The Effect of Mannitol Addition on Hydration in Acute Kidney Injury Event After High Dose Cisplatin Chemotherapy: An Ambispective Cohort Study

The Effect of Mannitol Addition on Hydration in Acute Kidney Injury Event After High Dose Cisplatin Chemotherapy: An Ambispective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Mannitol Addition on Hydration in Acute Kidney Injury Event After High Dose Cisplatin Chemotherapy: An Ambispective Cohort Study Andhika Rachman, Syahidatul Wafa, Pringgodigdo Nugroho, Sukamto Koesnoe This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-643773/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Apr, 2022 Read the published version in BMC Cancer → Version 1 posted 11 You are reading this latest preprint version Abstract Background: Saline hydration with addition of mannitol have commonly being strategy to avoid cisplatin induced acute kidney injury. While the initial reports demonstrated that mannitol diuresis decreased cisplatin induced renal injury, others have shown renal injury to be worsened. Objective: To compare the risk of acute kidney injury in cancer patients receiving high dose cisplatin with addition and without addition of mannitol. Method: This was an ambispective cohort study based on consecutive sampling at Cipto Mangunkusumo General Hospital and Mochtar Riady Comprehensive Cancer Centre (MRCCC) Siloam Hospitals. The data was obtained from September 2017 to February 2018. The choice of mannitol administration based on responsible physician clinical judgement. The outcome was any increment more than 0,3 mg/dl or 1,5 times from baseline of serum creatinine. Analysis was done by using SPSS statistic for univariate, bivariate and multivariate logistic regression to obtain crude risk ratio and adjusted risk ratio of cisplatin induced acute kidney injury probability of mannitol addition on hydration. Result: Data from 110 patients (57,3% male) with a median age of 44,5 years (range 19 to 60 years) were collected; 47 received saline alone and 63 received saline with addition of mannitol. Acute kidney injury were higher in mannitol vs non mannitol group. Bivariate analysis showed higher probability of post chemotherapy AKI in mannitol group (RR 2,168; 95% CI 0,839-5,6). On multivariate analysis the adjusted RR was 3,52 (95% CI 1,11-11,162; p value = 0,033) by controlling age. Conclusion: The addition of mannitol on hydration had higher risk of AKI after high dose cisplatin chemotherapy. Cancer Biology Oncology High dose cisplatin mannitol acute kidney injury Figures Figure 1 Figure 2 Introduction Cisplatin is a platinum-based chemotherapy agent that currently used as front-line therapy in the treatment of various solid organ cancers, including head and neck, lung, testis, ovary, breast, bladder cancer and sarcoma (1–7). The therapeutic effects of cisplatin are significantly improved by dose escalation. However, high dose therapy of cisplatin is limited by significant side effects, such as nephrotoxicity, neurotoxicity, ototoxicity and emetogenicity (8–10). In particular, renal toxicity occurs in 20%-40% of patients in a dose dependent manner, therefore limits the amount of drug that can be administered(11–13). Cisplatin injures mitochondrial DNA, mostly at the third segment of proximal tubular cells, result in renal mitochondrial dysfunction. This injury led to a decline in adenosine triphosphate production. Reduced Na-K-ATPase activity leads to altered intracellular-extracellular sodium gradient, which inhibit normal sodium reabsorption. The reduction in renal blood flow (RBF) and glomerular filtration rate (GFR) is due to increased renal vascular resistance, activated by tubuloglomerular feedback from increased sodium delivery to the macula densa in the early distal tubule. Additionally, cisplatin could directly induce necrosis and apoptosis of renal tubular cells, resulting an inflammation and oxidative stress that worsen the renal injury (10,11,14,15). The decrease in the glomerular filtration rate causes an increase in serum creatinine within 6 to 7 days and tend to remain elevated for 3–4 weeks after cisplatin administration (16–19). Although renal impairment is transient and reversible, 43% of patients with acute kidney injury went on to develop an irreversible renal failure (20). Nephrotoxicity was the main reason of discontinuation of chemotherapy and inferior survival of patients (12,13,20–23). The main protective measures currently employed in clinical practice are based on avoiding the excessive exposure of kidneys, basically by hydration and diuresis, such as mannitol. Mannitol, since it was filtered by the kidneys but not reabsorbed, it remains in the renal tubules and causes an increase in the delivery of sodium to the distal tubules and a continued osmotic diuresis. This results in a “flushing” effect in the renal tubules thus reducing cisplatin contact time with tubular cells, preventing it from evolving into toxic compounds that damage the kidneys and increase the elimination of cisplatin in the urine (24–26). On the other hand, potential nephrotoxicity of mannitol raised clinician’s concerns. When administered to patients with normal kidney function, mannitol may cause hypokalemia due to increased flow rates in the aldosterone-responsive distal nephron which leads to increased potassium loss. In contrast, given to patients with preexisting kidney failure, mannitol is found to be retained in circulation and may cause extracellular fluid volume expansion, hyponatremia, metabolic acidosis, and hyperkalemia (27,28). Moreover, mannitol may induce extensive isometric renal proximal tubular vacuolization and intense afferent arteriolar constriction resulting in acute kidney injury (29,30). Meta-analysis from Bo Yang et al in adult patients at increased risk of AKI revealed that intravascular administration of mannitol does not convey additional benefit beyond adequate hydration (31). The role of mannitol as prevention of cisplatin-associated AKI has been investigated in some trials, but the result was conflicting whether nephroprotective or nephrotoxic so no definite recommendation regarding the nephroprotective effect of mannitol has emerged. The non-comparative study by Hayes (1977)(16) was the first to state the advantage of hydration plus mannitol to reduce the risk of cisplatin nephrotoxicity. Then, the prospective phase II trial by Al-Sarraf (1982) (32) supported the results of the Hayes study (incidence of nephrotoxicity in mannitol plus hydration was 15% vs. 30% in hydration alone), unfortunately this result was not statistically validated and in the next cycle of cisplatin chemotherapy, mannitol showed no nephroprotective effect. After Al-Sarraf, there are four studies, i.e. by Santoso, Leu, Morgan and McKibbin. The only randomized controlled trials, so far, held by Santoso (2003)(17), reported that combination of hydration and mannitol resulted in significant decreased of 24-h creatine clearance rate (in ml/min) after chemotherapy compared to normal saline group (31 ± 2,7 vs 5,4 ± 5,1, p = 0.02) so the study was prematurely terminated due to the trend of worse outcomes with concomitant mannitol. Leu (2010) (33), supported the result of Santoso study, revealed that combination of hydration and mannitol resulted in higher incidence of nephrotoxicity (9% vs 2%, p = 0.36). Meanwhile, Morgan (2014) (34) reported that patients who did not receive mannitol had a higher risk of nephrotoxicity (OR 2,646; 95% CI = 1,008 − 6,944; p = 0,048). McKibbin (2015) (35) 33 , supported the result of Morgan, reported that saline-mannitol combination resulted in lower nephrotoxicity (OR 0,16; 95% CI 0,04 − 0,65; p = 0,01). However, those three studies were retrospective, with the limitation of missing data analysis. Recent studied regarding the topic still had split conclusions. A study by Williams et al. (2016) (36) found elevation of serum creatinine is more common in patients without mannitol and therefore suggested that in Mannitol reduces nephrotoxicity in patients receiving ≥ 70mg/m 2 Cisplatin. In the other hand a retrospective study by Begin et al. (2020) (37) stated that Mannitol is better given for patients who receive < 75mg/m 2 in terms of nephroprotection and that there is no benefit of adding Mannitol when the dose of Cisplatin is ≥ 75mg/m 2 . Meanwhile, a research by El Hamamsy in (2017) (38) reported that when compared to hydration and acetazolamide, hydration and mannitol exhibits more frequent cisplatin-induced acute kidney injuries. However, Hamroun (39) and Makimoto (40) stated that there’s still no compelling evidence of significance in the use of mannitol in regards of reducing nephrotoxicity. In our institution, the administration of mannitol was still debatable. Since there was no prevailing standard of prevention of cisplatin nephrotoxicity, the choice of mannitol administration was based on responsible physician clinical judgement. Therefore, we undertook this study to determine if there was any difference in the risk of acute kidney injury in solid organ cancer patients treated by high dose cisplatin (≥ 75 mg/m 2 ), between patients receiving saline hydration alone compared to those receiving saline with addition of mannitol. Method Patient Selection This was an ambispective study (combination of prospective and retrospective method) of solid organ cancer patients treated with high dose cisplatin (≥ 75 mg/m 2 ) at the Cipto Mangunkusumo General Hospital (CMGH) and Mochtar Riady Comprehensive Cancer Centre (MRCCC) Siloam Hospitals, Jakarta, approved by institutional review board. Data were collected from September 2017 until February 2018. On the prospective method, we took samples of patients underwent high doses of cisplatin chemotherapy at the chemotherapy ward of CMGH since September 2017. On the retrospective method, the patient data were collected from the medical record of CMGH and MRCCC Siloam Hospitals. Patients were included if they were 18–60 years old, had a pathologically confirmed diagnosis of solid organ cancer, had an adequate baseline of glomerular filtration rate equal to or greater than 60 ml/menit/1.73 m 2 , had a good performance status (Karnofsky score ≥ 80), received high dose cisplatin chemotherapy. The exclusion criteria were as follows : receive other potentially nephrotoxic drugs such as furosemide, non-steroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, amphotericin B and cephalosporins or another chemotherapy agent (permetrexed, ifosfamide, gemcitabine, bevacizumab, cetuximab), had comorbidity such as malignant / uncontrolled hypertension with diastolic blood pressure ≥ 100 mmHg, congestive heart failure, any structural abnormalities of kidney (obstruction of the urinary tract, kidney cyst or kidney and urinary tract stones) diagnosed by radiology examination, suffered from any acute infection and was a pregnant women. Treatment Schedule The subjects were allocated into two groups: the group receiving the addition of mannitol to hydration prior to cisplatin chemotherapy, and the group receiving no mannitol. The administration of mannitol was based on clinical judgement of responsible physician, no intervention from researcher. Patient demographic information include age, sex, type of cancer, history of diabetes and history of hypertension, treatment data include mannitol use, chemotherapy regimen, cisplatin dose, history of previous cisplatin chemotherapy and cumulative cisplatin dose before current therapy, number of cycles of chemotherapy and concomitant radiotherapy. All subjects received the same saline-based hydration with 1-2L of 0,9% saline over 1–2 hours and achieved euvolemic status before chemotherapy. All doses of cisplatin were diluted in 500 ml of 0,9% saline and infused over 2–3 hour. Patients in the mannitol cohort received 20 g admixed in the 0,9% 100ml saline prehydration. All patients received antiemetic premedication such as dexamethasone, a H 2 receptor blocker and diphenhydramine. Assessment of Outcome The outcome of this study was any grade of acute kidney injury (AKI), was defined using the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE v 4.0) grading scale for chemotherapy (41). AKI was defined by an increase of more than 0,3 mg/dl or 1,5 times from baseline of serum creatinine which was measured within 28 days after cisplatin chemotherapy. Statistical analysis The collected data was processed using SPSS statistics program version 20.0. To evaluate the differences in the patient characteristics, the