Onconephrology: New Frontiers Necessitate New Skills?

The rapidly evolving field of oncology with the availability of newer anticancer drugs like targeted and immunotherapy has resulted in improved patient outcomes and longer survival. Consequently, the aging population with cancer is now confronted with the challenge of managing not only the primary disease but also coexisting chronic non-communicable conditions, including kidney disease. Additionally, the renal complications arising from cancer itself or the therapies used to treat it can lead to acute kidney injury (AKI) and/or chronic kidney disease (CKD), thereby further complicating patient care and potentially limiting the use of necessary therapies due to nephrotoxicity.

Traditionally, cancer care in India has been limited to tertiary care centers and dedicated cancer hospitals located in urban areas. This approach has resulted in significant gaps in infrastructure and personnel, thereby hindering the delivery of high-quality cancer care. With dedicated institutes for cancer care in our countries the diagnostic and management skills for patients with cancer are state-of-the-art. Whereas these centers excel at the oncology-related infrastructure and resources, often there is a serious lack of nephrology-related infrastructure including a regular round-the-clock nephrology referral service.

Compounding this issue is the reality that the care of kidney diseases in the context of cancer has not been prioritized, hampering the effective management of these patients. An issue we face as healthcare providers in India is the attitude of society toward patients with chronic or terminal diseases like cancer and kidney diseases. Aggressive diagnostic plans, interventional strategies like dialysis or kidney biopsies, and expensive treatment modalities like plasma exchange may not be accepted by the patient and their families. The intricate nature of kidney care in cancer patients, coupled with a prevailing lack of awareness about cancer in our society, underscores the critical need for a multidisciplinary and coordinated approach. A change in the mindset with an openness to discuss possible interventions and long-term therapies is also the need of the hour.

The mounting evidence highlighting the crucial relationship between oncology and nephrology has led to the establishment of a dedicated Journal of Onconephrology,[1] conference sessions, and symposiums focused exclusively on onconephrology. Additionally, the recent formation of international societies like the American Society of Onconephrology[2] reflects the growing recognition of this field. We are still in a nascent stage of recognizing and understanding the unique intersection of oncology and nephrology, persuading our oncology colleagues about prioritizing early referrals and multidisciplinary care, and dispelling misconceptions amongst the general public about the potential reversibility of kidney diseases with early diagnosis and treatment in cancer patients. The time has come for the nephrology community in India to acknowledge the crucial intersection between nephrology and oncology. and take definitive steps to provide outstanding support to our oncology colleagues. To deliver improved care for this challenging cohort of patients, nephrologists must enhance their skills and expand their knowledge base.

Onconephrology fellowships or certificate courses would ignite curiosity among our nephrology fellows regarding this subject. These courses should include perspectives and information not only from nephrology but also from our oncology colleagues. Dedicated symposia or sessions on onconephrology in our conferences will be an essential step toward understanding the pathophysiology and unique clinical spectrum of patients with malignancy and kidney diseases. It will facilitate the development of networks and connections among colleagues across the country who are interested in this sub-specialty, leading to enhanced collaborations in teaching and research. The maintenance of registries and data sharing amongst the interested nephrology and oncology teams will help develop interest and strengthen our clinical practice. There are several unaddressed and complex research questions, which include but are not restricted to, determining the impact of newer classes of anti-cancer drugs, optimizing treatment strategies for drug-induced AKI, and understanding the long-term sequelae of kidney disease in oncology patients. Recognizing establishing working groups will help set up research studies directed at answering these dilemmas. Seeking help from our oncology colleagues in understanding newer cancer therapies will help nephrologists in identifying the renal adverse effects earlier and offer treatment accordingly.

In the rapidly advancing landscape of technology and social media, setting up chat groups or other social media platforms to discuss difficult onconephrology cases can provide clinicians with an avenue to collaborate, share expertise, and collectively find innovative solutions to challenging clinical scenarios.[3] We need to utilize collaboration opportunities like the Sister Renal Centers program[4] of the International Society of Nephrology, which can provide guidance and support to our institutes by pairing them with established onconephrology units around the world. Enhanced communication and dedicated multidisciplinary review courses with our oncology colleagues are essential for fostering bidirectional knowledge sharing.

In conclusion, the field of onconephrology holds significant importance as the incidence of kidney diseases among cancer patients continues to rise. The intersection between nephrology and oncology presents unique challenges that require a multidisciplinary and coordinated approach. By recognizing and addressing these challenges, we can improve patient outcomes and enhance the delivery of high-level cancer care [Figure 1].

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Figure 1

Challenges in Onconephrology in India

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