Bevacizumab

Glomerular Injury / Proteinuria — representative incidence ~18% (11.7–26.6% 95% CI).

In a 72-trial meta-analysis (21,902 bevacizumab cases vs 20,608 controls), all-grade proteinuria was 18% (95% CI 11.7–26.6%) and high-grade 2.4% (1.8–3.2%); all-grade hypertension was 25.3% (21.5–29.5%). Relative to controls the risk ratios were 3.37 for all-grade and 5.49 for high-grade proteinuria. A separate 16-trial meta-analysis put high-grade proteinuria at 2.2% and nephrotic syndrome at RR 7.78, with renal cell carcinoma carrying the highest cumulative incidence (10.2%).

Source: Zhao et al., Oncotarget 2017 (PMID 28881662); Wu et al., JASN 2010 (PMID 20538785)

Reported injury signatures: Glomerular Injury / Proteinuria, Hypertension, Thrombotic Microangiopathy.

1. Glomerular Injury / ProteinuriaPrimary~2.2%High-grade (grade 3-4) proteinuria 2.2% (95% CI 1.2-4.3) in a 12,268-patient meta-analysis; all-grade proteinuria far more common and dose-dependent, highest in renal-cell carcinoma (cumulative incidence 10.2%). VEGF blockade injures podocytes.
2. HypertensionSecondary~23.6%All-grade hypertension 23.6% (95% CI 20.5-27.1), high-grade 7.9% (95% CI 6.1-10.2) across 12,656 patients; RR 5.28 for high-grade vs control.
3. Thrombotic MicroangiopathyRareCase-level: renal thrombotic microangiopathy described in a 6-patient series with corroborating podocyte-VEGF-knockout mouse model; no cohort incidence rate established.

Subacute (~1–6 weeks) — Develops over weeks to months and is dose-dependent.

• Higher dose
• Pre-existing hypertension / CKD
• Renal cell carcinoma

• Proactive hypertension treatment

• Quantify proteinuria with urine dipstick before each cycle; if >=2+, confirm with a urine protein-to-creatinine ratio (UPCR) or 24-hour collection and hold dosing for proteinuria >=2 g/24 h.
• Measure blood pressure before every infusion and intermittently at home; treat new or worsening hypertension promptly (ACE inhibitor/ARB preferred given concurrent proteinuria).
• Track serum creatinine/eGFR each cycle, but recognize that early VEGF-inhibitor injury is often proteinuric with preserved GFR rather than a creatinine rise.
• Evaluate for TMA (schistocytes on smear, falling platelets, rising LDH, low haptoglobin, worsening anemia) when proteinuria escalates abruptly or hypertension becomes refractory.
• Consider nephrology referral and kidney biopsy for nephrotic-range proteinuria, AKI, or suspected TMA to guide whether to permanently discontinue.

• Eremina et al. NEJM 2008 — mechanistic case series plus podocyte-specific Vegfa-knockout mouse model establishing that VEGF blockade causes a glomerular thrombotic microangiopathy with proteinuria, the foundational lesion for this class.
• AVF2107g (Hurwitz, NEJM 2004) — pivotal metastatic colorectal cancer trial adding bevacizumab to IFL, which documented increased grade 3+ hypertension and proteinuria as on-target class toxicities.
• AVOREN (Escudier, Lancet 2007) — bevacizumab plus interferon in metastatic RCC, reporting higher rates of proteinuria and hypertension than interferon alone.
• Wu et al. Am J Kidney Dis 2010 — meta-analysis of randomized trials quantifying a significantly increased relative risk of proteinuria and high-grade proteinuria with bevacizumab across tumor types.

