|Year : 2015 | Volume
| Issue : 2 | Page : 293-296
|Comparison of measured glomerular filtration rates with isotope infusion and with the modification of diet in renal disease equation in cancer patients with raised serum creatinine
Amrah Javaid1, Saghir Ahmed Jaffri2, Iqbal Munir3, Muhammad H Qazi2, Muhammad Khalid Nawaz3
1 Department of Basic Sciences, College of Medicine, Princess Noura Bint Abdul Rehman University, Riyadh, Kingdom of Saudi Arabia
2 Institute of Molecular Biology and Biotechnology, University of Lahore, Lahore, Pakistan
3 Shaukat Khanam Memorial Cancer Hospital and Research Center, Lahore, Pakistan
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|Date of Web Publication||3-Mar-2015|
| Abstract|| |
To compare the measured glomerular filtration rate (rGFR) using [99mTc] diethylene triamine pentacetic acid (DTPA) clearance or estimated GFR (eGFR) by the Modification of Diet in Renal Disease (MDRD) equation in cancer patients with raised serum creatinine level, we studied 100 cancer patients; 50 patients with normal serum creatinine (control group) and 50 patients with abnormal serum creatinine (study group). History of patients, including site of cancer, chemotherapy regime and dose of chemotherapy, was recorded. The rGFR and eGFR were increased in the study group as compared with the control group, but the GFR recorded by the MDRD formula or DTPA revealed similar values. It is therefore concluded that the MDRD equation may be recommended for eGFR estimation even with abnormal creatinine, without the need for exposure to radiation.
|How to cite this article:|
Javaid A, Jaffri SA, Munir I, Qazi MH, Nawaz MK. Comparison of measured glomerular filtration rates with isotope infusion and with the modification of diet in renal disease equation in cancer patients with raised serum creatinine. Saudi J Kidney Dis Transpl 2015;26:293-6
|How to cite this URL:|
Javaid A, Jaffri SA, Munir I, Qazi MH, Nawaz MK. Comparison of measured glomerular filtration rates with isotope infusion and with the modification of diet in renal disease equation in cancer patients with raised serum creatinine. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 May 18];26:293-6. Available from: https://www.sjkdt.org/text.asp?2015/26/2/293/152422
| Introduction|| |
Renal failure remains an important complication of cancer and a side-effect of its treatment. The spectrum of cancer-associated renal disease has changed due to the use of newer chemoradiotherapy regimens. Early diagnosis and treatment of renal failure is vital-both to improve renal health and to prepare the patient for oncologic treatment. ,,,,,
Measurement of glomerular filtration rate (rGFR) by using 99mTc-diethylene triamine pentacetic acid (99mTc-DPTA) is an accurate method of determining the renal function. ,,,,, However, there are some problems with the use of isotopes in clinical practice, including the exposure to radiation and the restricted availability of the procedure and equipment necessary for the isotopic renograms.
The mathematical equations that estimate GFR (eGFR), such as the Modification of Diet in Renal Disease (MGRD) equation, can be more practical as it depends on factors involving the measurement of serum creatinine, which is widely available.  Validation of such an equation in cancer patients with elevated serum creatinine requires comparison with the isotope methods.
The aim of our study was to evaluate the reliability of estimated GFR (eGFR) in detecting changes in kidney function assessed by the MDRD equation in cancer patients treated with nephrotoxic chemotherapeutic drugs. To determine its validation in this population, we compared the eGFR by the MDRD equation with that measured by the use of a Tc99m-DPTA renogram.
| Methods|| |
We conducted a cross-sectional observational study at the Nuclear Medicine Department, Shaukat Khanum Memorial Center Hospital and Research Center, Lahore, Pakistan. A total of 100 cancer patients, 50 with normal serum creatinine (control group) and 50 with abnormal serum creatinine (study group), were referred from the oncology department.
