Opinion: Novel Risk Assessment Tool Helps Predict Cisplatin-Induced Acute Kidney Injury

Amanda Brink, DNP, APRN, FNP-BC, AOCNP

Cisplatin, a platinum-based chemotherapy agent, is an integral part of the treatment of various malignancies, including ovarian, testicular, bladder, and lung cancers, among others. Despite its efficacy, cisplatin is well known for its dose-limiting nephrotoxicity, which can lead to acute kidney injury. Cisplatin-induced acute kidney injury (CP-AKI) can also increase the risk of experiencing other side effects from cisplatin therapy.¹

As oncology nurses, recognizing the risk for cisplatin-induced acute kidney injury and counseling patients about this risk are essential for optimizing patient outcomes. The development of cisplatin-induced acute kidney injury can complicate a patient’s current cancer treatment by potentially necessitating treatment interruptions or discontinuation. It can also adversely affect the patient's overall prognosis and quality of life, especially if hospitalization occurs. Therefore, early identification of patients at risk for cisplatin-induced acute kidney injury is crucial.

Risk Assessment Tool for Cisplatin-Induced Acute Kidney Injury

Gupta et al. developed a novel risk assessment tool designed to predict the likelihood of developing cisplatin-induced acute kidney injury.¹

The authors studied adult patients treated with intravenous cisplatin at 6 major academic cancer centers across the United States. They collected data on various risk factors, including age, sex, race, ethnicity, body mass index, and comorbidities such as hypertension, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, and cirrhosis. Additionally, they noted whether patients were current or former smokers, baseline laboratory values (such as serum creatinine, white blood cell and platelet counts, hemoglobin, serum magnesium, calcium, and albumin), date and dose of administered cisplatin, and receipt of other nephrotoxic chemotherapy (including immune checkpoint inhibitors, pemetrexed, cetuximab [Erbitux], and ifosfamide) administered within 30 days before cisplatin.

The authors defined cisplatin-induced acute kidney injury as an increase in serum creatinine level that is 2 times greater than baseline or the initiation of dialysis within 14 days of the first dose of cisplatin. This definition aligns with stage 2 or 3 acute kidney injury, as outlined by the Kidney Disease: Improving Global Outcomes (KDIGO) consensus guidelines, which provide standardized criteria for diagnosing and classifying acute kidney injury.²

The study developed and validated predictive models for cisplatin-induced acute kidney injury. A total of 24,717 adults were included in the study, with 11,766 in the derivation cohort and 12,951 in the validation cohort. The derivation cohort consists of participants used to create a predictive model or tool. The validation cohort is a separate group used to test and confirm the accuracy of this model. This ensures that the findings are dependable and applicable beyond the initial group.

Cisplatin-induced acute kidney injury occurred in 608 patients (5.2%, 608 out of 11,766) in the derivation cohort and in 421 patients (3.3%, 421 out of 12,951) in the validation cohort.

In the primary model, several factors independently increased cisplatin-induced acute kidney injury risk, including age, hypertension, diabetes mellitus, serum creatinine level, hemoglobin level, white blood cell count, platelet count, serum albumin level, serum magnesium level, and cisplatin dose.

A simplified risk model was developed using the 9 risk factors identified in the primary model. Patients were assigned risk scores ranging from 0 to 22.5 based on these factors. Each risk factor is assigned a specific number of points. For instance, patients aged ≤ 45 receive 0 points, whereas those aged 46-60 receive 2.5 points. Patients with a history of hypertension receive 1 point. Detailed point assignments for each risk factor are provided in the article. Higher scores indicate a greater predicted risk of developing cisplatin-induced acute kidney injury.

Low risk was defined as 0-5.5 points, moderate risk as 6-9.5 points, high risk as 10-15.5 points, and very high risk as greater than 16 points. Rates of cisplatin-induced acute kidney injury in the derivation cohort ranged from 1.3% in low-risk patients to 23.5% in those categorized as very high risk. In the validation cohort, rates ranged from 1.1% in low-risk patients to 16.7% in patients classified as very high risk.

Nursing Considerations

All the information included in the cisplatin-induced acute kidney injury risk factor model is readily available to oncology nurses from a patient’s medical record. Therefore, nurses can easily calculate this risk score. When patients are identified as being at increased risk for cisplatin-induced acute kidney injury, oncology nurses can collaborate with the oncology team to consider more frequent monitoring for cisplatin-induced acute kidney injury. Nurses can also educate patients about symptoms of cisplatin-induced acute kidney injury to be aware of, such as changes in urine output.

Oncology nurses can also advocate for their patients who are at increased risk to participate in clinical trials aimed at preventing cisplatin-induced acute kidney injury.

In conclusion, integrating the cisplatin-induced acute kidney injury risk assessment into clinical practice has the potential to enhance patient outcomes through proactive management and personalized recommendations. Oncology nurses play a crucial role in leading the integration of this risk assessment into daily clinical practice.

References

1. Gupta S, Glezerman IG, Hirsch JS, et al. Derivation and external validation of a simple risk score for predicting severe acute kidney injury after intravenous cisplatin: cohort study [published correction appears in BMJ. 2024 Jun 20;385:q1207. doi: 10.1136/bmj.q1207]. BMJ. 2024;384:e077169. Published 2024 Mar 27. doi:10.1136/bmj-2023-077169
2. Acute Kidney Injury (AKI). KDIGO. Accessed July 8, 2024. https://kdigo.org/guidelines/acute-kidney-injury/