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A dedicated onconephrology service at Brigham and Women’s Hospital (BWH), Boston, improved acute kidney injury (AKI) recovery rates in patients treated for cancer, according to a preliminary before-and-after analysis.

Onconephrology is an emerging subspecialty focused on managing kidney complications in patients with cancer. These complications may stem from the cancer itself or from treatments such as chemotherapy, immunotherapy, or stem cell transplantation.

“There are a number of giants in the field who have helped pave the way for onconephrology to become recognized as an important area within nephrology,” Shruti Gupta, MD, MPH, onconephrologist in the Division of Nephrology at BWH, told Medscape Medical News.

This growth is reflected in the rapid increase in primary publications within the field and the establishment of the American Society of Onconephrology (ASON), founded by Gupta in 2021. The organization has since expanded to include members from 14 countries worldwide.

Implementing Onconephrology at BWH

Gupta, and Raad B. Chowdhury, MD, onconephrologist at BWH and current vice president of ASON, were instrumental in establishing a dedicated onconephrology consult service at the Dana-Farber Cancer Institute. This service aims to deliver specialized inpatient care to patients receiving treatment, mirroring the approach taken by cardio-renal services.

Gupta, Chowdhury, and colleagues detailed the development and implementation of the onconephrology consult service, along with its preliminary outcomes, challenges, and future directions approximately 1 year after its inception in the Clinical Journal of the American Society of Nephrology.

Beginning in July 2023, patients admitted to oncology with kidney issues were seen by the onconephrology service. A nephrology fellow handled the initial consult under the supervision of an onconephrology attending, who completed an Accreditation Council for Graduate Medical Education–accredited nephrology fellowship and either completed an onconephrology fellowship or expressed an interest in onconephrology.

Thereafter, daily follow-up was managed by the onconephrology attending who also coordinated outpatient follow-up appointments with onconephrology within 60 days of discharge. This approach differs from general nephrology, where the initial consult and follow-up involve both the fellow and attending, the authors noted.

They reviewed the data on 402 consults made by oncology to the general nephrology consult service during the year prior to the implementation of the onconephrology consult service. Additionally, they analyzed all 530 consults to the onconephrology service in its inaugural year of operation.

In both the pre- and post-implementation periods, hematologic malignancies were most common (35% and 27%, respectively), followed by gastrointestinal cancers (17% and 18%, respectively), and thoracic/lung cancers (18% and 7%, respectively).

AKI was the most common reason for consultation before and after implementation (68% and 66%, respectively). Hyponatremia was the most common consult for electrolyte abnormality both before and after implementation (19% and 25%, respectively).

Patients with AKI seen by the onconephrology service were more likely to have kidney recovery at sign-off and discharge than patients on the general nephrology consult service.

AKI recovery within 25% of baseline serum creatinine (SCr) at discharge was 45% for onconephrology patients compared with 35% for general nephrology patients. Recovery within 50% of baseline SCr at discharge was 60% and 49%, respectively.

There were no differences in relative increases in sodium levels in patients consulted for hyponatremia.

Acute interstitial nephritis was the most common diagnosis among patients who underwent a biopsy, often linked to immune checkpoint inhibitors.

In comments to Medscape Medical News, Chowdhury explained how the onconephrology service changed the care and improved the outcome of a patient receiving gemcitabine, a chemotherapy agent associated with thrombotic microangiopathy, particularly in the kidney.

“We pursued a kidney biopsy while the patient was admitted, identified the thrombotic microangiopathy, and initiated treatment with a complement-inhibitor called eculizumab. We then saw the patient in the outpatient clinic, and after discussing with the oncologist, learned that the gemcitabine was working very well for the cancer,” Chowdhury said.

“We therefore proceeded to rechallenge the patient with gemcitabine while also continuing the complement inhibitor, allowing the patient to continue their lifesaving cancer treatment. The patient and the oncologist were grateful for our subspecialized expertise and that we were thinking outside-the-box,” Chowdhury told Medscape Medical News.

“Because of the work that has been done in the field, we now understand risk factors for cisplatin-associated kidney injury and immune checkpoint inhibitor–associated acute kidney injury,” Gupta said.

“We now have a better understanding of what treatments may or may not work for chemotherapy-associated kidney damage. For example, we just found that glucarpidase, an antidote, improves kidney and other outcomes in patients with methotrexate-associated acute kidney injury,” Gupta added.

Challenges and Perceptions

As part of their before-and-after analysis, the researchers administered an anonymous survey to oncologists and advanced practice providers responsible for day-to-day patient care and communication with the subspecialists.

They found that 81% of those surveyed rated the onconephrology service as “very useful” and believed that having a dedicated onconephrology inpatient service improved patient care; 88% indicated that they were “very likely” to consult the service again for future patients.

Implementing the onconephrology consult service was not without growing pains.

“One of the biggest challenges we encountered when the service was first initiated was raising awareness among the oncology teams and building a high census in order to be a financially sustainable model. However, as time passed, and the advanced practice providers on the oncology teams interacted with us more and more, they were more inclined to get us involved early and more frequently. We now maintain a fairly busy service, with patient numbers continuing to rise,” Gupta told Medscape Medical News.

Growing the Subspecialty

Asked about the top priorities of ASON, Chowdhury, the current vice president of the organization, said “Our biggest priorities are to continue to expand our membership globally, in particular to trainees. We also hope to grow our research initiatives, since despite the immense progress in the field over the last 10 years, a number of key unanswered questions remain, particularly regarding the pathophysiology and mechanisms of kidney injury of various drugs.”

“We also hope to share our experiences with creating an onconephrology service, so that it can serve as a blueprint for other centers interested in doing the same,” Chowdhury concluded.

This research had no commercial funding. Gupta had consulted for GlaxoSmithKline, Secretome, Proletariat Therapeutics, Alexion, BTG International, Mersana Therapeutics, and received research funding from GE HealthCare, BTG International, National Institutes of Health, and AstraZeneca. Chowdhury has no disclosures.