• The injury is mechanism-based and on-target: bevacizumab sequesters circulating VEGF-A that podocytes secrete to maintain glomerular endothelial fenestrae, producing endotheliosis and a renal-limited TMA.
• Proteinuria and hypertension are the dominant, dose- and exposure-related signals; severe proteinuria or refractory hypertension should prompt suspicion of underlying TMA.
• Most proteinuria and hypertension are reversible after holding or stopping the drug, but TMA and nephrotic syndrome can persist and warrant permanent discontinuation.
• ACE inhibitors/ARBs are the antihypertensives of choice because they simultaneously address the renin-angiotensin-driven hypertension and reduce proteinuria.
• This is a class effect shared with other anti-VEGF/VEGFR agents (e.g., ramucirumab, aflibercept, VEGFR-TKIs), so prior anti-angiogenic exposure raises baseline risk.

Each recommendation below is this atlas's faithful summary of the source, not a quotation from it — follow the PubMed link for the wording the society published. Summaries may be superseded; consult the current full text and individualize to the patient.

• KDIGO (2021) — Management of Blood Pressure in Patients With Chronic Kidney Disease Not Receiving Dialysis: Synopsis of the 2021 KDIGO Clinical Practice GuidelineRecommends standardized office BP measurement and a target systolic BP <120 mm Hg for most CKD patients, with RAAS inhibitors first-line when albuminuria is present — the BP-management basis for anti-VEGF/TKI-induced hypertension and proteinuria.Ann Intern Med · PMID 34152826
• ESC (2022) — 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS)For VEGF/VEGFR inhibitors, perform baseline cardiovascular risk assessment, monitor blood pressure (weekly during the first cycle, then regularly) and treat to a target <140/90 mmHg with ACE inhibitors/ARBs and dihydropyridine calcium-channel blockers; manage VEGFi-associated hypertension and proteinuria with interruption/dose modification when severe.Eur Heart J · PMID 36017568
• ESC (2022) — European Society of Cardiology quality indicators for the prevention and management of cancer therapy-related cardiovascular toxicity in cancer treatmentAdherence quality indicators require documented baseline cardiovascular risk assessment and structured monitoring of cardiovascular complications (including hypertension) during cancer therapy such as VEGF-pathway inhibitors.Eur Heart J Qual Care Clin Outcomes · PMID 36316010
• UK Consensus Panel (2010) — Using bevacizumab to treat metastatic cancer: UK consensus guidelinesAssess and monitor blood pressure and proteinuria during bevacizumab therapy; treat emergent hypertension to standard targets and interrupt/discontinue the drug for uncontrolled hypertension, nephrotic-range proteinuria or other severe vascular toxicity.Br J Hosp Med (Lond) · PMID 21135762
• ADQI (2026) — The nephrotoxic effects of anti-cancer therapies: consensus report of the 34th Acute Disease Quality Initiative workgroupProvides expert-based statements (modified Delphi) on preventing and managing cisplatin/platinum-associated AKI, including isotonic IV hydration, attention to volume status and concomitant nephrotoxins, and incorporates evidence that IV magnesium supplementation may reduce cisplatin-associated AKI; emphasizes risk stratification and standardized AKI definitions.Nat Rev Nephrol · PMID 41361704
• SIRM (2022) — SIRM-SIN-AIOM: appropriateness criteria for evaluation and prevention of renal damage in the patient undergoing contrast medium examinations-consensus statements from Italian College of Radiology (SIRM), Italian College of Nephrology (SIN) and Italian Association of Medical Oncology (AIOM)Recommends eGFR-based renal risk assessment and pre/post-contrast isotonic saline or sodium bicarbonate hydration; advises maintaining a 5-7 day interval between iodinated contrast administration and cisplatin in cancer patients to reduce additive nephrotoxicity.Radiol Med · PMID 35303246
• KDIGO (2020) — KDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancerIdentifies platinum compounds (especially cisplatin) as leading cytotoxic causes of acute tubular injury, AKI, and electrolyte/magnesium wasting; calls for interdisciplinary onco-nephrology care, accurate GFR estimation, and individualized drug dosing in patients with reduced kidney function.Kidney Int · PMID 33126977
