Pretherapeutic screening for Dihydropyrimidine deshydrogenase deficiency in measuring uracilemia in dialysis patients leads to a high rate of falsely positive results

Abstract

Pretherapeutic screening for dihydropyrimidine dehydrogenase (DPD) deficiency is recommended prior to the administration of fluoropyrimidine-based chemotherapy. However, the best strategy to identify DPD deficiency in End Stage Renal Disease (ESRD) patients is unknown. We assessed the characteristics of both DPD phenotypes and DPYD genotypes in 20 dialyzed patients before and after dialysis session. The extent to which the concentrations of uracil [U] and dihydrouracil [UH2] were affected by dialysis was evaluated. Mean [U] was 14\u2009±\u20093.3 ng/ml before the dialysis session, and 7.9\u2009±\u20092.7 ng/ml after. Notably, mean [U] in 119 non-ESRD patients during the same timeline was 8.7\u2009±\u20093.9 ng/ml, which is similar to [U] values after dialysis session (p\u2009=\u20090.38). [U] values\u2009>\u200916 ng/ml were measured in 4 ESRD patients (20%), whereas the rate was 3.3% in the non-ESRD cohort. Whole gene sequencing did not reveal DPYD deleterious allelic variants in the 4 ESRD patients with [U] values\u2009>\u200916 ng/ml. The profile of [UH2] values during dialysis was similar to that of [U]: 385\u2009±\u200986 ng/ml before, and 185\u2009±\u200962 ng/ml after (mean reduction rate 42.5%). Thus, [UH2]:[U] ratio remained unaffected by dialysis, and was similar to the values in non-ESRD patients (22.4\u2009±\u20097.1). Phenotyping based on measuring plasma [U] before a dialysis sessions in ESRD patients is associated with an unacceptable high rate of false positives. The optimal strategy for the identification of patients with DPD deficiency in this population would be the monitor the [UH2]:[U] ratio, which remains unaffected.