Kidney Failure Risk Equation and Cost of Care in Patients with Chronic Kidney Disease.

BACKGROUND AND OBJECTIVES: Patients with CKD exhibit heterogeneity in their rates of progression to kidney failure. The kidney failure risk equation (KFRE) has been shown to accurately estimate progression to kidney failure in adults with CKD. Our objective was to determine health care utilization patterns of patients on the basis of their risk of progression. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective cohort study of adults with CKD and eGFR of 15-59 ml/min per 1.73 m2 enrolled in multidisciplinary CKD clinics in the province of Saskatchewan, Canada. Data were collected from January 1, 2004 to December 31, 2012 and followed for 5 years (December 31, 2017). We stratified patients by eGFR and risk of progression and compared the number and cost of hospital admissions, physician visits, and prescription drugs. RESULTS: In total, 1003 adults were included in the study. Within the eGFR of 15-29 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and drug dispensations over the 5-year study period comparing high-risk patients with low-risk patients were (Canadian dollars) $89,265 versus $48,374 (P=0.008), $23,423 versus $11,231 (P<0.001), and $21,853 versus $16,757 (P=0.01), respectively. Within the eGFR of 30-59 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and prescription drugs were $55,944 versus $36,740 (P=0.10), $13,414 versus $10,370 (P=0.08), and $20,394 versus $14,902 (P=0.02) in high-risk patients in comparison with low-risk patients, respectively, for progression to kidney failure. CONCLUSIONS: In patients with CKD and eGFR of 15-59 ml/min per 1.73 m2 followed in multidisciplinary clinics, the costs of hospital admissions, physician visits, and drugs were higher for patients at higher risk of progression to kidney failure by the KFRE compared with patients in the low-risk category. The high-risk group of patients with CKD and eGFR of 15-29 ml/min per 1.73 m2 had stronger association with hospitalizations costs, physician visits, and drug utilizations.

Current status of systemic therapy in hepatocellular cancer.

Hepatocellular cancer (HCC) is a common cancer and an important cause of cancer-related death globally. Although surgery is the primary curative treatment, most patients at diagnosis are not surgical candidates and are treated with liver-directed therapy and or systemic therapy. Over the past decade, the systemic treatment options for patients with advanced HCC have evolved. This paper reviews recent progress in systemic therapy and the results of major clinical trials involving novel compounds in patients with HCC. A literature search was performed using keywords related to HCC and systemic therapy. The evidence shows that at the present time an effective adjuvant systemic therapy is not available for patients with early-stage HCC following surgery. In patients with advanced HCC, in addition to sorafenib at least four other targeted agents and several immune checkpoint inhibitors, alone or in combination have been shown to be associated with improved progression-free and overall survival. The optimal sequence of agents, is currently not known, and is determined by patient characteristics, toxicities profile, patients and physicians preference. The future identification of novel active agents and predictive biomarkers are vital to personalize systemic therapy in HCC.

Acute kidney injury from immune checkpoint inhibitor use.

Immune checkpoint inhibitors are novel oncological medications, current classes of which include monoclonal antibodies that target inhibitory receptors cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), programmed death 1 protein (PD-1) and programmed death-ligand 1. While they are novel in their ability to treat cancer, they also have a unique spectrum of immune-related adverse events. Renal-related immune adverse events, though rare, are an increasingly recognised clinical entity. We present the case of a 67-year-old man with acute kidney injury (AKI) after the second cycle of combination anti-CTLA-4 and anti-PD-1 antibodies for metastatic cutaneous melanoma. He presented with vomiting and diarrhoea, and AKI secondary to dehydration was treated with aggressive rehydration. After failing to recover biochemically, a renal biopsy was performed, which demonstrated severe acute interstitial nephritis. The culprit medications were held and he was treated with steroids. With immunosuppression, creatinine improved to pretreatment values.