After Grade-3 AKI from cisplatin in Post-Operative Chemoradiation (CRT) for Head and Neck Squamous Cell Carcinoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • What to do right now?
    • Stop cisplatin permanently:
      • Grade-3 renal toxicity signals significant tubular injury with risk of incomplete recovery:
        • Continuing platinum can cause irreversible damage
      • FDA labeling flags severe, cumulative nephrotoxicity and advises dose reduction or alternatives in renal impairment Cancer Treatment and Diagnosis+1
    • Continue radiation on schedule and switch the systemic partner only if the patient can tolerate it:
      • Preferred: 
        • RT + cetuximab (loading 400 mg / m² → 250 mg / m² weekly):
          • If infusion tolerance and skin toxicity risk acceptable
            • Evidence for postoperative use is not as mature as for cisplatin:
              • But RTOG 0234 showed feasibility and favorable signals with cetuximab-based regimens
            • Several groups (and guidelines) allow cetuximab when cisplatin is contraindicated
        • If not feasible, RT alone is acceptable PMC
  • Supportive care (same day):
    • Nephrology consult:
      • Classify per CTCAE v5.0 and KDIGO:
    • Aggressive IV hydration with isotonic saline and magnesium supplementation:
      • Hold other nephrotoxins:
        • NSAIDs, IV contrast, aminoglycosides
    • Routine mannitol isn’t required:
      • May be considered selectively at very high cisplatin doses:
        • Not applicable here since cisplatin is being stopped eviq.org.au
    • Frequent labs (serum Cr / eGFR, electrolytes) until recovery:
      • Document nadir eGFR for the chart
  • What NOT to do?
    • Do not re-challenge with cisplatin after a grade-3 AKI in the adjuvant setting:
      • Renal injury may recover incompletely and worsen with further exposure eviq.org.au+1
    • Avoid reflex “swap to carboplatin” in the adjuvant post-op setting after severe AKI:
      • Carboplatin is renally cleared and, while less nephrotoxic, lacks adjuvant level-I evidence with RT for head and neck
      • Prior cisplatin exposure can also predispose to carboplatin – AKI
      • If considered at all:
        • Do so only with nephrology input and careful pharmacokinetics Frontiers
  • Finishing the course (practical scenarios):
    • If some cisplatin already given but < 200 mg /m²: 
      • Aim to complete RT with cetuximab if the patient can tolerate it:
        • Otherwise proceed with RT alone
    • ≥ 200 mg / m² is the commonly cited efficacy threshold in CRT literature:
      • If already achieved, simply finish RT BC Cancer
    • If weekly cisplatin was planned (JCOG1008 context): 
      • That RCT supports weekly as a valid starting schedule post-op:
        • But once grade-3 AKI occurs:
          • The same rules appl:
            • Stop cisplatin and transition as above PubMed
  • One-page order set:
    • Hold cisplatin permanently.
    • RT: 
      • Continue per plan
      • Coordinate new concurrent agent start within 0 to 3 days
    • Cetuximab (if chosen):
      • 400 mg / m² load → 250 mg / m² weekly through RT
        • Premedicate; dermatitis prophylaxis PMC
    • Renal bundle: 
      • NS 1 to 2 L / day IV while inpatient or symptomatic
      • MgSO₄ per lab
      • Stop ACEi/ARBs/NSAIDs/IV contrast if possible
      • Daily weights
      • I/Os eviq.org.au
    • Monitoring: 
      • BMP / Mg daily until stable:
        • Then every 48 to 72 hours
      • Re-stage eGFR at 2 to 4 weeks
      • KDIGO-based follow-up for AKI recovery KDIGO
  • Bottom line: 
    • After grade-3 AKI, do not give more cisplatin
    • Finish radiation and, if feasible, add cetuximab (or proceed with RT alone) while executing a tight renal-recovery plan (hydration, magnesium, nephrotoxin avoidance, close labs)
    • This balances cure intent with kidney safety, in line with contemporary supportive-care guidance
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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