chi-square test was used. Bivariate analysis was performed to determine crude relative risk (RR) probability of post-chemotherapy AKI between mannitol group to non-mannitol group. Multivariate logistic regression models were created to assess the potential confounders and revealed adjusted RR. All analyzes used 5% significance limits. Results Patient characteristics A total of 110 patients were included, 63 patients received addition of mannitol and 47 patients did not. The patient characteristics were listed in Table 1 . The median age was 44,5 years old with an almost equal proportion of male and female (57,3% vs. 41,8%). More than 60% of patients diagnosed with head and neck cancer and treated with combination of cisplatin and 5-fluorouracyl (44,5%). Most of patient underwent first cycle of cisplatin chemotherapy, received cisplatin dosage of 100 mg / m2 (67,3%). Greater than 95% of patients had never previous cisplatin chemotherapy series, so that cumulative dose received before current chemotherapy was lower than 100mg/m 2 . Regarding comorbidities, only a small proportion of subjects were diagnosed with Diabetes Mellitus (2.7%) and hypertension (7.3%). For concomitant radiotherapy, most subjects (83.5%) were not given concomitant radiotherapy. All of patients were on good performance status before chemotherapy. In this study, both groups received > 3000ml of hydration in 24 hours pre and post chemotherapy, with an adequate urine production for 6 hours post-chemotherapy of (mean value of 2,58 ± 1,01 ml / kgBW / hour). All subjects had good pre-chemotherapy renal function, i.e. median ureum 24 mg / dl, creatinine 0,8 mg / dL and glomerular filtration rate (CKD-EPI) was 103,85 ml / minute / 1.73 m2. No subjects had creatinine > 1,5 mg / dL pre-chemotherapy. All of subjects had a good median potassium value of 4,07 mEq / L with similar results on both groups. The clinical characteristics were listed in Table 2 . Table 1 Patient Demographics and Characteristics Mannitol (n = 63) No Mannitol (n = 47) P value Male sex , (n = 63 ; 57,3%) 40 (63,5) 24 (51,1) 0,189 Age , median 44,5 yo ≥ 40 years old (n = 71; 64,5) 32 (51,6) 39 (81,2) 0,001 Type of cancer Nasopharynx (n = 61 ; 55,5%) 41 (66,1) 20 (41,7) 0,001 Head and neck cancer other than nasopharyngeal (n = 14 ; 12,7%) 8 (12,9) 6 (12,5) Osteosarcoma (n = 11 ; 10%) 8 (12,9) 3 (6,2) Breast (n = 3 ; 2,7%) 0 (0) 3 (6,2) Ovary (n = 4 ; 3,6%) 0 (0) 4 (8,5) Others (n = 17 ; 15,5%) 5 8,0) 12 (25,1) Anticancer drugs 5FU (n = 49 ; 44,5%) 40 (64,5) 9 (18,8) 0,00 Docetaxel (n = 20 ; 18,2%) 10 (16,1) 9 (18,8) Paclitaxel (n = 10 ; 9,1%) 2 (3,2) 8 (16,7) Doxorubicin (n = 9 ; 8,2) 7 (11,3) 3 (6,2) Nimotuzumab (n = 7 ; 6,45) 0 (0) 7 (14,6) Etoposide (n = 5 ; 4,5) 1 (1,6) 4 (8,3) Others (n = 10; 9%) 2 (3,2) 8 (16,7) Dose of Cisplatin (mg/m 2 ) 100 (n = 74 ; 67,3) 80 (n = 7 ; 6.4) 75 (n = 29 ; 6,4) 53(84,1) 2(3,2) 8(12,7) 21(44,7) 5(10,6) 21 (44,7) 0,00 Chemotherapy Cycle 1st (n = 69 [62,7]) 34 (54,0) 35 (74,5) 0,81 2nd (n = 22 [ 20 ]) 17 (27,0) 5 (10,6) 3rd (n = 3 [ 14 ]) 8 (12,7) 6 (12,8) 4th (n = 5 [ 4 , 5 ]) 4 (6,3) 1 (2,1) Diabetes Mellitus (n = 3 [2.7]) 0 (0) 3 (6,4) 0,75 Hypertension (n = 8 [7.3]) 4 (6,3) 4 (8,5) 0,47 Concomitant Radiotherapy No (n = 91 [83,5]) 55 (60,4) 36 (39,6) 0,102 Table 2 Clinical Characteristics of Subjects Before Chemotherpy After Chemotherapy Mannitol No Mannitol Mannitol No Mannitol Ureum , median {min-max) 22 (4–68) 24 (10–47) 28,5 (8–76) 27 (13–81) Creatinine , median {min-max) mg/dl 0,8 (0,3 − 1,2) 0,8 (0,29 − 1,4) 1,0 (0,4 − 2,2) 0,9 (0,41 − 2,3) 1,5 n(%) 0 0 6 (9,7) 2 (4,2) GFR , median {min-max) ml/minute/1,73m 2 106,5 (62,7-169,8) 102 (60–253,4) 90,11 ± 28,67 90,48 ± 35,58 90 , n(%) 48 (77,4) 34 (70,8) 33 (53,2) 21 (43,8) Kalium , median {min-max) 4,14 (3,03–5,46) 3,9 (2,8 − 5,01) 3,845 (2,8 − 5,37) 4,0 (2,3–5,1) Pre-chemotherapy hydration , mean ± SB 4270,95 ± 740,11 3150,63 ± 656,28 4215,32 ± 759,47 3322,34 ± 780,87 Incidence and outcome of AKI The incidence of AKI was observed in 14 patients (22.6%) in mannitol group versus 5 patients (10.4%) in no mannitol group (p value = 0,076; RR 2,168; 95% CI 0,839-5,6). All of subjects developed an increase of serum creatinine and decrease of glomerular filtration rate after chemotherapy. The decrease of renal function was more noticeable in mannitol group than no mannitol group. The increase of serum creatinine was 29% in mannitol vs. 16,7% in no mannitol group. The increase of serum creatinine from less than 1,0 mg/dL to 1,1–1,5 mg / dL was found to be greater in the mannitol group than no mannitol group (30,6% vs 22,9%). In addition, the increase in creatinine to more than 1,5 mg / dL were found to be higher in the group receiving mannitol than without mannitol (9,7% vs 4,2%). Similarly, a decrease in GFR from more than 90 ml / min / 1,73 m 2 to less than 60 ml / min / 1,73 m 2 , was greater in the mannitol group than without mannitol (17,7% vs. 10,4%). The pre-post chemotherapy comparison of renal function is detailed in Table 3 and shown in Graph 1 and 2. Table 3 The mean decline of pre-and post-chemotherapy renal function in the mannitol and no mannitol groups Mean of Creatinine Increase SD P Value 95% CI Mean of GFR Decline SD P value 95% CI Mannitol 0,218 0,291 0,00 0,144-0,291 16,532 21,12 0,00 11,17–21,89 No Mannitol 0,154 0,244 0,00 0,087 − 0,229 14,577 29,98 0,00 5,87 − 23,28 Potential risk factor for developing AKI We conducted bivariate analysis to analyze the potential confounding factor for such variables: age, sex, type of cancer, chemotherapy regimen, cisplatin dose, chemotherapy cycle, comorbidity of diabetes and hypertension and the administration of concomitant radiotherapy. The variables having p values < 0,25 in bivariate analysis were included in the multivariate analysis. The result of bivariate analysis was listed in Table 4. Based on bivariate analysis, the variables included in the multivariate analysis were age and chemotherapy regimen. Multivariate analysis and changes of crude RR (relative risk) to be adjusted RR between mannitol and post-chemotherapy AKI incidence by controlling the potential confounding factors were listed in Table 5 . Table 4 The relationship between potential confounding factors and post-cisplatin acute kidney injury Variables Post chemotherapy AKI (%) p Yes No Age < 40 years old ≥ 40 years old 10,3 21,1 89,7 78,9 0,149 Sex Male Female 18,5 15,6 81,5 84,4 0,692 Type of Cancer Nasopharyngeal Head and neck other than nasopharyngeal Osteosarcoma Others 18,0 7,1 9,1 25 82,0 92,9 90,9 75 0,467 Regimen of Chemotherapy 5FU Docetaxel Paclitaxel Doxorubicin Others 26,5 10,5 10,0 0 13,6 73,5 89,5 90,0 100 86,4 0,146 Dose of Cisplatin ( mg/m 2 ) 100 80 75 10,3 0 21,6 89,7 100 78,4 0,525 Cycle of Chemotherapy 1st 2 nd 3 rd 4 th 16,2 21,7 20,0 0 83,8 78,3 80,0 100 1,00 Diabetes Mellitus No DM Hypertension No Hypertension 0 17,8 36,4 15,2 100 82,2 63,6 84,8 1,00 0,942 Concomitant Radiotherapy Yes No 11,1 18,5 89,8 81,5 0,734 Table 5 Crude RR and Adjusted RR with 95% CI of mannitol on post-chemotherapy AKI with the addition of potential confounding factors gradually Variables RR (CI 95%) P value RR value changes with confounder Crude RR 2,168 (0,839-5,6) 0,094 Adjusted RR + Chemotherapy regimen 5 fluorouracyl 2,190 (0,555-8,632) 0,448 (2,190-2,168)/2,190 x 100% = 1% + Age ≥ 40 years old 2,852 (0,68 − 11,96) 0,152 (2,852-2,190)/2,190 x 100% = 23% On multivariate analysis by controlling age and chemotherapy regimen, the risk of post cisplatin AKI was 3,5 times greater in saline with addition of mannitol than saline only (adjusted RR was 3,52; 95% CI 1,11–11,162, p value = 0,033). Discussion Our data suggest that the addition of mannitol to saline hydration increased the risk of cisplatin-induced acute kidney injury (adjusted RR 2,446; 95% CI 0,614-9,741, p value = 0,204). Age ≥ 40 years old was concluded to be confounding factors. The results of this study were consistent with the study from Santoso, et al (17) in the United States. This randomized controlled clinical trial found that decreased renal function, in this study assessed by 24 hours creatinine clearance, occurred more heavily in the group given the combination of hydration and mannitol than hydration alone (31 ml/min vs 5,4 ml/min, p value = 0,04). This study was discontinued prematurely because of higher tendency of nephrotoxicity in mannitol group, so that the expected sample size was not achieved (there were only 49 subjects). The discontinuation of study showed that nephrotoxicity potency of mannitol. However, the limitation of Santoso study was renal function parameters used, which was 24 hours creatinine clearance which required urine storage for 24 hours. Therefore, the potential of adherence-related bias in accommodating urine was a weakness of this study. Our study also support the result of Leu et al (33), who reported the tendency of greater risk of nephrotoxicity in saline and mannitol group versus saline only (the decrease of creatinine clearance was 38, 9 ml/min vs. 33,9 ml/min, p = 0,09) (33). However, Leu included the subjects treated with low dose cisplatin (40–75 mg/ m 2 ), who were excluded in our study. Our results differ from those of Hayes et al. (16), Morgan et al. (34), and McKibbin et al (35). However, the studies from Hayes (16) was non-comparative trial (no comparison data with patients receiving saline only), so it was difficult to analyze whether the nephroprotective outcome came from mannitol or adequate hydration only. Meanwhile, study from Morgan, reported the higher risk of nephrotoxicity from the group without mannitol (OR 2,646 (95% CI 1,008 − 6,944; p = 0.048) was a retrospective study and had small sample size (only 47 patients received high dose cisplatin). The study from McKibbin et al, (35) which support nephroprotective effect of mannitol after multivariate analysis (odds ratio of third grade nephrotoxicity in mannitol group was 0,16 ; 95% CI 0,04 − 0,65, p value = 0.01) had a limitation in the analysis of concomitant use of nephrotoxic substance due to missing data because of the retrospective nature of study. Our study also differs from a more recent study by Begin et al. which included stated that there was no difference in AKI incidence between subject which was given mannitol in addition to hydration and hydration alone (HR 1.17 [0.75–1.82]) after administration of Cisplatin ≥ 75 mg/m 2 . The different hydration protocol in this study i.e., 3 L before and 1 L after Cisplatin compared to 1 L in our study, might be one of the reasons of this different outcome (37). The underlying mechanisms of nephrotoxicity of mannitol was through the osmotic effect of mannitol which inhibits the reabsorption of water in the proximal tubule, resulted in urinary dilution and an increased diuresis. In one side, this effect decreased the contact time of cisplatin with renal tubular cells and increased the clearance of necrotic cell debris at renal tubules after injured by cisplatin. However, this mechanism seemed to have nephrotoxic potential, which was related with hemodynamic changes in the kidney. Mannitol triggered a marked decrease in the reabsorption of water and salt along the renal tubules, resulted in increased flow of water and salts from the proximal tubules, followed by increased sodium reabsorption in loop of Henle, distal tubules and collecting ducts. Increased excretion of urine solutes induced by the mannitol osmotic diuretic effect lead to increased tubuloglomerular feedback which stimulate afferent arteriolar vasoconstriction, hence resulted in decrease of glomerular filtration rate (42,43). Besides that, mannitol would lead the osmotic nephrosis effect on renal tubules. Histologically, tubular cells with toxic effects of mannitol appeared to contain vacuoles resulting in edema, called osmotic nephrosis. Pathophysiologically, the mechanism was through the pinocytosis effect of mannitol into the proximal tubular cell at high osmolality which then causes tubular cell vacuolization. These vacuoles would become fused and develop an edematous cell, resulting an obstruction of renal tubules (44), then led to a decline in glomerular flow and acute kidney injury. Meta-analysis of Bo Yang et al. (31) in 626 subjects revealed that intravascular mannitol administration did not provide additional benefit than adequate hydration alone in patients at risk of AKI, however in contrast-induced nephropathy, the effect was even detrimental (31). We controlled age as confounding variables. Decreased renal