Bendamustine
Treanda · Alkylator
Tumor lysis-mediated AKI is the principal risk; TMA is rare.
PRETMALYTE
ModerateOpen →
Radioimmunotherapy (Y-90 anti-CD20)
Ibritumomab tiuxetan
Zevalin · IBRI
A pure beta-emitting anti-CD20 radioimmunoconjugate whose kidney risk is not radiation but tumor lysis in bulky lymphoma.
MildRadioimmunotherapy (Y-90 anti-CD20) · approved 2002
Relapsed or refractory low-grade or follicular B-cell non-Hodgkin lymphomaConsolidation in previously untreated follicular lymphoma achieving response to first-line chemotherapy
Signature kidney injury
Prerenal / Hemodynamic AKI
Direct renal radiation toxicity is essentially negligible — yttrium-90 is a pure beta-emitter and the kidney is not a critical organ on dosimetry; the dose-limiting toxicity is delayed myelosuppression. The renal hazard is indirect tumor lysis syndrome (TLS) in bulky/high-burden disease; a drug-specific TLS rate is not well quantified and is rare.
Source: Witzig et al., J Clin Oncol 2002
Toxicity fingerprint
Tap a signature to trace where it strikes the nephron.
Incidence not quantified
SeverityMild
ReversibilityReversible
Evidence0 refs
Nephron map
Vasculature / EndotheliumGlomerular & peritubular capillaries
Distal Tubule / Collecting Duct
Tubular Lumen
Prerenal / Hemodynamic AKI
Renal hypoperfusion from capillary leak and cytokine storm — IL-2 and CAR-T cytokine release syndrome.
Mechanism of kidney injury
No meaningful direct radiation nephropathy: the pure beta-emitter clears with low renal absorbed dose. The kidney injury that occurs is metabolic — rapid lymphoma cell lysis releases uric acid and phosphate, producing crystal (urate/calcium-phosphate) nephropathy with intratubular obstruction and hemodynamic AKI. Myelosuppression (the true dose-limiting toxicity) is hematologic, not renal.
Clinical presentation
When TLS occurs: hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia and a rising creatinine within days of therapy. Renal labs are otherwise typically unaffected; the dominant on-label toxicity is delayed cytopenias (nadir ~7-9 weeks).
Onset
TLS is early (hours to days); cytopenias are delayed (weeks).
Reversibility
Reversible
Anticancer mechanism
Murine anti-CD20 monoclonal antibody chelated (tiuxetan) to yttrium-90, a pure high-energy beta-emitter. After a rituximab pre-dose to clear circulating B cells, the radioconjugate binds CD20 on B-cell non-Hodgkin lymphoma, delivering cross-fire beta radiation plus antibody-mediated cytotoxicity (radioimmunotherapy).
Management
Standard TLS management: aggressive hydration, urate-lowering (rasburicase for established hyperuricemia), correct electrolytes, and dialysis for severe/refractory derangements. Support cytopenias with transfusion and growth factors. The radioconjugate itself is not removed by dialysis.
Risk factors
- Bulky disease / high circulating tumor burden
- High LDH and rapidly proliferative lymphoma
- Pre-existing CKD and dehydration
- High pre-treatment uric acid
Prevention
- TLS prophylaxis in at-risk/bulky patients: IV hydration plus allopurinol or rasburicase
- Electrolyte and uric-acid monitoring around treatment
- Activity capping by platelet count and marrow involvement (hematologic, not renal, threshold)
Note · Established (2002) agent; no dedicated renal cohort exists because direct renal toxicity is not a recognized effect. Renal framing rests on the pivotal dosimetry (kidney non-critical) plus the TLS literature for bulky lymphoma.
Clinical depth
Renal dose adjustment
Administered activity is capped by platelet count (e.g. reduced to 0.3 mCi/kg if platelets 100,000-149,000/uL; contraindicated if platelets <100,000/uL or >25% lymphomatous marrow involvement) — a hematologic threshold. No renal CrCl-based dose adjustment is defined; the kidney does not drive dosing.
Dialyzability & ESKD dosing
The radioimmunoconjugate is not dialyzable. Dialysis is relevant only for managing TLS metabolic derangements, not for removing the drug.
Differential diagnosis
Distinguish TLS-driven AKI (urate/phosphate burden, early, post-treatment) from contrast/medication nephrotoxins, lymphomatous renal infiltration or obstruction, and sepsis. Radiation nephropathy is not part of the differential here.
Monitoring
- CBC weekly for up to ~3 months (marrow nadir surveillance)
- Electrolytes, uric acid, phosphate and creatinine peri-treatment in TLS-risk patients
- Volume status/urine output in bulky disease
Key trials & series
- Pivotal randomized trial of Y-90 ibritumomab vs rituximab (Witzig, J Clin Oncol 2002)
- Pivotal-trial dosimetry (Wiseman, Crit Rev Oncol Hematol 2001) — kidneys not a critical organ
Clinical pearls
- Direct renal radiation toxicity is negligible — the renal story is tumor lysis, not the radioisotope.
- Dosing is limited by platelets and marrow involvement, not by kidney function.
- Bulky lymphoma is the red flag for TLS prophylaxis with hydration and rasburicase/allopurinol.
- The dose-limiting toxicity overall is delayed myelosuppression (nadir ~7-9 weeks).
Where it strikes
Nephron segments
Vasculature / Endothelium
Glomerular & peritubular capillaries
Tubular Lumen
The urine flow path
Injury signatures
Prerenal / Hemodynamic AKICrystal / Obstructive NephropathyElectrolyte Wasting
Evidence
6 peer-reviewed references. Citation metadata via PubMed / NLM.
LandmarkRandomized controlled trial of yttrium-90-labeled ibritumomab tiuxetan radioimmunotherapy versus rituximab immunotherapy for patients with relapsed or refractory low-grade, follicular, or transformed B-cell non-Hodgkin's lymphoma.Witzig TE et al. · J Clin Oncol 2002 · PMID 12011122Pivotal registrational RCT and core safety dataset.PMIDBiodistribution and dosimetry results from a phase III prospectively randomized controlled trial of Zevalin radioimmunotherapy for low-grade, follicular, or transformed B-cell non-Hodgkin's lymphoma.Wiseman GA et al. · Crit Rev Oncol Hematol 2001 · PMID 11418315Pivotal-trial dosimetry showing low renal absorbed dose — supports minimal direct renal radiation risk.PMIDAdditional radiation absorbed dose estimates for Zevalin radioimmunotherapy.Wiseman GA et al. · Cancer Biother Radiopharm 2003 · PMID 12804052Expanded organ dosimetry confirming kidneys are not a critical organ; marrow is dose-limiting.PMIDYttrium 90-labeled ibritumomab tiuxetan radioimmunotherapy produces high response rates and durable remissions in patients with previously treated B-cell lymphoma.Gordon LI et al. · Clin Lymphoma 2004 · PMID 15453924Pooled efficacy/durability across pivotal trials — clinical-outcome anchor.PMIDMonoclonal antibodies in the treatment of cancer, Part 1.Cersosimo RJ et al. · Am J Health Syst Pharm 2003 · PMID 12951753Documents tumor lysis risk and adverse-event profile of anti-CD20 agents including ibritumomab.PMIDUnique aspects of supportive care using monoclonal antibodies in cancer treatment.Dillman RO et al. · Support Cancer Ther 2003 · PMID 18628130Notes true tumor lysis with high bulky tumor burden — the key renal/metabolic concern for this agent.
Related agents
Other agents sharing the same signature kidney injury.