ABSTRACT
Cancer and chronic kidney disease prevalence both increase with age. As a consequence, physicians are more frequently encountering older people with cancer who need dialysis, or patients on dialysis diagnosed with cancer. Decisions in this context are particularly complex and multifaceted. In this Review, we aim to provide an overview of the key points to address when making a treatment strategy in these patients. We provide information on what happens if dialysis is not started or is stopped, and how physicians should deal with such patients. Informed decisions about dialysis require a personalised care plan that considers the prognosis and treatment options for each condition while also respecting patient preferences. The concept of prognosis should include quality-of-life considerations, functional status, and burden of care. Close collaboration between oncologists, nephrologists, and geriatricians is crucial to making optimal treatment decisions, and several tools are available for estimating cancer prognosis, prognosis of renal disease, and general age-related prognosis. Emerging evidence shows that these geriatric assessment tools, which measure degrees of frailty, are useful in patients with chronic kidney disease. In this Review, we try to hand tools to practising physicians, to guide decision making regarding the initiation and termination of dialysis in patients with advanced cancer.
ABSTRACT
OBJECTIVES: The Schnitzler syndrome is a rare inflammatory disorder, with a chronic urticaria-like rash and an IgM (rarely IgG) monoclonal gammopathy as cardinal features. Interleukin-1 ß is regarded as the key mediator and the interleukin-1 receptor antagonist anakinra has been proposed as first-line treatment. This case series of eleven patients is intended to enhance disease awareness and to compare our centre's experience with that of literature. METHODS: We describe the clinical features and disease course of 11 patients with a definite Schnitzler syndrome, according to the Strasbourg diagnostic criteria, encountered in the University Hospital, Leuven, Belgium, between 1995 and 2015. RESULTS: Eleven patients, with a median age of 55 years, were diagnosed with Schnitzler syndrome. All but one were diagnosed during the last decade. Of 6 patients treated with anakinra, 2 had a suboptimal response and 2 had poor tolerance (injection site reaction and neutropenia, respectively). Two of the 11 patients died as a consequence of the disease, culminating in Waldenström's macroglobulinaemia and AA amyloidosis, respectively. CONCLUSIONS: The Schnitzler syndrome is rare, but probably underdiagnosed. In a patient with a chronic urticaria-like dermatosis, minor itch, intermittent fever and bone or joint aches, protein electrophoresis and immunofixation should be ordered. Especially, a finding of a monoclonal IgM kappa fits the diagnosis of Schnitzler syndrome. Anakinra may provide symptomatic relief, although the response is not always spectacular. The outcome is not always benign as fatal complications may occur.