function as an increasing of age was associated with decreased plasma flow velocity in glomerular capillaries and glomerular capillary ultrafiltration coefficient. In addition, there were hemodynamic changes associated with structural changes such as decreased renal mass, increased sclerotic glomeruli and tubulointerstitial fibrosis (45). The Davies and Shock study of inulin clearance reported a glomerular filtration rate decrease of 8 ml / min / 1.73 m2 in each year from the age of 40 years old (46). The increasing trend of incidence of AKI with age was consistent with previous research results from Prasaja et al, which reported that over 50 years of age have a higher risk of nephrotoxicity after four cycles of chemotherapy (OR 3,433; 95% CI 1,363-8,645) (47). The study from Perazella et al (48), Caglar et al (22), and de Jongh et al (49), revealed same result, that advancing age was one of the factors that increased the risk of nephrotoxicity (48). Our study supports the potential nephrotoxic effect of mannitol after cisplatin chemotherapy. Our study had a larger sample size than Santoso’s study and stronger association between mannitol addition to saline and the incidence of post cisplatin acute kidney injury than Leu study. Our study only included subjects who received high doses of chemotherapy and excluded subjects who received nephrotoxic drugs simultaneously, two important things that became a limitation in previous studies. For the outcome of renal function, we used serum creatinine parameters, as recommended by the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE v 4.0) grading scale for chemotherapy to minimize bias due to other measures, such as using 24-hour clearance creatinine (41). There are several other things to consider when evaluating these results. Most notably, because of cohort nature of this study, we did not randomize patients to receive or not receive mannitol, rather we submit a decision based on clinical judgement of responsible physician. Besides that, our study did not analyze fluid intake at home and excess fluid loss caused by vomiting as a side effect of cisplatin chemotherapy. However, all our subjects had the same approach of post chemotherapy nausea and vomiting; the medication for nausea and vomiting prophylaxis was given to all subjects. There is a need for future prospective study where fluid intake and water balance are strictly controlled to determine better the magnitude of risk from mannitol. We hope the results of our study might become a consideration regarding the policy of addition of mannitol to hydration in cisplatin chemotherapy. This might have an added benefit in the cost-effectiveness of chemotherapy if administration of mannitol is no longer routinely given in high-dose cisplatin chemotherapy nowadays. Conclusion In our patients, the addition of mannitol to hydration increases the risk of post high dose cisplatin chemotherapy acute kidney injury as compared with hydration only. Age ≥ 40 years old were confounding factor in our study. Abbreviations AKI: acute kidney injury CI: confidence interval CMGH: Dr. Cipto Mangunkusumo General Hospital CTCAE: Common Terminology Criteria for Adverse Events DM: Diabetes Mellitus 5FU: fluorouracil GFR: glomerular filtration rate HR: hazard ratio MRCCC: Mochtar Riady Comprehensive Cancer Center NSAID: Non-steroid anti inflammatory drugs OR: odds ratio RR: relative risk Declarations Acknowledgements: none to declare Funding: none Availability of data and materials: not applicable Ethics approval and consent to participate: Ethical approval for this study was granted by The Ethics Committee of The Faculty of Medicine, Universitas Indonesia. EA number: 815/UN2.F1/ETIK/2017 Competing interests: The authors declare that they have no competing interests. Consent for publication: Yes. Authors’ contributions: All the authors contributed equally References Blanchard EM. Cisplatin and solid tumors: Still working, after all these years. J Solid Tumors. 2012;2(1):26–33. Schiller JH, Harrington D, Belani CP, Langer C, Sandler A, Krook J, et al. Comparison of Four Chemotherapy Regimens for Advanced Non–Small-Cell Lung Cancer. N Engl J Med. 2002;346(2):92–8. Turrisi AT, Kim K, Blum R, Sause WT, Livingston RB, Komaki R, et al. Twice-Daily Compared with Once-Daily Thoracic Radiotherapy in Limited Small-Cell Lung Cancer Treated Concurrently with Cisplatin and Etoposide. N Engl J Med. 1999;340(4):265–71. Grossman BH, Natale RB, Tangen CM, Speight VO, Vogelzang NJ, Trump DL, et al. Neoadjuvant Chemotherapy Plus Cystectomy Compared With Cystectomy Alone for Locally Advanced Bladder Cancer. N Engl J Med. 2003;349(9):859–66. Bajorin DF, Sarosdy MF, Pfister DG, Mazumdar M, Motzer RJ, Scher HI, et al. Randomized trial of etoposide and cisplatin versus etoposide and carboplatin in patients with good-risk germ cell tumors: A multiinstitutional study. J Clin Oncol. 1993;11(4):598–606. Adelstein DJ, Li Y, Adams GL, Wagner H, Kish JA, Ensley JF, et al. An intergroup phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer. J Clin Oncol. 2003;21(1):92–8. Silver DP, Richardson AL, Eklund AC, Wang ZC, Szallasi Z, Li Q, et al. Efficacy of neoadjuvant cisplatin in triple-negative breast cancer. J Clin Oncol. 2010;28(7):1145–53. Hartmann JT, Lipp HP. Toxicity of platinum compounds. Expert Opin Pharmacother. 2003;4(6):889–901. Yao X, Panichpisal K, Kurtzman N, Nugent K. Cisplatin nephrotoxicity: A review. Am J Med Sci [Internet]. 2007;334(2):115–24. Available from: http://dx.doi.org/10.1097/MAJ.0b013e31812dfe1e Miller RP, Tadagavadi RK, Ramesh G, Reeves WB. Mechanisms of cisplatin nephrotoxicity. Toxins. 2010. Dos Santos NAG, Rodrigues MAC, Martins NM, Dos Santos AC. Cisplatin-induced nephrotoxicity and targets of nephroprotection: An update. Arch Toxicol. 2012;86(8):1233–50. Tezcan S, Izzettin FV, Sancar M, Yumuk PF, Turhal S. Nephrotoxicity Evaluation in Outpatients Treated with Cisplatin-Based Chemotherapy Using a Short Hydration Method. Pharmacol & Pharm. 2013; Bhat ZY, Cadnapaphornchai P, Ginsburg K, Sivagnanam M, Chopra S, Treadway CK, et al. Understanding the risk factors and long- term consequences of cisplatin-associated acute kidney injury: An observational cohort study. PLoS One. 2015; Hanigan MH, Devarajan P. Cisplatin nephrotoxicity: molecular mechanisms. Cancer Ther. 2003;(1):47–61. Kubala M, Geleticova J, Huliciak M, Zatloukalova M, Vacek J, Sebela M. Na+/K+-ATPase inhibition by cisplatin and consequences for cisplatin nephrotoxicity. Biomed Pap. 2014;158(2):194–200. Hayes DM, Cvitkovic E, Golbey RB, Scheiner E, Helson L, Krakoff IH. High dose Cis‐platinum diammine dichloride. Amelioration of renal toxicity by mannitol diuresis. Cancer. 1977; Santoso JT, Lucci JA, Coleman RL, Schafer I, Hannigan E V. Saline, mannitol, and furosemide hydration in acute cisplatin nephrotoxicity: A randomized trial. Cancer Chemother Pharmacol. 2003;52(1):13–8. Cornelison TL, Reed E. Nephrotoxicity and hydration management for cisplatin, carboplatin, and ormaplatin. Vol. 50, Gynecologic Oncology. 1993. p. 147–58. Taguchi T, Nazneen A, Abid MR, Razzaque MS. Cisplatin-associated nephrotoxicity and pathological events. Contrib Nephrol. 2005;148(Ii):107–21. Kidera Y, Kawakami H, Sakiyama T, Okamoto K, Tanaka K, Takeda M, et al. Risk factors for cisplatin-induced nephrotoxicity and potential of magnesium supplementation for renal protection. PLoS One. 2014;9(7). Morgan KP, Buie LW, Savage SW. The Role of Mannitol as a Nephroprotectant in Patients Receiving Cisplatin Therapy. Ann Pharmacother. 2012; Caglar K, Kinalp C, Arpaci F, Turan M, Saglam K, Ozturk B, et al. Cumulative prior dose of cisplatin as a cause of the nephrotoxicity of high-dose chemotherapy followed by autologous stem-cell transplantation. Nephrol Dial Transplant. 2002;17(11):1931–5. Hoek J, Bloemendal KM, van der Velden LAA, van Diessen JNA, van Werkhoven E, Klop WMC, et al. Nephrotoxicity as a dose-limiting factor in a high-dose cisplatin-based chemoradiotherapy regimen for head and neck carcinomas. Cancers (Basel). 2016;8(2):1–9. Muraki K, Koyama R, Honma Y, Yagishita S, Shukuya T, Ohashi R, et al. Hydration with magnesium and mannitol without furosemide prevents the nephrotoxicity induced by cisplatin and pemetrexed in patients with advanced non-small cell lung cancer. J Thorac Dis. 2012;4(6):562–8. Tsai SF, Shu KH. Mannitol-induced acute renal failure. Clin Nephrol. 2010;74(1):70–3. Fang L, You H, Chen B, Xu Z, Gao L, Liu J, et al. Mannitol is an independent risk factor of acute kidney injury after cerebral trauma: A casecontrol study. Ren Fail. 2010;32(6):673–9. Fanous AA, Tick RC, Gu EY, Fenstermaker RA. Life-Threatening Mannitol-Induced Hyperkalemia in Neurosurgical Patients. World Neurosurg [Internet]. 2016;91:672.e5-672.e9. Available from: http://dx.doi.org/10.1016/j.wneu.2016.04.021 Kim MY, Park JH, Kang NR, Jang HR, Lee JE, Huh W, et al. Increased risk of acute kidney injury associated with higher infusion rate of mannitol in patients with intracranial hemorrhage: Clinical article. J Neurosurg. 2014;120(6):1340–8. Visweswaran P, Massin EK, Dubose TD. Mannitol-Induced Acute Renal Failure. J Am Soc Nephrol. 1997;8:1028–33. Dickenmann M, Oettl T, Mihatsch MJ. Osmotic Nephrosis: Acute Kidney Injury With Accumulation of Proximal Tubular Lysosomes Due to Administration of Exogenous Solutes. Am J Kidney Dis. 2008;51(3):491–503. Yang B, Xu J, Xu F, Zou Z, Ye C, Mei C, et al. Intravascular administration of mannitol for acute kidney injury prevention: A systematic review and meta-analysis. PLoS One. 2014;9(1):1–9. Al-Sarraf M, LeBlanc M, Giri PGS, Fu KK, Cooper J, Vuong T, et al. Chemoradiotherapy versus radiotherapy in patients with advanced nasopharyngeal cancer: Phase III randomized Intergroup study 0099. J Clin Oncol. 1998; Leu L, Baribeault D. A comparison of the rates of cisplatin (cDDP) - Induced nephrotoxicity associated with sodium loading or sodium loading with forced diuresis as a preventative measure. J Oncol Pharm Pract. 2010;16(3):167–71. Morgan KP, Snavely AC, Wind LS, Buie LW, Grilley-Olson J, Walko CM, et al. Rates of Renal Toxicity in Cancer Patients Receiving Cisplatin With and Without Mannitol. Ann Pharmacother. 2014;48(7):863–9. McKibbin T, Cheng LL, Kim S, Steuer CE, Owonikoko TK, Khuri FR, et al. Mannitol to prevent cisplatin-induced nephrotoxicity in patients with squamous cell cancer of the head and neck (SCCHN) receiving concurrent therapy. Support Care Cancer [Internet]. 2016;24(4):1789–93. Available from: http://dx.doi.org/10.1007/s00520-015-2978-0 Williams RP, Ferlas BW, Morales PC, Kurtzweil AJ. Mannitol for the prevention of cisplatin-induced nephrotoxicity: A retrospective comparison of hydration plus mannitol versus hydration alone in inpatient and outpatient regimens at a large academic medical center. J Oncol Pharm Pract. 2016;23(6):422–8. Bégin AM, Monfette ML, Boudrias-Dalle É, Lavallée E, Samouelian V, Soulières D, et al. Effect of mannitol on acute kidney injury induced by cisplatin. Support Care Cancer. 2020;29(4):2083–91. El Hamamsy M, Kamal N, Bazan NS, El Haddad M. Evaluation of the effect of acetazolamide versus mannitol on cisplatin-induced nephrotoxicity, a pilot study. Int J Clin Pharm [Internet]. 2018;40(6):1539–47. Available from: https://doi.org/10.1007/s11096-018-0677-x Hamroun A, Lenain R, Bigna JJ, Speyer E, Bui L, Chamley P, et al. Prevention of Cisplatin-Induced Acute Kidney Injury: A Systematic Review and Meta-Analysis. Drugs [Internet]. 2019;79(14):1567–82. Available from: https://doi.org/10.1007/s40265-019-01182-1 Makimoto G, Hotta K, Oze I, Ninomiya K, Nakanishi M, Hara N, et al. Randomized study comparing mannitol with furosemide for the prevention of cisplatin-induced renal toxicity in non-small cell lung cancer: The OLCSG1406 trial. Asia Pac J Clin Oncol. 2021;17(1):101–8. US Department of Health and Human Services. Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. National Cancer Institute. 2009. Goldwasser P, Fotino S. Acute renal failure following massive mannitol infusion: appropriate response of tubuloglomerular feedback? Am J Nephrol. 1984;144(Nov):2214–6. Lin SY, Tang SC, Tsai LK, Yeh SJ, Shen LJ, Wu FLL, et al. Incidence and risk factors for acute kidney injury following mannitol infusion in patients with acute stroke. Med (United States). 2015;94(47):e2032. Nomani AZ, Nabi Z, Rashid H, Janjua J, Nomani H, Majeed A, et al. Osmotic nephrosis with mannitol: Review article. Ren Fail. 2014;36(7):1169–76. Weinstein JR, Anderson S. The Aging Kidney: Physiological Changes. Adv Chronic Kidney Dis [Internet]. 