Maecke, Helmut

Mueller-Brand, Jan

Schumacher, Tilmann

Waldherr, Christian

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European Journal of Nuclear Medicine Vol. 29, No. 3, March 2002Eur J Nucl Med (2002) 29:435DOI 10.1007/s00259-001-0720-2Published online: 21 December 2001© Springer-Verlag 2001Kidney failure after treatment with 90Y-DOTATOCDear Sir,We read with interest the case report of Cybulla and co-workers [1] and the comprehensive editorial comment[2] on a case of kidney failure after 90Y-DOTATOC ther-apy, and strongly feel that some comments and clarifica-tion are needed. Certainly, tumour therapy often – if notalways – appears to be like sailing between Scylla andCharybdis. Complete tumour remissions would most of-ten be achieved with a number of therapeutic agents ifthe dose-dependent side-effects could be neglected. Theknowledge of tubular re-absorption of peptides and, thus,potential radiation-induced kidney toxicity in radiopep-tide therapy is not new. The Basel experience began in1996, when the first patients were treated with 90Y-DOTATOC. Initial results regarding tumour responseand symptomatic relief were promising, but it becameevident that kidney protection was necessary [3]. Frommultiple studies it is known that an amino acid solutionis able to reduce renal tubular uptake of labelled peptidesor antibodies [4, 5, 6, 7]. Since the middle of 1998, eachpatient treated in Basel has received a Hartmann-Hepa8% solution [Ringer-Lactate Hartmann (500 ml), Pro-teinsteril Hepa 8% (1,500 ml), and Mg 5-Sulfat 10%(30 ml)] for kidney protection, beginning 30 min beforethe therapeutic injection and in each 90Y-DOTATOCtreatment session.The patient to whom Cybulla et al. [1] refer was treat-ed in the transitional period; unfortunately she receivedkidney protection only in the last of the four treatmentsessions. An important detail in the history of this patientwas not mentioned by the authors or escaped theirnotice: she suffered from bilateral hydronephrosis afterrecurrent urinary tract infections prior to the 90Y-DOTATOC treatment. The fate of this particular patientis known in detail to us, and was an essential part of twoearlier publications from this hospital [3, 8]. The publi-cation by Moll et al. [8], which surprisingly is not quotedin the case report, deals exclusively with the topic ofrenal thrombotic microangiopathy following 90Y-DOTATOC treatment; this indicates the high importancegiven to the issue in our department. The report ofCybulla et al. [1] is thus the third publication to dealwith this patient in particular.During long-term follow-up of up to 5 years in nearly400 patients, renal insufficiency after 90Y-DOTATOCtherapy has not appeared frequently. It is conceivablethat there might be a correlation between the develop-ment of renal failure after 90Y-DOTATOC treatment andtumour mass, the somatostatin receptor density of the tu-mour, the health status of the patient, prior chemotherapy(especially with carboplatin and methotrexate), externalbeam irradiation or other forms of internal radiotherapy(e.g. radioiodine). A publication on long-term efficacyand safety data is in internal revision.Decision making in desperate situations of progres-sive disease is always like sailing between Scylla andCharybdis, the potential benefit of treatment beingweighed against the generally low risk of a potentiallyharmful side-effect. The decision on the use of 90Y-DOTATOC therapy has to be reached in discussions be-tween the patient, the referring physician and the nuclearmedicine department.Tilmann Schumacher (✉), Christian Waldherr, Jan Mueller-Brand, Helmut MaeckeInstitute of Nuclear Medicine and Radiological Chemistry Unit, University Hospitals, Petersgraben 4, 4031 Basel, Switzerlande-mail: tschumacher@uhbs.chTel.: +41-61-2654706, Fax: +41-61-2654925References1. Cybulla M, Steiner SM, Otte A. End-stage renal disease aftertreatment with 90Y-DOTATOC. Eur J Nucl Med 2001; 28:1552–1554.2. Boerman OC, Oyen WJG, Corstens FHM. Between the Scyllaand Charybdis of peptide radionuclide therapy: hitting the tumorand saving the kidney. Eur J Nucl Med 2001; 28:1447–1449.3. Otte A, Herrmann R, Heppeler A, Behe M, Jermann E, PowellP, Maecke HR, Muller J. Yttrium-90 DOTATOC: first clinicalresults. Eur J Nucl Med 1999; 26:1439–1447.4. Hammond PJ, Wade AF, Gwilliam ME, Peters AM, MyersMJ, Gilbey SG, Bloom SR, Calam J. Amino acid infusionblocks renal tubular uptake of an indium-labelled somatostatinanalogue. Br J Cancer 1993; 67:1437–1439.5. Behr TM, Sharkey RM, Juweid ME, Blumenthal RD, DunnRM, Griffiths GL, Bair HJ, Wolf FG, Becker WS, GoldenbergDM. Reduction of the renal uptake of radiolabeled monoclonalantibody fragments by cationic amino acids and their deriva-tives. Cancer Res 1995; 55:3825–3834.6. Behr TM, Goldenberg DM, Becker W. Reducing the renal up-take of radiolabeled antibody fragments and peptides for diag-nosis and therapy: present status, future prospects and limita-tions. Eur J Nucl Med 1998; 25:201–212.7. Bernard BF, Krenning EP, Breeman WA, Rolleman EJ, BakkerWH, Visser TJ, Macke H, de Jong M. D-Lysine reduction ofindium-111 octreotide and yttrium-90 octreotide renal uptake.J Nucl Med 1997; 38:1929–1933.8. Moll S, Nickeleit V, Mueller-Brand J, Brunner FP, MaeckeHR, Mihatsch MJ. A new cause of renal thrombotic microan-giopathy: yttrium 90-DOTATOC internal radiotherapy. Am JKidney Dis 2001; 37:847–851.Letters to the editor

Kidney failure after treatment with 90Y-DOTATOC

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Kidney failure after treatment with 90Y-DOTATOC

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