Acute kidney injury is very common during the treatment of childhood cancer: over a third of children are affected by it. Researcher and trainee nurse specialist Paulien Raymakers-Janssen investigated how kidney injury in children with cancer can be recognised at an early stage and how these children can be protected. On Thursday 3 September, she was awarded her PhD at Utrecht University.
More and more children with cancer are being cured; survival rates have risen over recent decades from around 20 per cent to nearly 80 per cent. However, the intensive treatments that make this possible – such as chemotherapy, antibiotics, surgery, stem cell transplants and radiotherapy – can also damage the kidneys.
A nationwide study involving more than 1,500 children with cancer shows that acute kidney injury occurs regularly during treatment. The greater the total exposure to medicines that can be harmful to the kidneys, the greater the risk of acute kidney injury. “Unfortunately, acute kidney injury is not always temporary,” explains Paulien. “Children who experience acute kidney injury once are at greater risk of developing chronic kidney problems later on. This risk increases further with multiple episodes. For children who survive cancer, this can have major consequences for their quality of life and possibly also for their life expectancy.”
Led by Professor Marry van den Heuvel-Eibrink and Professor Marta Fiocco, Paulien investigated kidney damage during various stages of treatment for children with cancer. She also studied specific groups at increased risk of kidney problems, such as children with a kidney tumour and seriously ill children who had to be admitted to the paediatric intensive care unit, where kidney function had to be temporarily taken over.
In severely ill children with cancer, kidney problems are not always detectable at an early stage through routine blood and urine tests. Paulien’s research shows that the extent to which children retain fluid – and consequently gain weight – can provide important information. Children who retained more than 10 per cent fluid prior to the start of renal replacement therapy were at greater risk of dying. Careful monitoring of fluid balance and body weight can help healthcare professionals recognise a deterioration earlier and determine the right time for treatment.
“The standard measure we use to detect kidney damage – the blood creatinine level – often only shows signs of damage at a late stage,” says Paulien. “We therefore need to monitor kidney function much more closely before treatment begins and during treatment. This can be done using existing biomarkers, supplemented by new ones such as NGAL: a small protein in the urine that may reveal kidney damage at an earlier stage.” This approach has been in use at UMC Utrecht/WKZ and the Prinses Máxima Center since March, partly thanks to this research.”
Paulien Raymakers-Janssen’s research findings show which children are at greater risk of kidney damage and where healthcare professionals can intervene earlier. This can be achieved, for example, through alerts in the electronic health record (EHR), which warn doctors and nurses when the risk of kidney damage increases. Monitoring kidney function remains important even after cancer treatment has ended, as kidney problems sometimes only develop later and more gradually. It is therefore important that kidney function becomes an essential part of existing follow-up protocols.
The next step is to apply this knowledge to day-to-day care. This requires close collaboration between paediatric oncologists, intensive care specialists, paediatric nephrologists, nurses and other healthcare professionals.
At the Princess Máxima Centre, the paediatric nephrology and infectious diseases departments of the WKZ and the pharmacy are working together to prevent, as far as possible, drug-induced kidney damage in children undergoing stem cell transplants. “We aim to extend this approach to several departments within the Princess Máxima Centre and UMC Utrecht/WKZ soon. Furthermore, all data-driven technology offers great opportunities.
This project is co-funded by the WKZ Fund. The implementation process is made possible in part by the Prinses Máxima Centre Foundation.