2010;17(4):302–7. Available from: http://dx.doi.org/10.1053/j.ackd.2010.05.002 DAVIES DF, SHOCK NW. Age changes in glomerular filtration rate, effective renal plasma flow, and tubular excretory capacity in adult males. J Clin Invest. 1950;29(5):496–507. Prasaja Y, Sutandyo N, Andrajati R. Incidence of cisplatin-induced nephrotoxicity and associated factors among cancer patients in Indonesia. Asian Pacific J Cancer Prev. 2015; Perazella MA. Renal vulnerability to drug toxicity. Clin J Am Soc Nephrol. 2009;4(7):1275–83. De Jongh FE, Van Veen RN, Veltman SJ, De Wit R, Van Der Burg MEL, Van Den Bent MJ, et al. Weekly high-dose cisplatin is a feasible treatment option: Analysis on prognostic factors for toxicity in 400 patients. Br J Cancer. 2003;88(8):1199–206. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Apr, 2022 Read the published version in BMC Cancer → Version 1 posted Editorial decision: Major revision 17 Jan, 2022 Reviews received at journal 15 Jan, 2022 Reviewers agreed at journal 05 Jan, 2022 Reviews received at journal 03 Jan, 2022 Reviewers agreed at journal 24 Dec, 2021 Reviewers agreed at journal 19 Jul, 2021 Reviewers invited by journal 16 Jul, 2021 Editor assigned by journal 16 Jul, 2021 Editor invited by journal 29 Jun, 2021 Submission checks completed at journal 29 Jun, 2021 First submitted to journal 20 Jun, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-643773","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":36211026,"identity":"40933053-a0a5-4172-82f8-4935790edeff","order_by":0,"name":"Andhika Rachman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYHACM4aEAyCaB0TYADFj4wFStKSBtDQQ1sKA0HIYLIRXC//s5m0PHpyxy+dvP3t0w88d5+3Wth8G2lJjE41Li8SdY+UGCTeSLWecyUu72XvmdvK2M4lALcfSchtw6bmRYyaR8IHZgOEGj9kN3rbbyWYHgFoYGw7j1CIP0VJvIA/UcvNv27lks/MP8WsxAGu5cdjAAKjlNm/bATuzGwRsMbyRViaRcOa4geGZHLPbsm3JCWY3gLYk4PGL3I3kbZI/jlUbyB0/Y3bzbZudvdn59IcPPtTY4PY+OkgEq0wgVjkI2JOieBSMglEwCkYGAACfKWqfNOV/aAAAAABJRU5ErkJggg==","orcid":"","institution":"Universitas Indonesia","correspondingAuthor":true,"prefix":"","firstName":"Andhika","middleName":"","lastName":"Rachman","suffix":""},{"id":36211027,"identity":"2b8fd27b-d0ff-4bc6-9868-4c65b0962df4","order_by":1,"name":"Syahidatul Wafa","email":"","orcid":"","institution":"Universitas Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Syahidatul","middleName":"","lastName":"Wafa","suffix":""},{"id":36211028,"identity":"08fb9340-a7ec-48c4-bd8d-9ee7b2da2224","order_by":2,"name":"Pringgodigdo Nugroho","email":"","orcid":"","institution":"Universitas Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Pringgodigdo","middleName":"","lastName":"Nugroho","suffix":""},{"id":36211029,"identity":"ffb5e94e-3cb1-495d-9962-6b23b807ce82","order_by":3,"name":"Sukamto Koesnoe","email":"","orcid":"","institution":"Universitas Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Sukamto","middleName":"","lastName":"Koesnoe","suffix":""}],"badges":[],"createdAt":"2021-06-21 02:14:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-643773/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-643773/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12885-022-09456-w","type":"published","date":"2022-04-12T07:52:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":10969052,"identity":"036e89aa-e620-4e0f-b617-78a4715e3db3","added_by":"auto","created_at":"2021-06-30 17:10:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":59410,"visible":true,"origin":"","legend":"The comparison of glomerular filtration rate before and after chemotherapy","description":"","filename":"Graph1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-643773/v1/d715c9b8e2c08c4f62404d17.jpg"},{"id":10969202,"identity":"c975a454-fc11-44f8-baa3-b77397bc4f17","added_by":"auto","created_at":"2021-06-30 17:13:47","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57724,"visible":true,"origin":"","legend":"The comparison of serum creatinine before and after chemotherapy","description":"","filename":"Graph2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-643773/v1/ec7739407e48549f00eaa3f2.jpg"},{"id":20229689,"identity":"e4fbdcec-715f-4cb8-8b0b-379f1baa5cab","added_by":"auto","created_at":"2022-04-12 07:52:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":553413,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-643773/v1/2a828dcc-378f-4e98-9db5-93e5d8efc5b2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Effect of Mannitol Addition on Hydration in Acute Kidney Injury Event After High Dose Cisplatin Chemotherapy: An Ambispective Cohort Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eCisplatin is a platinum-based chemotherapy agent that currently used as front-line therapy in the treatment of various solid organ cancers, including head and neck, lung, testis, ovary, breast, bladder cancer and sarcoma (1\u0026ndash;7). The therapeutic effects of cisplatin are significantly improved by dose escalation. However, high dose therapy of cisplatin is limited by significant side effects, such as nephrotoxicity, neurotoxicity, ototoxicity and emetogenicity (8\u0026ndash;10). In particular, renal toxicity occurs in 20%-40% of patients in a dose dependent manner, therefore limits the amount of drug that can be administered(11\u0026ndash;13).\u003c/p\u003e \u003cp\u003eCisplatin injures mitochondrial DNA, mostly at the third segment of proximal tubular cells, result in renal mitochondrial dysfunction. This injury led to a decline in adenosine triphosphate production. Reduced Na-K-ATPase activity leads to altered intracellular-extracellular sodium gradient, which inhibit normal sodium reabsorption. The reduction in renal blood flow (RBF) and glomerular filtration rate (GFR) is due to increased renal vascular resistance, activated by tubuloglomerular feedback from increased sodium delivery to the macula densa in the early distal tubule. Additionally, cisplatin could directly induce necrosis and apoptosis of renal tubular cells, resulting an inflammation and oxidative stress that worsen the renal injury (10,11,14,15). The decrease in the glomerular filtration rate causes an increase in serum creatinine within 6 to 7 days and tend to remain elevated for 3\u0026ndash;4 weeks after cisplatin administration (16\u0026ndash;19).\u003c/p\u003e \u003cp\u003eAlthough renal impairment is transient and reversible, 43% of patients with acute kidney injury went on to develop an irreversible renal failure (20). Nephrotoxicity was the main reason of discontinuation of chemotherapy and inferior survival of patients (12,13,20\u0026ndash;23). The main protective measures currently employed in clinical practice are based on avoiding the excessive exposure of kidneys, basically by hydration and diuresis, such as mannitol. Mannitol, since it was filtered by the kidneys but not reabsorbed, it remains in the renal tubules and causes an increase in the delivery of sodium to the distal tubules and a continued osmotic diuresis. This results in a \u0026ldquo;flushing\u0026rdquo; effect in the renal tubules thus reducing cisplatin contact time with tubular cells, preventing it from evolving into toxic compounds that damage the kidneys and increase the elimination of cisplatin in the urine (24\u0026ndash;26). On the other hand, potential nephrotoxicity of mannitol raised clinician\u0026rsquo;s concerns. When administered to patients with normal kidney function, mannitol may cause hypokalemia due to increased flow rates in the aldosterone-responsive distal nephron which leads to increased potassium loss. In contrast, given to patients with preexisting kidney failure, mannitol is found to be retained in circulation and may cause extracellular fluid volume expansion, hyponatremia, metabolic acidosis, and hyperkalemia (27,28). Moreover, mannitol may induce extensive isometric renal proximal tubular vacuolization and intense afferent arteriolar constriction resulting in acute kidney injury (29,30).\u003c/p\u003e \u003cp\u003eMeta-analysis from Bo Yang et al in adult patients at increased risk of AKI revealed that intravascular administration of mannitol does not convey additional benefit beyond adequate hydration (31). The role of mannitol as prevention of cisplatin-associated AKI has been investigated in some trials, but the result was conflicting whether nephroprotective or nephrotoxic so no definite recommendation regarding the nephroprotective effect of mannitol has emerged.\u003c/p\u003e \u003cp\u003eThe non-comparative study by Hayes (1977)(16) was the first to state the advantage of hydration plus mannitol to reduce the risk of cisplatin nephrotoxicity. Then, the prospective phase II trial by Al-Sarraf (1982) (32) supported the results of the Hayes study (incidence of nephrotoxicity in mannitol plus hydration was 15% vs. 30% in hydration alone), unfortunately this result was not statistically validated and in the next cycle of cisplatin chemotherapy, mannitol showed no nephroprotective effect. After Al-Sarraf, there are four studies, i.e. by Santoso, Leu, Morgan and McKibbin. The only randomized controlled trials, so far, held by Santoso (2003)(17), reported that combination of hydration and mannitol resulted in significant decreased of 24-h creatine clearance rate (in ml/min) after chemotherapy compared to normal saline group (31\u0026thinsp;\u0026plusmn;\u0026thinsp;2,7 vs 5,4\u0026thinsp;\u0026plusmn;\u0026thinsp;5,1, p\u0026thinsp;=\u0026thinsp;0.02) so the study was prematurely terminated due to the trend of worse outcomes with concomitant mannitol. Leu (2010) (33), supported the result of Santoso study, revealed that combination of hydration and mannitol resulted in higher incidence of nephrotoxicity (9% vs 2%, p\u0026thinsp;=\u0026thinsp;0.36). Meanwhile, Morgan (2014) (34) reported that patients who did not receive mannitol had a higher risk of nephrotoxicity (OR 2,646; 95% CI\u0026thinsp;=\u0026thinsp;1,008\u0026thinsp;\u0026minus;\u0026thinsp;6,944; p\u0026thinsp;=\u0026thinsp;0,048). McKibbin (2015) (35)\u003csup\u003e33\u003c/sup\u003e, supported the result of Morgan, reported that saline-mannitol combination resulted in lower nephrotoxicity (OR 0,16; 95% CI 0,04\u0026thinsp;\u0026minus;\u0026thinsp;0,65; p\u0026thinsp;=\u0026thinsp;0,01). However, those three studies were retrospective, with the limitation of missing data analysis. Recent studied regarding the topic still had split conclusions. A study by Williams et al. (2016) (36) found elevation of serum creatinine is more common in patients without mannitol and therefore suggested that in Mannitol reduces nephrotoxicity in patients receiving\u0026thinsp;\u0026ge;\u0026thinsp;70mg/m\u003csup\u003e2\u003c/sup\u003e Cisplatin. In the other hand a retrospective study by Begin et al. (2020) (37) stated that Mannitol is better given for patients who receive\u0026thinsp;\u0026lt;\u0026thinsp;75mg/m\u003csup\u003e2\u003c/sup\u003e in terms of nephroprotection and that there is no benefit of adding Mannitol when the dose of Cisplatin is \u0026ge;\u0026thinsp;75mg/m\u003csup\u003e2\u003c/sup\u003e. Meanwhile, a research by El Hamamsy in (2017) (38) reported that when compared to hydration and acetazolamide, hydration and mannitol exhibits more frequent cisplatin-induced acute kidney injuries. However, Hamroun (39) and Makimoto (40) stated that there\u0026rsquo;s still no compelling evidence of significance in the use of mannitol in regards of reducing nephrotoxicity.\u003c/p\u003e \u003cp\u003eIn our institution, the administration of mannitol was still debatable. Since there was no prevailing standard of prevention of cisplatin nephrotoxicity, the choice of mannitol administration was based on responsible physician clinical judgement. Therefore, we undertook this study to determine if there was any difference in the risk of acute kidney injury in solid organ cancer patients treated by high dose cisplatin (\u0026ge;\u0026thinsp;75 mg/m\u003csup\u003e2\u003c/sup\u003e), between patients receiving saline hydration alone compared to those receiving saline with addition of mannitol.