obstruction syndrome

Introduction Sinusoidal obstruction syndrome (SOS) is a well-described complication of the high-dose conditioning regimens used in hematopoietic stem cell transplantation (HSCT), as well as certain hepatotoxic chemotherapies or radiation therapy used in other settings, and is a well-recognized cause of HSCT patient mortality. It was previously known as hepatic veno-occlusive disease based on the pathologic features, but the term was changed to SOS when it became…

Hematopoietic cell transplant associated kidney injury

Kidney injury in graft versus host disease Introduction Hematopoietic cell transplant (HCT) is a commonly used procedure to treat both malignant and nonmalignant conditions. As transplant methods have improved, the overall survival of patients following HCT has also improved. However, morbidities associated with HCT remain a significant problem, and acute kidney injury (AKI) and chronic kidney disease (CKD) occur frequently after transplant, affecting between 10% and…

Fibrillary and immunotactoid glomerulonephritis

Fibrillary glomerulonephritis Overview and epidemiology Fibrillary glomerulonephritis (FGN) was first described in 1977. It is a rare disease, with incidence of less than 1% of native kidney biopsies. It is mostly a disease of Caucasians, with more than 90% of patients in the two largest series self-identified as white. Clinically, the patient with FGN can present with hypertension, proteinuria (full nephrotic syndrome [NS] in up to…

Monoclonal immunoglobulin deposition disease

Introduction Monoclonal immunoglobulin deposition disease (MIDD) is characterized by the deposition of monoclonal light and/or heavy chains within glomerular, tubular, and vessel wall basement membranes. Three subtypes of MIDD have been described and they are subdivided according to the composition of monoclonal protein deposited. The most common form of MIDD is light chain deposition disease (LCDD), where either kappa or lambda light chains are deposited in…

Systemic light chain amyloidosis

Introduction Systemic amyloidoses encompass a group of diseases characterized by deposition of abnormal, insoluble, misfolded, β-pleated protein fibrils in different organs. Amyloid protein positively stains with Congo red and demonstrates apple-green birefringence under polarized light. The deposition of the β-pleated amyloid fibrils causes disruption of tissue architecture and thereby results in organ dysfunction and eventually organ failure. The kidneys, heart, gastrointestinal tract, peripheral nerves, and liver…

Cast nephropathy

Introduction Acute kidney injury (AKI) remains a common presentation of multiple myeloma (MM). Depending on the definition of AKI used, between 18% and 56% of patients with MM are affected. It is not infrequent that myeloma is first identified during the workup of a patient with unexplained AKI. When this AKI is severe, it has historically been associated with a limited chance of renal recovery and…

Paraproteins

Introduction This section of the book focuses on paraprotein-related kidney disorders. In this chapter, we describe a general overview of paraproteins and their adverse effects on the kidneys with emphasis on proximal tubule disorders. In the following chapters, detailed discussions on other types of paraprotein-mediated kidney disorders, including cast nephropathy, monoclonal immunoglobulin light chain (AL) amyloidosis, light and heavy chain diseases, etc., are provided. Paraprotein basics…

Volume disorders and fluid resuscitation

Introduction Volume disorders are common in patients with cancer, given the vast array of organ dysfunction that occurs in these patients, as well as the frequent toxicities associated with many of the chemotherapeutics and biologics used for treatment. In healthy physiology, a complex system is in place to preserve volume homeostasis and maintain equilibrium across the major fluid compartments of the body. However, in disease states,…

Calcium and phosphorus disorders

Introduction Disturbances in calcium and phosphorus homeostasis are commonly encountered when caring for cancer patients. These may result from the malignancy itself or as a complication of the treatment process. A thorough understanding of the pathophysiologic processes, whereby the tumor or its therapy result in abnormalities of calcium and phosphorus balance, is essential to managing cancer patients. Disorders of calcium homeostasis Disturbances in calcium homeostasis resulting…

Potassium disorders

Introduction Potassium abnormalities, both hypo- and hyperkalemia, can occur with significant consequences in patients with malignancies. In addition to typical causes of disturbances in potassium homeostasis, there are unique etiologies within this special cohort including anticancer agent-induced disturbances on potassium excretion, direct effects of malignancies on cellular potassium release or uptake and potassium excretion by the kidneys, as well as artefactual changes more frequently seen in…

Dysnatremias in cancer

Hyponatremia Hyponatremia and cancer relationship Hyponatremia is the most common electrolyte abnormality observed in cancer patients. In a retrospective cohort study from a comprehensive cancer center, hyponatremia (serum Na + < 137 mEq/L) was noted in 47% of hospitalized cancer patients [VO2]. In general, hyponatremia is categorized as mild (130–134 mEq/L), moderate (120–129 mEq/L), and severe (< 120 mEq/L), according to serum sodium concentrations. Hyponatremia has…

Kidney function

Introduction Kidney function in oncologic patients is an important parameter for several reasons. In some specific cases, like urologic cancers, the tumor itself can cause acute or chronic kidney dysfunction. However, the renal function parameter is more frequently followed in oncologic patients because, on one hand, they are likely to get nephrotoxic drugs, and on the other hand, some oncologic patients have chronic kidney disease (CKD)…

Nephrology beginnings

1. Why the history of nephrology? “To understand a science it is necessary to know its history,” said August Comte (1798–1857), founder of modern sociology. Rooted in sociology, this saying evolved into what is now known as the theory of path dependence, which explains how decisions made in any given new circumstance are determined and limited by decisions made in the past, even though past circumstances…

Palliative care in nephrology

Overview of palliative care and role in nephrology care 1. What is palliative care? Palliative care is specialized care that treats the symptoms and burdens associated with serious illness. Palliative care is delivered by an interdisciplinary team that includes physicians, nurses, social workers, and chaplains. Palliative care is not synonymous with hospice care (see later). 2. What are the domains of palliative care? Palliative care collaboratively…

Metabolic alkalosis

Introduction and physiology 1. What is metabolic alkalosis? The metabolic alkaloses represent a heterogeneous group of disorders that have in common a high concentration of plasma bicarbonate [HCO 3 − ] and a low concentration of H + in plasma. This constellation of findings can be seen in a number of different pathophysiologic entities. Hence metabolic alkalosis is a syndrome of metabolic findings and not a…

Metabolic acidosis

Metabolic acidosis The “secrets” of metabolic acidosis will be the emphasis of this chapter, given the breadth of this topic. This chapter is parsed into, first, a brief overview of relevant physiology and, second, an algorithmic, clinically relevant approach to the metabolic acidosis. The final section of the chapter will discuss, in more detail, specific examples of this diverse group of metabolic abnormalities. Background and key…

Disorders of magnesium metabolism

Normal magnesium physiology 1. How is magnesium measured? The molecular weight of magnesium is 24.3 g/mol, with a 2+ valence (Mg2+). The normal serum magnesium level is 0.7 to 0.85 mmol/L, but it is often expressed as equivalents per liter, 1.4 to 1.7 mEq/L (mEq/L = mmol/L × valence), or in conventional units, 1.7 to 2.1 mg/dL (mg/dL = mmol/L × molecular weight divided by 10).…