Book Review

Cancer and the Kidney

N Engl J Med 2006; 354:882-883February 23, 2006

Article

Cancer and the Kidney
Edited by Eric P. Cohen. 276 pp., illustrated. New York, Oxford University Press, 2005. $125. ISBN: 0-19-852644-X

The kidney excretes toxins and water and maintains salt, water, and acid–base balance. It accomplishes these tasks with an architecture that is a porous and efficient filtration system. The large volume of fluid filtered by the glomerulus is reduced by the rest of the nephron into manageable amounts of urine. Controlled by interwoven channels, hormones, and vasoactive substances, this system strives to maintain a steady state regardless of dietary indiscretion and pharmacologic interventions. The zealous efficiency of the kidney can unintentionally cause damage to itself by concentrating pharmacologic agents, environmental factors, and abnormal endogenous proteins that promote structural weakness and even mutagenic events within the organ.

Cancer and the Kidney considers how the kidney's structure and function are impaired by all kinds of cancers and their associated therapies. In each chapter, internationally renowned investigators discuss different aspects of cancer and the kidney. Each chapter begins with a seminal clinical case and poses a series of relevant clinical questions, which are answered in the ensuing chapter. The comprehensive coverage of the topic begins with an explanation of basic kidney function and the emerging demand to use appropriate clinical and laboratory clues for the early detection of kidney dysfunction, which has become important for all kinds of kidney disorders, including hypertensive and diabetic glomerulopathy. This emphasis reflects the hope and promising reality that the early identification of kidney disease will slow, or possibly halt, the decline of kidney dysfunction and improve survival. A series of chapters considers the acid–base balance, fluid and electrolyte disorders, chemotherapy, and paraneoplastic syndromes.

The function of the kidney makes it vulnerable to attack and destruction from filtered molecules that directly injure the nephron or induce an immunologic response that causes injury. For example, myeloma paraproteins filtered and deposited within the glomerulus or along the tubules result in kidney damage. Many cancers shed proteins that lodge within the glomerulus, resulting in an immune response and producing many forms of glomerular injury. The discussion of glomerulopathies, which are found in many cancers, provides the most complete compendium to date on this topic, compiled from a morass of smaller series and case reports.

Conventional discussions of the kidney and cancer home in on the cancers that emanate from the kidney parenchyma. This is an exciting area of basic investigation, with a new understanding of the pathogenesis of kidney cancers based on the interaction of the von Hippel–Landau protein and hypoxia-inducible factors in mutagenic events. From the clinical perspective, the classic clinical triad of pain, palpable mass, and macroscopic hematuria has rapidly become an anachronism as a consequence of widespread screening studies using computed tomography or magnetic resonance imaging that identify clinically silent kidney cancers. When should we screen? How can we identify patients at risk? The smaller the cancer, the better the outcome, and the lower the morbidity, since many of these lesions can be removed by partial nephrectomy with the use of hand-assisted laparoscopic techniques.

Kidney cancers develop in the setting of cystic disease, in patients undergoing dialysis and renal-transplant recipients. Careful attention is paid in this book to the unsolved problems of how to work up incidentally discovered cysts within the kidney. For how long should these cysts be followed? What is the best imaging technique for detecting small cancers arising within them? When should they be removed? What is the best approach? How much kidney tissue can and should be removed? These questions are nicely addressed, albeit unresolved, in their respective chapters.

This book brings well-known but previously dispersed observations on cancer and the kidney into one well-edited book that serves as a clinical reference for students and practicing physicians alike. The clinical focus is excellent, and the pace is fast. My only request for the next edition would be for better images, in color.

Ronald J. Falk, M.D.
University of North Carolina Kidney Center, Chapel Hill, NC 27599