Management of anticancer treatment in patients under chronic dialysis: results of the multicentric CANDY (CANcer and DialYsis) study.

BACKGROUND: One million people worldwide benefit from chronic dialysis, with an increased rate in Western countries of 5% yearly. Owing to increased incidence of cancer in dialyzed patients, the management of these patients is challenging for oncologists/nephrologists. PATIENTS AND METHODS: The CANcer and DialYsis (CANDY) retrospective multicenter study included patients under chronic dialysis who subsequently had a cancer (T0). Patients were followed up for 2 years after T0. Prescriptions of anticancer drugs were studied with regard to their renal dosage adjustment/dialysability. RESULTS: A total of 178 patients from 12 institutions were included. The mean time between initiation of dialysis and T0 was 30.8 months. Fifty patients had received anticancer drug treatment. Among them, 72% and 82% received at least one drug needing dosage and one drug to be administered after dialysis sessions, respectively. Chemotherapy was omitted or prematurely stopped in many cases where systemic treatment was indicated or was often not adequately prescribed. CONCLUSIONS: Survival in dialysis patients with incident cancer was poor. It is crucial to consider anticancer drug treatment in these patients as for non-dialysis patients and to use current available specific drug management recommendations in order to (i) adjust the dose and (ii) avoid premature elimination of the drug during dialysis sessions.

[Removal of prednisone and prednisolone during plasma exchange]. / Extraction de prednisone et de prednisolone au cours des échanges plasmatiques.

Prednisone and prednisolone extraction was determined during seven sessions of plasma exchange in four patients. Each patient received 0.5 mg/kg of prednisone administered orally 2 hours before plasma exchange. Concentrations of prednisone and prednisolone were determined in blood before, every half hour during and at the end of plasma exchange. Both drugs were also determined in removed plasma, mean volume of removed plasma being 0.96 plasmatic mass. The amount of combined prednisone and prednisolone removed by plasma exchange was 1.70% of the administered prednisone dose. This quantity appears minimal and supplemental dosing of prednisone or modification of administration time would seem to be unnecessary.

Hemodynamic changes induced by regular hemodialysis and sequential ultrafiltration hemodialysis: A comparative study.

The effects of a mean ultrafiltration of 2000 ml on hemodynamics during regular hemodialysis (RD) and during sequential ultrafiltration hemodialysis (SUH) have been compared in ten patients on maintenance dialysis. Each patient was submitted to two dialysis sessions at 2 days' interval. The hemodynamic studies were performed with a thermistor Swan-Ganz catheter. The control values of mean systemic arterial pressure, cardiac output, and heart rate were similar with either RD or SUH. During ultrafiltration without diffusion, there was an immediate prolonged and significant decrease in cardiac and stroke indexes and in pulmonary wedge pressure. The mean systemic arterial pressure remained unchanged as long as the total vascular resistance was significantly increased. During the diffusion period of SUH, total vascular resistance decreased, and seven patients became hypotensive. When ultrafiltration was associated with diffusion during RD, the total vascular resistance remained stable, despite a decrease in cardiac index. This was found to result in severe hypotensive episodes, despite a moderate ultrafiltration. These results suggest that diffusion can induce arterial vasodilation and poor hemodynamic adaptation to ultrafiltration-induced hypovolemia SUH, undertaken under careful medical control, appears to be an excellent procedure to deplete severely overhydrated dialyzed patients, but it should not be used routinely as a substitute for RD.

Importance of the plasma refilling rate in the genesis of hypovolaemic hypotension during regular dialysis and controlled sequential ultrafiltration-haemodialysis.

The effects of ultrafiltration (UF) on plasma volume (PV) have been studied in eight patients using regular dialysis (RD) and controlled sequential ultrafiltration-haemodialysis (CSU) performed with a Rhodial 75 dialysis system. For a given value of UF the reduction of PV is determined by the plasma refilling rate. During CSU ultrafiltration induces a rapid increase in oncotic pressure without decreasing plasma osmolality. The high plasma refilling rate which can reach 1500 ml/hr allows moderate hypovolaemia despite high rates of UF and contributes to the usual good clinical tolerance of CSU. During RD a rapid decrease in plasma osmolality contributes to a water shift from the vascular space towards the interstitial and intracellular spaces and severe hypovolaemia can occur despite moderate ultrafiltration. CSU offers an adequate treatment for sodium overloaded patients with hypervolaemia, but is of no benefit in routine conditions.