\u003c/p\u003e "},{"header":"Method","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Selection\u003c/h2\u003e \u003cp\u003eThis was an ambispective study (combination of prospective and retrospective method) of solid organ cancer patients treated with high dose cisplatin (\u0026ge;\u0026thinsp;75 mg/m\u003csup\u003e2\u003c/sup\u003e) at the Cipto Mangunkusumo General Hospital (CMGH) and Mochtar Riady Comprehensive Cancer Centre (MRCCC) Siloam Hospitals, Jakarta, approved by institutional review board. Data were collected from September 2017 until February 2018. On the prospective method, we took samples of patients underwent high doses of cisplatin chemotherapy at the chemotherapy ward of CMGH since September 2017. On the retrospective method, the patient data were collected from the medical record of CMGH and MRCCC Siloam Hospitals. Patients were included if they were 18\u0026ndash;60 years old, had a pathologically confirmed diagnosis of solid organ cancer, had an adequate baseline of glomerular filtration rate equal to or greater than 60 ml/menit/1.73 m\u003csup\u003e2\u003c/sup\u003e, had a good performance status (Karnofsky score\u0026thinsp;\u0026ge;\u0026thinsp;80), received high dose cisplatin chemotherapy. The exclusion criteria were as follows : receive other potentially nephrotoxic drugs such as furosemide, non-steroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, amphotericin B and cephalosporins or another chemotherapy agent (permetrexed, ifosfamide, gemcitabine, bevacizumab, cetuximab), had comorbidity such as malignant / uncontrolled hypertension with diastolic blood pressure\u0026thinsp;\u0026ge;\u0026thinsp;100 mmHg, congestive heart failure, any structural abnormalities of kidney (obstruction of the urinary tract, kidney cyst or kidney and urinary tract stones) diagnosed by radiology examination, suffered from any acute infection and was a pregnant women.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTreatment Schedule\u003c/h2\u003e \u003cp\u003eThe subjects were allocated into two groups: the group receiving the addition of mannitol to hydration prior to cisplatin chemotherapy, and the group receiving no mannitol. The administration of mannitol was based on clinical judgement of responsible physician, no intervention from researcher. Patient demographic information include age, sex, type of cancer, history of diabetes and history of hypertension, treatment data include mannitol use, chemotherapy regimen, cisplatin dose, history of previous cisplatin chemotherapy and cumulative cisplatin dose before current therapy, number of cycles of chemotherapy and concomitant radiotherapy. All subjects received the same saline-based hydration with 1-2L of 0,9% saline over 1\u0026ndash;2 hours and achieved euvolemic status before chemotherapy. All doses of cisplatin were diluted in 500 ml of 0,9% saline and infused over 2\u0026ndash;3 hour. Patients in the mannitol cohort received 20 g admixed in the 0,9% 100ml saline prehydration. All patients received antiemetic premedication such as dexamethasone, a H\u003csub\u003e2\u003c/sub\u003e receptor blocker and diphenhydramine.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of Outcome\u003c/h2\u003e \u003cp\u003eThe outcome of this study was any grade of acute kidney injury (AKI), was defined using the National Cancer Institute\u0026rsquo;s Common Terminology Criteria for Adverse Events (CTCAE v 4.0) grading scale for chemotherapy (41). AKI was defined by an increase of more than 0,3 mg/dl or 1,5 times from baseline of serum creatinine which was measured within 28 days after cisplatin chemotherapy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe collected data was processed using SPSS statistics program version 20.0. To evaluate the differences in the patient characteristics, the chi-square test was used. Bivariate analysis was performed to determine crude relative risk (RR) probability of post-chemotherapy AKI between mannitol group to non-mannitol group. Multivariate logistic regression models were created to assess the potential confounders and revealed adjusted RR. All analyzes used 5% significance limits.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":"\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003ePatient characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 110 patients were included, 63 patients received addition of mannitol and 47 patients did not. The patient characteristics were listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The median age was 44,5 years old with an almost equal proportion of male and female (57,3% vs. 41,8%). More than 60% of patients diagnosed with head and neck cancer and treated with combination of cisplatin and 5-fluorouracyl (44,5%). Most of patient underwent first cycle of cisplatin chemotherapy, received cisplatin dosage of 100 mg / m2 (67,3%). Greater than 95% of patients had never previous cisplatin chemotherapy series, so that cumulative dose received before current chemotherapy was lower than 100mg/m\u003csup\u003e2\u003c/sup\u003e. Regarding comorbidities, only a small proportion of subjects were diagnosed with Diabetes Mellitus (2.7%) and hypertension (7.3%). For concomitant radiotherapy, most subjects (83.5%) were not given concomitant radiotherapy. All of patients were on good performance status before chemotherapy.\u003c/p\u003e\n \u003cp\u003eIn this study, both groups received\u0026thinsp;\u0026gt;\u0026thinsp;3000ml of hydration in 24 hours pre and post chemotherapy, with an adequate urine production for 6 hours post-chemotherapy of (mean value of 2,58\u0026thinsp;\u0026plusmn;\u0026thinsp;1,01 ml / kgBW / hour). All subjects had good pre-chemotherapy renal function, i.e. median ureum 24 mg / dl, creatinine 0,8 mg / dL and glomerular filtration rate (CKD-EPI) was 103,85 ml / minute / 1.73 m2. No subjects had creatinine\u0026thinsp;\u0026gt;\u0026thinsp;1,5 mg / dL pre-chemotherapy. All of subjects had a good median potassium value of 4,07 mEq / L with similar results on both groups. The clinical characteristics were listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePatient Demographics and Characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMannitol (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo Mannitol (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale sex\u003c/strong\u003e, (n\u0026thinsp;=\u0026thinsp;63 ; 57,3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (63,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (51,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,189\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e, median 44,5 yo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;40 years old (n\u0026thinsp;=\u0026thinsp;71; 64,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (51,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (81,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of cancer\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNasopharynx (n\u0026thinsp;=\u0026thinsp;61 ; 55,5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41 (66,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (41,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHead and neck cancer other than nasopharyngeal (n\u0026thinsp;=\u0026thinsp;14 ; 12,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (12,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (12,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteosarcoma (n\u0026thinsp;=\u0026thinsp;11 ; 10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (12,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (6,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBreast (n\u0026thinsp;=\u0026thinsp;3 ; 2,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (6,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOvary (n\u0026thinsp;=\u0026thinsp;4 ; 3,6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (8,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers (n\u0026thinsp;=\u0026thinsp;17 ; 15,5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 8,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (25,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnticancer drugs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e5FU (n\u0026thinsp;=\u0026thinsp;49 ; 44,5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40 (64,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (18,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDocetaxel (n\u0026thinsp;=\u0026thinsp;20 ; 18,2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (16,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (18,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePaclitaxel (n\u0026thinsp;=\u0026thinsp;10 ; 9,1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoxorubicin (n\u0026thinsp;=\u0026thinsp;9 ; 8,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (11,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (6,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNimotuzumab (n\u0026thinsp;=\u0026thinsp;7 ; 6,45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (14,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEtoposide (n\u0026thinsp;=\u0026thinsp;5 ; 4,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (8,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers (n\u0026thinsp;=\u0026thinsp;10; 9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDose of Cisplatin (mg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e100 (n\u0026thinsp;=\u0026thinsp;74 ; 67,3)\u003c/p\u003e\n \u003cp\u003e80 (n\u0026thinsp;=\u0026thinsp;7 ; 6.4)\u003c/p\u003e\n \u003cp\u003e75 (n\u0026thinsp;=\u0026thinsp;29 ; 6,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53(84,1)\u003c/p\u003e\n \u003cp\u003e2(3,2)\u003c/p\u003e\n \u003cp\u003e8(12,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21(44,7)\u003c/p\u003e\n \u003cp\u003e5(10,6)\u003c/p\u003e\n \u003cp\u003e21 (44,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy Cycle\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1st (n\u0026thinsp;=\u0026thinsp;69 [62,7])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34 (54,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (74,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2nd (n\u0026thinsp;=\u0026thinsp;22 [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (27,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (10,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3rd (n\u0026thinsp;=\u0026thinsp;3 [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (12,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (12,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4th (n\u0026thinsp;=\u0026thinsp;5 [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (6,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes Mellitus\u003c/strong\u003e (n\u0026thinsp;=\u0026thinsp;3 [2.7])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (6,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e (n\u0026thinsp;=\u0026thinsp;8 [7.3])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (6,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (8,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eConcomitant Radiotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;91 [83,5])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e55 (60,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36 (39,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical Characteristics of Subjects\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eBefore Chemotherpy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAfter Chemotherapy\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMannitol\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo Mannitol\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMannitol\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo Mannitol\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUreum\u003c/strong\u003e, median {min-max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (4\u0026ndash;68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (10\u0026ndash;47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28,5 (8\u0026ndash;76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (13\u0026ndash;81)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCreatinine\u003c/strong\u003e, median {min-max) mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,8 (0,3\u0026thinsp;\u0026minus;\u0026thinsp;1,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,8 (0,29\u0026thinsp;\u0026minus;\u0026thinsp;1,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,0 (0,4\u0026thinsp;\u0026minus;\u0026thinsp;2,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,9 (0,41\u0026thinsp;\u0026minus;\u0026thinsp;2,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;1, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (88,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (89,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (59,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (72,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,1\u0026ndash;1,5 