Radiation Nephropathy Treatment & Management

Updated: Sep 17, 2019
  • Author: Eric P Cohen, MD; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Treatment

Approach Considerations

As with chronic renal disease of any kind, the major risk with radiation nephropathy and bone marrow transplantation (BMT) nephropathy is progressive loss of renal function with evolution to end-stage renal disease. Concomitant hypertension predisposes patients to stroke and heart disease, and uncontrolled hypertension may accelerate the loss of renal function. To slow the progression of renal disease, good control of blood pressure must be maintained; this is also true for radiation nephropathy and BMT nephropathy. (Monitoring blood pressure for 24 hours [ambulatory blood pressure monitoring] may help to differentiate true hypertension from white-coat hypertension.)

Antihypertensive agents are an important part of clinical management of radiation nephropathy or BMT nephropathy. The goal of therapy is to keep blood pressure at less than 130/85 mm Hg, or 125/75 mm Hg if the patient has proteinuria of greater than 1000 mg/d.

Other drugs used in renal disease treatment include the following:

  • Diuretics - Treat fluid overload and enhance potassium excretion
  • Sodium polystyrene sulfonate- Treats hyperkalemia
  • Fludrocortisone - Treats aldosterone deficiency and hyperkalemia

Patients with radiation nephropathy or BMT nephropathy may be more anemic than expected for their level of renal function. Anemia may be treated with recombinant human erythropoietin.

Dietary salt restriction probably helps to control hypertension in cases of radiation nephropathy or BMT nephropathy. Patients must avoid instant, processed, or snack foods, and they must not use salt in cooking or at the dining table. No specific activity restrictions are necessary.

No specific consultations are necessary other than those that may arise from intercurrent illness. A patient who has undergone BMT may have other medical problems, such as hypothyroidism, cataracts, or bone avascular necrosis. Secondary cancers are a substantial risk, so ongoing oncologic follow-up is essential. Patient transfer or referral may be necessary in the event of complications or management difficulty.

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Antihypertensive Agents

Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and/or calcium channel blockers control blood pressure. Improved blood pressure control helps to slow the progression of renal failure. In patients with chronic kidney disease, especially when the serum creatinine level is elevated or the glomerular filtration rate (GFR) is reduced, more than 1 antihypertensive drug is typically needed to control blood pressure.

No proof suggests that one type of antihypertensive agent is superior to another in radiation nephropathy and BMT nephropathy. Nonetheless, ACE inhibitors are favored because of their known benefit in other progressive kidney diseases. [20] An ARB was shown to be very effective in a single case of radiation nephropathy. [21]  However, no randomized trials of ACE inhibitors or ARBs in human radiation nephropathy have been published.

In experimental studies of radiation nephropathy, ACE inhibitors and ARBs have been particularly effective in the treatment and prevention of histologic injury and renal function loss. [22] Conversely, angiotensin II infusion in experimental radiation nephropathy models has had distinct adverse effects. The use of ACE inhibitors (eg, captopril) may mitigate, or even entirely prevent, radiation nephropathy if these agents are started soon enough after the initial irradiation. [23] This effect has been demonstrated in experimental animals.

In a clinical study of the use of captopril versus a placebo in patients who underwent radiation-based hematopoietic stem cell transplantation, a lower serum creatinine level and a higher GFR were found after 1 year in the captopril patients, in comparison with the placebo patients. [23]

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Inpatient Care

In-hospital care may be needed for complications, such as fluid overload or hyperkalemia. With any patient with chronic renal disease, intercurrent illness may precipitate hospitalization.

In the case of acute BMT nephropathy associated with an hemolytic-uremic syndrome and/or a thrombotic thrombocytopenia purpura–like disorder, the use of plasma exchange may be considered. This treatment may reverse the hematologic component, but it does not improve renal function. [24]

Most patients with renal insufficiency require a dose adjustment for many medications. One should avoid the use of any nephrotoxic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). Should it become necessary to use intravenous (IV) radiocontrast, the use of IV isotonic sodium chloride solution should reduce the risk of contrast-induced nephropathy.

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Long-Term Monitoring

Outpatient care of any patient with chronic renal failure requires sufficient frequency of doctor visits, attention to blood pressure control, and assessment of the rate at which renal function is lost. These principles are valid for radiation nephropathy and BMT nephropathy. Monthly or weekly outpatient visits may be needed for patients whose blood pressure remains uncontrolled or who have fluid overload requiring an adjustment of diuretic doses.

The rate of loss of kidney function is adequately assessed by construction of a graph of 100/plasma creatinine versus time. Such a graph should be updated after each visit. Such a graph may permit prediction of future decline in renal function and its timing. (See Rate of Kidney Function Loss.)

Follow-up of patients who have received therapeutic irradiation must address not only the cancer for which they were irradiated but also the possible injury to healthy tissue. For this reason, patients who have undergone BMT must have periodic medical visits.

In addition, the use of new therapies involving radiation, such as radioisotope therapies, requires careful monitoring for unexpected injuries to healthy tissue. These injuries have occurred with the use of 90Y-tagged somatostatin and 166Ho-tagged phosphonate. [6, 7]

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Patient Education

Any patient with chronic renal disease must comply with outpatient follow-up and blood pressure control. This compliance helps to slow the decline in renal function; the same is true for patients with radiation nephropathy or BMT nephropathy.

Patients must be aware of their maintenance medications and dosages. They must avoid nephrotoxins, such as over-the-counter nonsteroidal arthritis medicines, including ibuprofen. 

For patient education information, see Kidney Disease.

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Prevention

Technetium 99m (99mTc) mertiatide is the radiopharmaceutical of choice for the evaluation of both children and adults suspected of having renal obstruction. While the package insert suggests an administered dose range of 185 MBq (5 mCi) to 370 MBq (10 mCi) for the average adult patient who weighs 70 kg, for most 99mTc-MAG3 renal imaging examinations, administration of doses in this range fails to have a diagnostic effect and results in unnecessary radiation to the patient. Current guidelines recommend a range of 37–185 MBq be used. [25]

 

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