• KDIGO (2020) — KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantationAddresses chemotherapy-associated AKI/CKD in hematologic cancer, GFR estimation and chemotherapy dosing in patients with reduced kidney function, and management priorities and research gaps for onco-nephrology care.Kidney Int · PMID 33276867
• ADDIKD (2025) — Integrating International Consensus Guidelines for Anticancer Drug Dosing in Kidney Dysfunction (ADDIKD) into everyday practiceProvides GRADE-based, drug-specific dose-adjustment recommendations for anticancer agents in kidney dysfunction (illustrated for methotrexate, cisplatin, carboplatin and nivolumab); the recommendations build on Part 1's standardised CKD-EPI eGFR assessment rather than Cockcroft-Gault creatinine clearance.EClinicalMedicine · PMID 40290844
• ADDIKD (2025) — Aligning kidney function assessment in patients with cancer to global practices in internal medicineThree consensus recommendations: assess kidney function by GFR (measured GFR or CKD-EPI eGFR), classify it using KDIGO categories, and use this uniform approach to dose anticancer drugs — moving cancer medicine away from Cockcroft-Gault estimated creatinine clearance.EClinicalMedicine · PMID 40290845
• ADDIKD (2025) — A methodology for determining dosing recommendations for anticancer drugs in patients with reduced kidney functionEstablishes that, where RCT evidence is lacking, anticancer drug dosing recommendations in kidney dysfunction should be derived by critically appraising observational literature via GRADE combined with structured international multidisciplinary consensus voting.EClinicalMedicine · PMID 40290846
• KDIGO (2013) — Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)Defines/stages AKI by serum creatinine and urine output; emphasizes avoiding nephrotoxins, maintaining euvolemia/perfusion, dose-adjusting drugs to kidney function, and monitoring high-risk patients — the framework applied to nephrotoxic anti-cancer agents.Crit Care · PMID 23394211
• KDIGO (2024) — Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknownsEvaluate and risk-stratify CKD, manage to delay progression and its complications, and practise explicit medication management and drug stewardship — the framework the atlas's G1–G5 eGFR banding and every renal dose-adjustment recommendation sit inside. Because the guideline excludes dialysis and transplant recipients by its own statement of scope, its recommendations do not carry to those settings, where this atlas's dialyzability and post-transplant guidance rests on other sources.Kidney Int · PMID 38519239
• KDIGO (2021) — Executive summary of the KDIGO 2021 Guideline for the Management of Glomerular DiseasesProvides the staging/treatment framework for drug-associated glomerular lesions (e.g., bisphosphonate- and interferon-related collapsing FSGS, VEGF-inhibitor podocytopathy/proteinuria), including immunosuppression and supportive RAAS-blockade strategies.Kidney Int · PMID 34556300
• KDIGO (2024) — Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of ANCA-Associated VasculitisUpdates immunosuppressive induction (rituximab/cyclophosphamide), incorporates avacopan and lower-dose or glucocorticoid-sparing regimens — the management framework for drug- and checkpoint-inhibitor-associated ANCA/pauci-immune glomerulonephritis.Kidney Int · PMID 38388147
• KDIGO (2024) — Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of Lupus NephritisUpdates first-line lupus nephritis therapy to combination immunosuppression with the addition of belimumab or a calcineurin inhibitor (voclosporin) — informs management of immune-complex/lupus-like glomerulonephritis encountered with immunotherapy.Kidney Int · PMID 38182299
• KDIGO (2025) — Executive summary of the KDIGO 2025 Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV)Encourages liberal kidney biopsy and stricter proteinuria control (<0.5 g/d, ideally <0.3 g/d) with RAAS blockers, SGLT2 inhibitors, and targeted-release budesonide — the framework for IgA-dominant glomerular lesions, including those triggered by immune-modulating cancer therapy.Kidney Int · PMID 40975525