n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (11,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (10,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (30,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (22,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;1,5 n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (9,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (4,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGFR\u003c/strong\u003e, median {min-max) \u003cstrong\u003eml/minute/1,73m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106,5 (62,7-169,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102 (60\u0026ndash;253,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90,11\u0026thinsp;\u0026plusmn;\u0026thinsp;28,67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90,48\u0026thinsp;\u0026plusmn;\u0026thinsp;35,58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;60\u003c/strong\u003e, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (17,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (10,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e60\u0026ndash;90\u003c/strong\u003e, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (22,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (29,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (45,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;\u0026thinsp;90\u003c/strong\u003e, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (77,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (70,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (53,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (43,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eKalium\u003c/strong\u003e, median {min-max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,14 (3,03\u0026ndash;5,46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,9 (2,8\u0026thinsp;\u0026minus;\u0026thinsp;5,01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,845 (2,8\u0026thinsp;\u0026minus;\u0026thinsp;5,37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,0 (2,3\u0026ndash;5,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-chemotherapy hydration\u003c/strong\u003e, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4270,95\u0026thinsp;\u0026plusmn;\u0026thinsp;740,11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3150,63\u0026thinsp;\u0026plusmn;\u0026thinsp;656,28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4215,32\u0026thinsp;\u0026plusmn;\u0026thinsp;759,47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3322,34\u0026thinsp;\u0026plusmn;\u0026thinsp;780,87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003eIncidence and outcome of AKI\u003c/h2\u003e\n \u003cp\u003eThe incidence of AKI was observed in 14 patients (22.6%) in mannitol group versus 5 patients (10.4%) in no mannitol group (p value\u0026thinsp;=\u0026thinsp;0,076; RR 2,168; 95% CI 0,839-5,6). All of subjects developed an increase of serum creatinine and decrease of glomerular filtration rate after chemotherapy. The decrease of renal function was more noticeable in mannitol group than no mannitol group. The increase of serum creatinine was 29% in mannitol vs. 16,7% in no mannitol group. The increase of serum creatinine from less than 1,0 mg/dL to 1,1\u0026ndash;1,5 mg / dL was found to be greater in the mannitol group than no mannitol group (30,6% vs 22,9%). In addition, the increase in creatinine to more than 1,5 mg / dL were found to be higher in the group receiving mannitol than without mannitol (9,7% vs 4,2%). Similarly, a decrease in GFR from more than 90 ml / min / 1,73 m\u003csup\u003e2\u003c/sup\u003e to less than 60 ml / min / 1,73 m\u003csup\u003e2\u003c/sup\u003e, was greater in the mannitol group than without mannitol (17,7% vs. 10,4%). The pre-post chemotherapy comparison of renal function is detailed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and shown in Graph 1 and 2.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe mean decline of pre-and post-chemotherapy renal function in the mannitol and no mannitol groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean of Creatinine Increase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean of GFR Decline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMannitol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,144-0,291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16,532\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21,12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,17\u0026ndash;21,89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Mannitol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,087\u0026thinsp;\u0026minus;\u0026thinsp;0,229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14,577\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29,98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,87\u0026thinsp;\u0026minus;\u0026thinsp;23,28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cdiv class=\"Section3\" id=\"Sec10\"\u003e\n \u003ch2\u003ePotential risk factor for developing AKI\u003c/h2\u003e\n \u003cp\u003eWe conducted bivariate analysis to analyze the potential confounding factor for such variables: age, sex, type of cancer, chemotherapy regimen, cisplatin dose, chemotherapy cycle, comorbidity of diabetes and hypertension and the administration of concomitant radiotherapy. The variables having p values\u0026thinsp;\u0026lt;\u0026thinsp;0,25 in bivariate analysis were included in the multivariate analysis. The result of bivariate analysis was listed in Table\u0026nbsp;4. Based on bivariate analysis, the variables included in the multivariate analysis were age and chemotherapy regimen. Multivariate analysis and changes of crude RR (relative risk) to be adjusted RR between mannitol and post-chemotherapy AKI incidence by controlling the potential confounding factors were listed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe relationship between potential confounding factors and post-cisplatin acute kidney injury\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\" style=\"width: 266px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePost chemotherapy AKI (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\" style=\"width: 47px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 266px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;40 years old\u003c/p\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;40 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10,3\u003c/p\u003e\n \u003cp\u003e21,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e89,7\u003c/p\u003e\n \u003cp\u003e78,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 266px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18,5\u003c/p\u003e\n \u003cp\u003e15,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e81,5\u003c/p\u003e\n \u003cp\u003e84,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,692\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 266px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Cancer\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNasopharyngeal\u003c/p\u003e\n \u003cp\u003eHead and neck other than nasopharyngeal\u003c/p\u003e\n \u003cp\u003eOsteosarcoma\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18,0\u003c/p\u003e\n \u003cp\u003e7,1\u003c/p\u003e\n \u003cp\u003e9,1\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e82,0\u003c/p\u003e\n \u003cp\u003e92,9\u003c/p\u003e\n \u003cp\u003e90,9\u003c/p\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 266px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegimen of Chemotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e5FU\u003c/p\u003e\n \u003cp\u003eDocetaxel\u003c/p\u003e\n \u003cp\u003ePaclitaxel\u003c/p\u003e\n \u003cp\u003eDoxorubicin\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26,5\u003c/p\u003e\n \u003cp\u003e10,5\u003c/p\u003e\n \u003cp\u003e10,0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e13,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e73,5\u003c/p\u003e\n \u003cp\u003e89,5\u003c/p\u003e\n \u003cp\u003e90,0\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e86,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,146\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 266px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDose of Cisplatin (\u003c/strong\u003emg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10,3\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e21,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e89,7\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e78,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,525\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 266px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle of Chemotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1st\u003c/p\u003e\n \u003cp\u003e2 nd\u003c/p\u003e\n \u003cp\u003e3 rd\u003c/p\u003e\n \u003cp\u003e4 th\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16,2\u003c/p\u003e\n \u003cp\u003e21,7\u003c/p\u003e\n \u003cp\u003e20,0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e83,8\u003c/p\u003e\n \u003cp\u003e78,3\u003c/p\u003e\n \u003cp\u003e80,0\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1,00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 266px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes Mellitus\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo DM\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e17,8\u003c/p\u003e\n \u003cp\u003e36,4\u003c/p\u003e\n \u003cp\u003e15,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"width: 68px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003cp\u003e82,2\u003c/p\u003e\n \u003cp\u003e63,6\u003c/p\u003e\n \u003cp\u003e84,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1,00\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,942\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 266px;\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eConcomitant Radiotherapy\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11,1\u003c/p\u003e\n \u003cp\u003e18,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e89,8\u003c/p\u003e\n \u003cp\u003e81,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,734\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Taba\"\u003e\n \u003ccaption\u003e\n \u003cp\u003eTable 5\u003c/p\u003e\n \u003cp\u003eCrude RR and Adjusted RR with 95% CI of mannitol on post-chemotherapy AKI with the addition of potential confounding factors gradually\u003c/p\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRR (CI 95%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRR value changes with confounder\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCrude RR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,168 (0,839-5,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAdjusted RR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+ Chemotherapy regimen 5 fluorouracyl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,190 (0,555-8,632)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,448\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(2,190-2,168)/2,190 x 100% = 1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e+ Age\u0026thinsp;\u0026ge;\u0026thinsp;40 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,852 (0,68\u0026thinsp;\u0026minus;\u0026thinsp;11,96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0,152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(2,852-2,190)/2,190 x 100% = 23%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eOn multivariate analysis by controlling age and chemotherapy regimen, the risk of post cisplatin AKI was 3,5 times greater in saline with addition of mannitol than saline only (adjusted RR was 3,52; 95% CI 1,11\u0026ndash;11,162, p value\u0026thinsp;=\u0026thinsp;0,033).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eOur data suggest that the addition of mannitol to saline hydration increased the risk of cisplatin-induced acute kidney injury (adjusted RR 2,446; 95% CI 0,614-9,741, p value\u0026thinsp;=\u0026thinsp;0,204). Age\u0026thinsp;\u0026ge;\u0026thinsp;40 years old was concluded to be confounding factors.