Onco-nephrology in clinical practice: pharmacokinetics, monitoring, and treatment strategies for patients with cancer and impaired renal function.

Renal dysfunction is common in patients with cancer and affects their pharmacokinetics, thereby altering treatment efficacy and safety. This review outlines the principles of dose adjustment based on renal function and highlights specific issues in patients undergoing dialysis or with proteinuria. In patients undergoing dialysis, dose adjustment can be rational if drug properties such as molecular weight and protein binding are considered. Metabolites of some drugs, such as fluorouracil (5-FU), may accumulate in patients with impaired renal function, thereby increasing the risk of toxicity. For oxaliplatin, increased platinum exposure in patients undergoing dialysis does not necessarily increase toxicity, possibly because reactive platinum species are eliminated independent of renal function. Proteinuria can lead to reduced drug exposure to monoclonal antibodies owing to abnormal urinary excretion. The early detection and management of drug-induced kidney injuries are essential. These strategies include identifying risk factors, adjusting doses, and implementing monitoring systems. Protocol-based approaches, such as pharmacist-led monitoring, can improve cancer pharmacotherapy. Automated systems and AI-based models have also been explored for risk prediction. Future studies should focus on deepening our understanding of pharmacokinetics in patients with advanced chronic kidney disease (CKD) or those on dialysis. Multidisciplinary collaboration in onco-nephrology is important to improve cancer care in this growing population.