Cancer patients receiving nephrotoxic drugs (cisplatin, ifosfamide, carboplatin and methotrexate) and with no previous history of renal failure were included in the study. All the patients signed an informed consent and the study was approved by the local ethics committee. The medical history of the patients, including the site of cancer, chemotherapy regime and dose of chemotherapy, was recorded. Serum creatinine and blood urea nitrogen were estimated by an autoanalyzer using standard kits of Merck, Durham, North Carolina, USA. Ultrasound reports for changes in the kidneys were also obtained on all the patients. The rGFR was obtained by using the 99mTc-DPTA renogram and the eGFR was calculated using the MDRD formula: GFR (mL/min/1.73 m 2 ) = 186 × serum creatinine -1.154 × age -0.203
Tc-99m-DTPA was prepared using a commercially available freeze-dried kit (Amershan Health, Buckinghamshire, United Kingdom). The patients were hydrated with 300 mL of water 20 min prior to the examination and lay down on a bed in the supine position. About 180-220 MBq 99mTc-DPTA was injected into the patients and controls. Tc-99m-DTPA was given in an antecubital vein and was followed by infusion of 20 mL of normal saline. Frames of 128 × 128 matrix were recorded with an online-computer, initially at 1 s for 1 min and then at 10 s for 20 min. The post-injection syringe with a straight needle, which was detached before the injection, was again counted by the two devices in the same way as the pre-injection. The region of interest (ROI) over each kidney was assigned manually on the frame added from 1-3 min following the injection. The semi-lunar back-ground ROI around each kidney was defined and was modified for the inferior ROIs in the original Gates.  The background-corrected time-activity curve was generated and the renal uptake of the individual kidney for 1 min from 2-3 min after the injection was calculated. The rGFR (by Gates) was automatically estimated by a commercially available computer (GMS-5500A/P, Toshiba, Tokyo, Japan) according to the Gates' algorithm. 
Diet was modified for all the patients who had abnormal serum creatinine level with decreased eGFR (<90 mL/min) according to the MDRD study modification. Protein was restricted to <60 g/day for a person with body weight 70 kg. The modified diet plan included salt, dry fruit and nuts restriction, two to three serving or 8 ounces of good-quality protein food (fish, lean meat and eggs) daily, half a cup of milk, yogurt or ice-cream/day, three fruits and vegetables with low potassium -three servings/day and limited fluids, including water, coffee, tea, lemonade and carbonated beverages to six cups or 48 ounces/day. There was no restriction for margarine use for cooking. The total calorie intake of patients was restricted to 40-45 Kcal/kg/day. 
| Statistical Analysis|| |
For method comparison, the Student "t" test was applied using the Computer software Program SPSS 14. P-values of 0.05 or less in the linear regression analysis were considered significant.
| Results|| |
Renal parameters including GFR in cancer patients with normal and abnormal renal function were tabulated [Table 1]. The levels of blood urea nitrogen (BUN), serum creatinine, albumin/creatinine ratio and rGFR and eGFR were significantly increased in the study group as compared with the control group. A significant difference (P <0.05) was observed in the case of serum creatinine, while the other parameters showed a highly significant difference between both groups.
|Table 1: Comparison of renal parameters including GFR in cancer patients with normal renal function and abnormal renal function.|
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| Discussion|| |
We observed an increase in albumin/creatinine ratio in the study group as compared with the control group. A study reported that the estimation of albumin/creatinine ratio may help in finding the improvement or deterioration of renal function in patients who underwent nephrotoxic chemotherapy. 
Interpretation of the elevated serum creatinine and BUN is limited as the measured levels are influenced by many non-renal factors, including the involvement of other organs such as liver and the decreased muscle mass and the advanced age of the individual as well as the actual method of measurement.  Creatinine clearance (CrCl) measurement, through 24-h urine collection is also dependant on accurate and complete urine collection. , Accordingly, the eGFR by using the validated equations is more practical and avoids the limitations of serum creatinine and direct CrCl.
GFR estimation via rGFR and eGFR were increased significantly (P <0.001) in the study group compared with the control group. Our study is in line with a study that observed a significantly increased GFR in patients who have abnormally increased serum creatinine, which may indicate renal toxicity in patients. 
In our study, we used two techniques for the determination of GFR based on accuracy, time duration and cost-effectiveness. We found that both techniques were accurate. A study favored the Tc99m-DTPA technique and reported that this technique may better help the oncologist in estimating renal function in cancerous patients. , In contrast, other studies found that the eGFR, by using the equation, was reliable for use instead of CrCl in cancer patients. , Finally, a contradictory report for both techniques found that neither the Tc-99 GFR nor the MDRD were predictive of the development of renal insufficiency. 
We conclude from our study that the MDRD equation may be recommended for GFR estimation due to its accuracy, less cost and because it is less time consuming compared with Tc-99m GFR and is easily available to doctors in remote areas as well. Further research is required to develop more reliable methods for estimating renal function, including a specific analysis of the co-variables for gender and also for the different levels of renal function.
| Acknowledgment|| |
The study was conducted at the Department of Nuclear Medicine, Shaukat Khanam Memorial Cancer Hospital and Research Center, Lahore, Pakistan as M. Phil student of the Institute of Molecular Biology and Biotechnology, University of Lahore.
Conflict of interest: None declared.
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Dr. Amrah Javaid
Department of Basic Sciences, College of Medicine, Princess Noura Bint Abdul Rehman University, Riyadh
Kingdom of Saudi Arabia
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