\u003c/p\u003e \u003cp\u003eThe results of this study were consistent with the study from Santoso, et al (17) in the United States. This randomized controlled clinical trial found that decreased renal function, in this study assessed by 24 hours creatinine clearance, occurred more heavily in the group given the combination of hydration and mannitol than hydration alone (31 ml/min vs 5,4 ml/min, p value\u0026thinsp;=\u0026thinsp;0,04). This study was discontinued prematurely because of higher tendency of nephrotoxicity in mannitol group, so that the expected sample size was not achieved (there were only 49 subjects). The discontinuation of study showed that nephrotoxicity potency of mannitol. However, the limitation of Santoso study was renal function parameters used, which was 24 hours creatinine clearance which required urine storage for 24 hours. Therefore, the potential of adherence-related bias in accommodating urine was a weakness of this study.\u003c/p\u003e \u003cp\u003eOur study also support the result of Leu et al (33), who reported the tendency of greater risk of nephrotoxicity in saline and mannitol group versus saline only (the decrease of creatinine clearance was 38, 9 ml/min vs. 33,9 ml/min, p\u0026thinsp;=\u0026thinsp;0,09) (33). However, Leu included the subjects treated with low dose cisplatin (40\u0026ndash;75 mg/ m\u003csup\u003e2\u003c/sup\u003e), who were excluded in our study.\u003c/p\u003e \u003cp\u003eOur results differ from those of Hayes et al. (16), Morgan et al. (34), and McKibbin et al (35). However, the studies from Hayes (16) was non-comparative trial (no comparison data with patients receiving saline only), so it was difficult to analyze whether the nephroprotective outcome came from mannitol or adequate hydration only. Meanwhile, study from Morgan, reported the higher risk of nephrotoxicity from the group without mannitol (OR 2,646 (95% CI 1,008\u0026thinsp;\u0026minus;\u0026thinsp;6,944; p\u0026thinsp;=\u0026thinsp;0.048) was a retrospective study and had small sample size (only 47 patients received high dose cisplatin). The study from McKibbin et al, (35) which support nephroprotective effect of mannitol after multivariate analysis (odds ratio of third grade nephrotoxicity in mannitol group was 0,16 ; 95% CI 0,04\u0026thinsp;\u0026minus;\u0026thinsp;0,65, p value\u0026thinsp;=\u0026thinsp;0.01) had a limitation in the analysis of concomitant use of nephrotoxic substance due to missing data because of the retrospective nature of study. Our study also differs from a more recent study by Begin et al. which included stated that there was no difference in AKI incidence between subject which was given mannitol in addition to hydration and hydration alone (HR 1.17 [0.75\u0026ndash;1.82]) after administration of Cisplatin\u0026thinsp;\u0026ge;\u0026thinsp;75 mg/m\u003csup\u003e2\u003c/sup\u003e. The different hydration protocol in this study i.e., 3 L before and 1 L after Cisplatin compared to 1 L in our study, might be one of the reasons of this different outcome (37).\u003c/p\u003e \u003cp\u003eThe underlying mechanisms of nephrotoxicity of mannitol was through the osmotic effect of mannitol which inhibits the reabsorption of water in the proximal tubule, resulted in urinary dilution and an increased diuresis. In one side, this effect decreased the contact time of cisplatin with renal tubular cells and increased the clearance of necrotic cell debris at renal tubules after injured by cisplatin. However, this mechanism seemed to have nephrotoxic potential, which was related with hemodynamic changes in the kidney. Mannitol triggered a marked decrease in the reabsorption of water and salt along the renal tubules, resulted in increased flow of water and salts from the proximal tubules, followed by increased sodium reabsorption in loop of Henle, distal tubules and collecting ducts. Increased excretion of urine solutes induced by the mannitol osmotic diuretic effect lead to increased tubuloglomerular feedback which stimulate afferent arteriolar vasoconstriction, hence resulted in decrease of glomerular filtration rate (42,43). Besides that, mannitol would lead the osmotic nephrosis effect on renal tubules. Histologically, tubular cells with toxic effects of mannitol appeared to contain vacuoles resulting in edema, called osmotic nephrosis. Pathophysiologically, the mechanism was through the pinocytosis effect of mannitol into the proximal tubular cell at high osmolality which then causes tubular cell vacuolization. These vacuoles would become fused and develop an edematous cell, resulting an obstruction of renal tubules (44), then led to a decline in glomerular flow and \u003cem\u003eacute kidney injury.\u003c/em\u003e Meta-analysis of Bo Yang et al. (31) in 626 subjects revealed that intravascular mannitol administration did not provide additional benefit than adequate hydration alone in patients at risk of AKI, however in contrast-induced nephropathy, the effect was even detrimental (31).\u003c/p\u003e \u003cp\u003eWe controlled age as confounding variables. Decreased renal function as an increasing of age was associated with decreased plasma flow velocity in glomerular capillaries and glomerular capillary ultrafiltration coefficient. In addition, there were hemodynamic changes associated with structural changes such as decreased renal mass, increased sclerotic glomeruli and tubulointerstitial fibrosis (45). The Davies and Shock study of inulin clearance reported a glomerular filtration rate decrease of 8 ml / min / 1.73 m2 in each year from the age of 40 years old (46). The increasing trend of incidence of AKI with age was consistent with previous research results from Prasaja et al, which reported that over 50 years of age have a higher risk of nephrotoxicity after four cycles of chemotherapy (OR 3,433; 95% CI 1,363-8,645) (47). The study from Perazella et al (48), Caglar et al (22), and de Jongh et al (49), revealed same result, that advancing age was one of the factors that increased the risk of nephrotoxicity (48).\u003c/p\u003e \u003cp\u003eOur study supports the potential nephrotoxic effect of mannitol after cisplatin chemotherapy. Our study had a larger sample size than Santoso\u0026rsquo;s study and stronger association between mannitol addition to saline and the incidence of post cisplatin acute kidney injury than Leu study. Our study only included subjects who received high doses of chemotherapy and excluded subjects who received nephrotoxic drugs simultaneously, two important things that became a limitation in previous studies. For the outcome of renal function, we used serum creatinine parameters, as recommended by the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE v 4.0) grading scale for chemotherapy to minimize bias due to other measures, such as using 24-hour clearance creatinine (41).\u003c/p\u003e \u003cp\u003eThere are several other things to consider when evaluating these results. Most notably, because of cohort nature of this study, we did not randomize patients to receive or not receive mannitol, rather we submit a decision based on clinical judgement of responsible physician. Besides that, our study did not analyze fluid intake at home and excess fluid loss caused by vomiting as a side effect of cisplatin chemotherapy. However, all our subjects had the same approach of post chemotherapy nausea and vomiting; the medication for nausea and vomiting prophylaxis was given to all subjects. There is a need for future prospective study where fluid intake and water balance are strictly controlled to determine better the magnitude of risk from mannitol.\u003c/p\u003e \u003cp\u003eWe hope the results of our study might become a consideration regarding the policy of addition of mannitol to hydration in cisplatin chemotherapy. This might have an added benefit in the cost-effectiveness of chemotherapy if administration of mannitol is no longer routinely given in high-dose cisplatin chemotherapy nowadays.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eIn our patients, the addition of mannitol to hydration increases the risk of post high dose cisplatin chemotherapy acute kidney injury as compared with hydration only. Age\u0026thinsp;\u0026ge;\u0026thinsp;40 years old were confounding factor in our study.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eAKI: acute kidney injury\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCI: confidence interval\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCMGH: Dr. Cipto Mangunkusumo General Hospital\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCTCAE: Common Terminology Criteria for Adverse Events\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eDM: Diabetes Mellitus\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e5FU: fluorouracil\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eGFR: glomerular filtration rate\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eHR: hazard ratio\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eMRCCC: Mochtar Riady Comprehensive Cancer Center\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eNSAID: Non-steroid anti inflammatory drugs\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eOR: odds ratio\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eRR: relative risk\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enone to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was granted by The Ethics Committee of The Faculty of Medicine, Universitas Indonesia. EA number: \u003cstrong\u003e815/UN2.F1/ETIK/2017\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors contributed equally\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBlanchard EM. Cisplatin and solid tumors: Still working, after all these years. J Solid Tumors. 2012;2(1):26\u0026ndash;33.\u003c/li\u003e\n \u003cli\u003eSchiller JH, Harrington D, Belani CP, Langer C, Sandler A, Krook J, et al. Comparison of Four Chemotherapy Regimens for Advanced Non\u0026ndash;Small-Cell Lung Cancer. N Engl J Med. 2002;346(2):92\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eTurrisi AT, Kim K, Blum R, Sause WT, Livingston RB, Komaki R, et al. Twice-Daily Compared with Once-Daily Thoracic Radiotherapy in Limited Small-Cell Lung Cancer Treated Concurrently with Cisplatin and Etoposide. N Engl J Med. 1999;340(4):265\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eGrossman BH, Natale RB, Tangen CM, Speight VO, Vogelzang NJ, Trump DL, et al. Neoadjuvant Chemotherapy Plus Cystectomy Compared With Cystectomy Alone for Locally Advanced Bladder Cancer. N Engl J Med. 2003;349(9):859\u0026ndash;66.\u003c/li\u003e\n \u003cli\u003eBajorin DF, Sarosdy MF, Pfister DG, Mazumdar M, Motzer RJ, Scher HI, et al. Randomized trial of etoposide and cisplatin versus etoposide and carboplatin in patients with good-risk germ cell tumors: A multiinstitutional study. J Clin Oncol. 1993;11(4):598\u0026ndash;606.\u003c/li\u003e\n \u003cli\u003eAdelstein DJ, Li Y, Adams GL, Wagner H, Kish JA, Ensley JF, et al. An intergroup phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer. J Clin Oncol. 2003;21(1):92\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eSilver DP, Richardson AL, Eklund AC, Wang ZC, Szallasi Z, Li Q, et al. Efficacy of neoadjuvant cisplatin in triple-negative breast cancer. J Clin Oncol. 2010;28(7):1145\u0026ndash;53.\u003c/li\u003e\n \u003cli\u003eHartmann JT, Lipp HP. Toxicity of platinum compounds. Expert Opin Pharmacother. 2003;4(6):889\u0026ndash;901.\u003c/li\u003e\n \u003cli\u003eYao X, Panichpisal K, Kurtzman N, Nugent K. Cisplatin nephrotoxicity: A review. Am J Med Sci [Internet]. 2007;334(2):115\u0026ndash;24. Available from: http://dx.doi.org/10.1097/MAJ.0b013e31812dfe1e\u003c/li\u003e\n \u003cli\u003eMiller RP, Tadagavadi RK, Ramesh G, Reeves WB. Mechanisms of cisplatin nephrotoxicity. Toxins. 2010.\u003c/li\u003e\n \u003cli\u003eDos Santos NAG, Rodrigues MAC, Martins NM, Dos Santos AC. Cisplatin-induced nephrotoxicity and targets of nephroprotection: An update. Arch Toxicol. 2012;86(8):1233\u0026ndash;50.\u003c/li\u003e\n \u003cli\u003eTezcan S, Izzettin FV, Sancar M, Yumuk PF, Turhal S. Nephrotoxicity Evaluation in Outpatients Treated with Cisplatin-Based Chemotherapy Using a Short Hydration Method. Pharmacol \u0026amp;amp; Pharm. 2013;\u003c/li\u003e\n \u003cli\u003eBhat ZY, Cadnapaphornchai P, Ginsburg K, Sivagnanam M, Chopra S, Treadway CK, et al. Understanding the risk factors and long- term consequences of cisplatin-associated acute kidney injury: An observational cohort study. PLoS One. 2015;\u003c/li\u003e\n \u003cli\u003eHanigan MH, Devarajan P. Cisplatin nephrotoxicity: molecular mechanisms. Cancer Ther. 2003;(1):47\u0026ndash;61.\u003c/li\u003e\n \u003cli\u003eKubala M, Geleticova J, Huliciak M, Zatloukalova M, Vacek J, Sebela M. Na+/K+-ATPase inhibition by cisplatin and consequences for cisplatin nephrotoxicity. Biomed Pap. 2014;158(2):194\u0026ndash;200.