Time-Limited Dialysis as a Bridge to Chemotherapy in Malignancy-Associated Obstructive Uropathy

Dear Editor,

The interface between nephrology and palliative medicine is increasingly relevant in oncology practice, particularly when acute kidney injury (AKI) or uremia threatens disease-directed therapy.¹ We highlight a case that underscores the importance of interdisciplinary collaboration in facilitating oncologic decision-making while maintaining a patient-centered approach.

A 42-year-old woman with stage IIIB cervical carcinoma presented with nausea, pruritus, oliguria (<300 mL/day), and drowsiness. Laboratory evaluation revealed serum creatinine 8.6 mg/dL, blood urea 182 mg/dL, potassium 6.1 mEq/L, bicarbonate 14 mEq/L, and pH 7.21. Imaging demonstrated bilateral hydroureteronephrosis due to malignant ureteric obstruction. Her ECOG performance status was 3. Chemotherapy was deferred in view of poor performance status and biochemical instability.

In advanced malignancy, the clinical dilemma centers on whether renal replacement therapy would offer meaningful benefit. After a joint discussion (nephrology-oncology-palliative care), a time-limited trial of renal replacement therapy was proposed. Predefined goals were: (i) correction of potassium to <5.0 mEq/L and bicarbonate ≥20 mEq/L; (ii) improvement in mentation and pruritus; (iii) urine output >800 mL/day following decompression; and (iv) Eastern Cooperative Oncology Group (ECOG) improvement to ≤2, enabling chemotherapy. Stop criteria included failure to achieve biochemical correction after two sessions, persistent ECOG 3-4, or patient preference against escalation.

The patient underwent one hemodialysis session and bilateral percutaneous nephrostomy insertion. Within 72 h, creatinine declined to 3.2 mg/dL, potassium to 4.6 mEq/L, bicarbonate to 21 mEq/L, urine output improved to 1.2 L/day, and ECOG improved to 2. Chemotherapy was subsequently initiated.

This case demonstrates that, in malignancy-associated obstructive uropathy, dialysis can serve as a goal-directed therapeutic trial aimed at symptom relief, metabolic stabilization, and reassessment of oncologic eligibility, rather than default escalation or withdrawal.^2,3 This case illustrates how a predefined, time-limited dialysis trial can support oncologic decision-making by restoring chemotherapy eligibility while respecting patient-centred goals of care.