Critical considerations in the administration of antineoplastic therapy for patients with malignant solid tumors undergoing hemodialysis

Patients with chronic kidney disease exhibit a higher risk of developing malignancies, and among those with end-stage renal disease (ESRD) on dialysis, approximately 7% are diagnosed with new-onset tumors within five years. Patients with ESRD who are receiving antineoplastic treatment exhibit a significantly higher incidence and greater severity of adverse effects associated with antineoplastic agents compared to individuals with normal renal function. This complexity involves multiple factors, including the therapy options and dose adjustment of antineoplastic agents, drug-related toxicities, management of fluid overload, and the maintenance of internal homeostasis in ESRD patients with malignancies. Patients undergoing hemodialysis are at heightened risk of drug toxicity if doses of renally cleared medications are not appropriately individualized; conversely, subtherapeutic drug exposure may occur due to premature and substantial removal of medications during the dialysis session. Unfortunately, there is little information on the appropriate dosing and pharmacokinetics of most chemotherapeutic agents in dialysis patients being treated for cancer. Therefore, ensuring the safety of antineoplastic therapy in ESRD patients has emerged as a significant clinical challenge for both nephrologists and oncologists. This article summarized the effects of uremia and hemodialysis on the pharmacokinetics of commonly used antineoplastic agents, along with an overview of real-world evidence on the use of these agents in patients with ESRD undergoing hemodialysis. It aims to provide clinically valuable information to optimize antineoplastic therapy in this patient population, with the ultimate goal of prolonging survival periods and reducing the incidence of severe drug-related complications.