Onco-nephrology — kidney care for patients who have had cancer or cancer treatment — is a nascent field. To date, only three programs in the world offer fellowship training in oncology-nephrology. And they’re relatively young, introduced within the past decade.
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In the U.S., fewer than a dozen specialists have graduated from these programs. Nephrologist Roman Shingarev, MD, helped train three of them while on faculty at Memorial Sloan Kettering Cancer Center. Dr. Shingarev joined Cleveland Clinic in November 2020.
“I didn’t study in an onco-nephrology program because one didn’t exist at the time,” he laughs. “I had special interest in vascular biology in patients undergoing chemotherapy and targeted therapy. That was my field of research. Then, working side by side with colleagues in nephrology, oncology, surgery and other fields at the cancer center — some of them with decades of clinical experience — I had an opportunity to learn from experts in their specialties. By focusing exclusively on patients with cancer these past few years, I have been able to integrate these bits and pieces, these subspecialty facts, into a solid body of knowledge of kidney care.”
Today Dr. Shingarev is the director of Cleveland Clinic’s new onco-nephrology program at Glickman Urological & Kidney Institute. The program is the latest in a growing number of similar programs across the U.S.
In this Q&A, Dr. Shingarev explains more about the subspecialty and his plans for the program at Cleveland Clinic.
Q: What patients are referred to your onco-nephrology program? What type of care do they receive?
Dr. Shingarev: Any patient with a cancer diagnosis can be referred by an oncologist, primary care physician or other specialist to our clinic, where we can address a range of conditions: high blood pressure, acute or chronic kidney disease, electrolyte and metabolic derangements, and immunosuppression after solid organ or bone marrow transplant, to name a few. There are so many unique features to these problems brought on either by the cancer or the cancer treatment, the recognition of which really requires special expertise at the intersection of oncology and nephrology.
Onco-nephrologists see patients before surgery or pharmacological cancer therapy to help optimize kidney care. We also evaluate kidney function to help calculate appropriate dosing of medical therapies. Among many things, we offer nuclear imaging, kidney tissue diagnosis and pharmacological management — routine nephrology tools that we can apply with greater precision with our knowledge of oncologic intricacies.
The world of oncology has advanced much in the past decade, with a dizzying array of new treatments emerging every year. Reflecting the overall trend in medicine, oncology has become more fractionalized, now with oncologists specializing by organ or part of an organ. We strive to mitigate this fractionalization by providing timely consultation for these very complex patients and preventing delays in cancer treatment.
Q: What is the prevalence of kidney problems in patients with cancer?
Dr. Shingarev: This is difficult to answer. There is such a wide variety of kidney-related complications. In oncology literature, kidney complications are reported using Common Terminology Criteria for Adverse Effects (CTCAE) that differ in some ways from the nephrologic definitions of the same problems. Further, when reporting kidney dysfunction, CTCAE provides a measurement of glomerular filtration rate at a specific time during cancer treatment, but this only tells a small part of the story. (It is similar to reporting the slower or faster speed of a car without explaining why it is changing.)
The overall prevalence of chronic kidney disease of any severity among cancer patients has been estimated to be 50-60%. However, the number is probably closer to 20-30% when we look at chronic kidney disease of clinical significance.
We’re not just dealing with kidney dysfunction though. Nephrologists care for patients with high blood pressure, which may be considered a “cardiovascular problem,” as well as many “endocrinologic problems.”
Q: What are your goals for patients treated in the onco-nephrology program?
Dr. Shingarev: Our patients tend to be the sickest of the sick. Often they are referred to us because they are developing complications from their third or fourth line of cancer therapy and often are in multiorgan failure. Much of our time is dedicated to mitigating the effects of treatment toxicities and improving quality of life — which often involves postponing dialysis as long as possible, because it adds a significant level of complexity and may make continuation of cancer treatment impossible.
As another example, we use our expertise to help determine the relative kidney toxicity of concurrent cancer drugs, which leads to the discontinuation of the culprit while allowing other effective drugs to be continued.
Q: What are your goals for the program at Cleveland Clinic?
Dr. Shingarev: Currently there are two clinicians in our program, me and Ali Mehdi, MD, MEd, who is also a recent addition to Glickman Urological & Kidney Institute. Our immediate goal is to establish a pattern of referral and build our clinical practice. Once we have done that, we can start generating clinical data that can be used for cross-pollination of oncology and nephrology, bringing databases together to create one body of knowledge to allow for more advances in research.
Of course, our ultimate goal is to improve the outcomes of oncology patients, a goal that is shared by all dedicated oncology centers. However, at Cleveland Clinic we also have an opportunity to expand cancer treatments to patients with chronic kidney disease, who are commonly excluded from many drug trials and are, thus, at a disadvantage. I think this is one of the most important things we can do at Cleveland Clinic because of our large general nephrology patient population and the fact that these patients may be at a higher risk of developing malignancies.
I’d eventually like to establish an onco-nephrology fellowship program at Cleveland Clinic. We have all the clinical resources to offer this kind of training experience to general nephrology graduates. Plus, to manage the entire patient population referred to us just from Cleveland Clinic Cancer Center, not to mention other regional cancer centers, we will need to expand our provider base. The best way to do that would be to train and hire our own fellows.