\u003c/li\u003e\n \u003cli\u003eHayes DM, Cvitkovic E, Golbey RB, Scheiner E, Helson L, Krakoff IH. High dose Cis‐platinum diammine dichloride. Amelioration of renal toxicity by mannitol diuresis. Cancer. 1977;\u003c/li\u003e\n \u003cli\u003eSantoso JT, Lucci JA, Coleman RL, Schafer I, Hannigan E V. Saline, mannitol, and furosemide hydration in acute cisplatin nephrotoxicity: A randomized trial. Cancer Chemother Pharmacol. 2003;52(1):13\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eCornelison TL, Reed E. Nephrotoxicity and hydration management for cisplatin, carboplatin, and ormaplatin. Vol. 50, Gynecologic Oncology. 1993. p. 147\u0026ndash;58.\u003c/li\u003e\n \u003cli\u003eTaguchi T, Nazneen A, Abid MR, Razzaque MS. Cisplatin-associated nephrotoxicity and pathological events. Contrib Nephrol. 2005;148(Ii):107\u0026ndash;21.\u003c/li\u003e\n \u003cli\u003eKidera Y, Kawakami H, Sakiyama T, Okamoto K, Tanaka K, Takeda M, et al. Risk factors for cisplatin-induced nephrotoxicity and potential of magnesium supplementation for renal protection. PLoS One. 2014;9(7).\u003c/li\u003e\n \u003cli\u003eMorgan KP, Buie LW, Savage SW. The Role of Mannitol as a Nephroprotectant in Patients Receiving Cisplatin Therapy. Ann Pharmacother. 2012;\u003c/li\u003e\n \u003cli\u003eCaglar K, Kinalp C, Arpaci F, Turan M, Saglam K, Ozturk B, et al. Cumulative prior dose of cisplatin as a cause of the nephrotoxicity of high-dose chemotherapy followed by autologous stem-cell transplantation. Nephrol Dial Transplant. 2002;17(11):1931\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eHoek J, Bloemendal KM, van der Velden LAA, van Diessen JNA, van Werkhoven E, Klop WMC, et al. Nephrotoxicity as a dose-limiting factor in a high-dose cisplatin-based chemoradiotherapy regimen for head and neck carcinomas. Cancers (Basel). 2016;8(2):1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eMuraki K, Koyama R, Honma Y, Yagishita S, Shukuya T, Ohashi R, et al. Hydration with magnesium and mannitol without furosemide prevents the nephrotoxicity induced by cisplatin and pemetrexed in patients with advanced non-small cell lung cancer. J Thorac Dis. 2012;4(6):562\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eTsai SF, Shu KH. Mannitol-induced acute renal failure. Clin Nephrol. 2010;74(1):70\u0026ndash;3.\u003c/li\u003e\n \u003cli\u003eFang L, You H, Chen B, Xu Z, Gao L, Liu J, et al. Mannitol is an independent risk factor of acute kidney injury after cerebral trauma: A casecontrol study. Ren Fail. 2010;32(6):673\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eFanous AA, Tick RC, Gu EY, Fenstermaker RA. Life-Threatening Mannitol-Induced Hyperkalemia in Neurosurgical Patients. World Neurosurg [Internet]. 2016;91:672.e5-672.e9. Available from: http://dx.doi.org/10.1016/j.wneu.2016.04.021\u003c/li\u003e\n \u003cli\u003eKim MY, Park JH, Kang NR, Jang HR, Lee JE, Huh W, et al. Increased risk of acute kidney injury associated with higher infusion rate of mannitol in patients with intracranial hemorrhage: Clinical article. J Neurosurg. 2014;120(6):1340\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eVisweswaran P, Massin EK, Dubose TD. Mannitol-Induced Acute Renal Failure. J Am Soc Nephrol. 1997;8:1028\u0026ndash;33.\u003c/li\u003e\n \u003cli\u003eDickenmann M, Oettl T, Mihatsch MJ. Osmotic Nephrosis: Acute Kidney Injury With Accumulation of Proximal Tubular Lysosomes Due to Administration of Exogenous Solutes. Am J Kidney Dis. 2008;51(3):491\u0026ndash;503.\u003c/li\u003e\n \u003cli\u003eYang B, Xu J, Xu F, Zou Z, Ye C, Mei C, et al. Intravascular administration of mannitol for acute kidney injury prevention: A systematic review and meta-analysis. PLoS One. 2014;9(1):1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eAl-Sarraf M, LeBlanc M, Giri PGS, Fu KK, Cooper J, Vuong T, et al. Chemoradiotherapy versus radiotherapy in patients with advanced nasopharyngeal cancer: Phase III randomized Intergroup study 0099. J Clin Oncol. 1998;\u003c/li\u003e\n \u003cli\u003eLeu L, Baribeault D. A comparison of the rates of cisplatin (cDDP) - Induced nephrotoxicity associated with sodium loading or sodium loading with forced diuresis as a preventative measure. J Oncol Pharm Pract. 2010;16(3):167\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eMorgan KP, Snavely AC, Wind LS, Buie LW, Grilley-Olson J, Walko CM, et al. Rates of Renal Toxicity in Cancer Patients Receiving Cisplatin With and Without Mannitol. Ann Pharmacother. 2014;48(7):863\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eMcKibbin T, Cheng LL, Kim S, Steuer CE, Owonikoko TK, Khuri FR, et al. Mannitol to prevent cisplatin-induced nephrotoxicity in patients with squamous cell cancer of the head and neck (SCCHN) receiving concurrent therapy. Support Care Cancer [Internet]. 2016;24(4):1789\u0026ndash;93. Available from: http://dx.doi.org/10.1007/s00520-015-2978-0\u003c/li\u003e\n \u003cli\u003eWilliams RP, Ferlas BW, Morales PC, Kurtzweil AJ. Mannitol for the prevention of cisplatin-induced nephrotoxicity: A retrospective comparison of hydration plus mannitol versus hydration alone in inpatient and outpatient regimens at a large academic medical center. J Oncol Pharm Pract. 2016;23(6):422\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eB\u0026eacute;gin AM, Monfette ML, Boudrias-Dalle \u0026Eacute;, Lavall\u0026eacute;e E, Samouelian V, Souli\u0026egrave;res D, et al. Effect of mannitol on acute kidney injury induced by cisplatin. Support Care Cancer. 2020;29(4):2083\u0026ndash;91.\u003c/li\u003e\n \u003cli\u003eEl Hamamsy M, Kamal N, Bazan NS, El Haddad M. Evaluation of the effect of acetazolamide versus mannitol on cisplatin-induced nephrotoxicity, a pilot study. Int J Clin Pharm [Internet]. 2018;40(6):1539\u0026ndash;47. Available from: https://doi.org/10.1007/s11096-018-0677-x\u003c/li\u003e\n \u003cli\u003eHamroun A, Lenain R, Bigna JJ, Speyer E, Bui L, Chamley P, et al. Prevention of Cisplatin-Induced Acute Kidney Injury: A Systematic Review and Meta-Analysis. Drugs [Internet]. 2019;79(14):1567\u0026ndash;82. Available from: https://doi.org/10.1007/s40265-019-01182-1\u003c/li\u003e\n \u003cli\u003eMakimoto G, Hotta K, Oze I, Ninomiya K, Nakanishi M, Hara N, et al. Randomized study comparing mannitol with furosemide for the prevention of cisplatin-induced renal toxicity in non-small cell lung cancer: The OLCSG1406 trial. Asia Pac J Clin Oncol. 2021;17(1):101\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eUS Department of Health and Human Services. Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. National Cancer Institute. 2009.\u003c/li\u003e\n \u003cli\u003eGoldwasser P, Fotino S. Acute renal failure following massive mannitol infusion: appropriate response of tubuloglomerular feedback? Am J Nephrol. 1984;144(Nov):2214\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eLin SY, Tang SC, Tsai LK, Yeh SJ, Shen LJ, Wu FLL, et al. Incidence and risk factors for acute kidney injury following mannitol infusion in patients with acute stroke. Med (United States). 2015;94(47):e2032.\u003c/li\u003e\n \u003cli\u003eNomani AZ, Nabi Z, Rashid H, Janjua J, Nomani H, Majeed A, et al. Osmotic nephrosis with mannitol: Review article. Ren Fail. 2014;36(7):1169\u0026ndash;76.\u003c/li\u003e\n \u003cli\u003eWeinstein JR, Anderson S. The Aging Kidney: Physiological Changes. Adv Chronic Kidney Dis [Internet]. 2010;17(4):302\u0026ndash;7. Available from: http://dx.doi.org/10.1053/j.ackd.2010.05.002\u003c/li\u003e\n \u003cli\u003eDAVIES DF, SHOCK NW. Age changes in glomerular filtration rate, effective renal plasma flow, and tubular excretory capacity in adult males. J Clin Invest. 1950;29(5):496\u0026ndash;507.\u003c/li\u003e\n \u003cli\u003ePrasaja Y, Sutandyo N, Andrajati R. Incidence of cisplatin-induced nephrotoxicity and associated factors among cancer patients in Indonesia. Asian Pacific J Cancer Prev. 2015;\u003c/li\u003e\n \u003cli\u003ePerazella MA. Renal vulnerability to drug toxicity. Clin J Am Soc Nephrol. 2009;4(7):1275\u0026ndash;83.\u003c/li\u003e\n \u003cli\u003eDe Jongh FE, Van Veen RN, Veltman SJ, De Wit R, Van Der Burg MEL, Van Den Bent MJ, et al. Weekly high-dose cisplatin is a feasible treatment option: Analysis on prognostic factors for toxicity in 400 patients. Br J Cancer. 2003;88(8):1199\u0026ndash;206.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"High dose cisplatin, mannitol, acute kidney injury","lastPublishedDoi":"10.21203/rs.3.rs-643773/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-643773/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSaline hydration with addition of mannitol have commonly being strategy to avoid cisplatin induced acute kidney injury. While the initial reports demonstrated that mannitol diuresis decreased cisplatin induced renal injury, others have shown renal injury to be worsened.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eTo compare the risk of acute kidney injury in cancer patients receiving high dose cisplatin with addition and without addition of mannitol.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eThis was an ambispective cohort study based on consecutive sampling at Cipto Mangunkusumo General Hospital and Mochtar Riady Comprehensive Cancer Centre (MRCCC) Siloam Hospitals. The data was obtained from September 2017 to February 2018. The choice of mannitol administration based on responsible physician clinical judgement. The outcome was any increment more than 0,3 mg/dl or 1,5 times from baseline of serum creatinine. Analysis was done by using SPSS statistic for univariate, bivariate and multivariate logistic regression to obtain crude risk ratio and adjusted risk ratio of cisplatin induced acute kidney injury probability of mannitol addition on hydration.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResult: \u003c/strong\u003eData from 110 patients (57,3% male) with a median age of 44,5 years (range 19 to 60 years) were collected; 47 received saline alone and 63 received saline with addition of\u0026nbsp;mannitol. Acute kidney injury were higher in mannitol vs non mannitol group. Bivariate analysis showed higher probability of post chemotherapy AKI in mannitol group (RR 2,168; 95% CI 0,839-5,6). On multivariate analysis the adjusted RR was 3,52 (95% CI 1,11-11,162; p value = 0,033) by controlling age.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe addition of mannitol on hydration had higher risk of AKI after high dose cisplatin chemotherapy.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"The Effect of Mannitol Addition on Hydration in Acute Kidney Injury Event After High Dose Cisplatin Chemotherapy: An Ambispective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-06-30 17:10:45","doi":"10.21203/rs.3.rs-643773/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-01-17T08:53:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-01-15T08:44:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"0e9bc565-615a-4244-9bed-19c60aab1a45","date":"2022-01-05T19:10:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-01-03T15:36:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9e31e54d-ef96-42ae-8f79-6d6a10d3673a","date":"2021-12-24T18:53:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1197f4c1-2749-47cb-99c4-f1a2f10a4245","date":"2021-07-19T14:44:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-07-16T13:55:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-07-16T13:39:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-06-29T11:29:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-06-29T11:23:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2021-06-21T02:09:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d2d747a-60f8-4556-95e4-365a5f1aa318","owner":[],"postedDate":"June 30th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":5390412,"name":"Cancer Biology"},{"id":5390413,"name":"Oncology"}],"tags":[],"updatedAt":"2022-04-12T07:52:05+00:00","versionOfRecord":{"articleIdentity":"rs-643773","link":"https://doi.org/10.1186/s12885-022-09456-w","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2022-04-12 07:52:05","publishedOnDateReadable":"April 12th, 2022"},"versionCreatedAt":"2021-06-30 17:10:45","video":"","vorDoi":"10.1186/s12885-022-09456-w","vorDoiUrl":"https://doi.org/10.1186/s12885-022-09456-w","workflowStages":[]},"version":"v1","identity":"rs-643773","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-643773","identity":"rs-643773","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}