Blood Res 2017; 52(3): 218-219  https://doi.org/10.5045/br.2017.52.3.218
Hematologists and nephrologists working together: moving forward with a new integrated care model for blood-related malignancies?
Pasquale Niscola1*, Tommaso Caravita1, Paola Tatangelo2, Agostina Siniscalchi1, Paolo de Fabritiis1, and Roberto Palumbo2

1Hematology Unit, Department of Medical Specialties S. Eugenio Hospital (ASL Roma 2), Rome, Italy.

2Nephrology Unit, Department of Medical Specialties S. Eugenio Hospital (ASL Roma 2), Rome, Italy.

Correspondence to: Pasquale Niscola. Hematology Unit, S. Eugenio Hospital, Rome 00144, Italy. pniscola@gmail.com
Received: November 6, 2016; Accepted: January 17, 2017; Published online: September 25, 2017.
© The Korean Journal of Hematology. All rights reserved.

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TO THE EDITOR: Patients with hematological malignancies (HM) are at high risk of renal complications [12]. Additionally, HM may occur in people with a pre-existing renal impairment (RI). Indeed, in patients with HM, several forms of RI may arise from the underlying disease, the adverse effects of antineoplastic therapies [1], or late clinical complications [2]. On the other hand, some forms of RI may be detectable during the initial diagnostic work-up for HM as the result of comorbid illnesses, such as hypertension or diabetes, which are typically observed in older individuals [3]. In addition, most HM tend to occur in elderly, in parallel with the age-related decline in renal function. The presence of a RI at the onset of disease has been recognized as an independent prognostic factor in the case of newly diagnosed diffuse large B-cell lymphoma [4] and multiple myeloma (MM) [5]. Furthermore, in patients with acute myeloid leukemia (AML), RI can be an insurmountable barrier to administering an appropriate and effective chemotherapy for optimal management [6]. Given the high incidence of RI, the baseline renal function should be accurately assessed in the initial work-up of a newly diagnosed HM, including even the patients with normal serum creatinine (sCr) levels. This assessment allows physicians to make appropriate choices for treatment such as adjusting the dosage of the chemotherapeutic agents [13], novel antineoplastic targeted compounds, antibiotics, or analgesics [7].

The coexistence of HM and renal disorders interrupt the optimal antineoplastic treatments because the pharmacological behavior of administered drugs and their active compounds may be influenced by the renal function. In order to unintended toxic effects due to an altered metabolism or a compromised renal excretion, it is important that physician fully understand the characteristics of drugs. Although our knowledge on this issue has improved in recent years, the management of patients with HM accompanying RI is challenging due to the lack of organizational structures and collaborative models between nephrologists and hematologists. Additionally, patients with RI are commonly excluded from preclinical development or phase I trials [8] because they are considered to be at high risk of complications. Therefore, a comprehensive team approach such as ‘hematonephrology’ or ‘nephrohematology’ is required to appropriately manage these vulnerable patients [9].

Would now be the time to think about reorganizing the hospital wards and providing integrated services for patients with HM by clinical teams composed of hematologists and nephrologists? In our opinion, this question should be addressed by operational trials involving nephrologists and hematologists working in the same team developed for patients with HM. In this comprehensive team, patients with HM could receive more specialized and constant nephrologic management throughout the course of the disease. Prospective studies could demonstrate the evidence for the clinical effectiveness and cost-effectiveness of early referral strategies for the management of these patients with or without evident markers of renal disease. This would optimize the treatment and prevent the progression of RI to more advanced stages through the use of chemotherapeutic agents and/or other antineoplastic agents, which may potentially induce further kidney damage and aggravate an already compromised renal function.

In conclusion, we recommend the development of new departments and clinics where hematologists and nephrologists could manage HM patients together. Thus, we advocate the development of a new and modern medical specialization such as hematonephrology, to improve our knowledge and outcomes of patients with HM and RI.

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