Renal impairment and DPD testing: Watch out for false-positive results!

Measuring uracil (U) levels in plasma is a convenient surrogate to establish dihydropyrimidine dehydrogenase (DPD) status in patients scheduled with 5-fluorouracil (5-FU) or capecitabine. To what extent renal impairment could impact on U levels and thus be a confounding factor is a rising concern. Here, we report the case of a cancer patient with severe renal impairment scheduled for 5-FU-based regimen. Determination of his DPD status was complicated because of his condition and the influence of intermittent haemodialysis when monitoring U levels. The patient was initially identified as markedly DPD-deficient upon U measurement (i.e., U = 40 ng/mL), but further monitoring between and immediately after dialysis showed mild deficiency only (i.e., U = 34 and U = 19 ng/mL, respectively). Despite this discrepancy, a starting dose of 5-FU was cut by 50% upon treatment initiation. Tolerance was good and 5-FU dosing was next shifted to 25% reduction, then further shifted to normal dosing at the 5th course, with still no sign for drug-related toxicities. Further DPYD genotyping showed none of the four allelic variants usually associated with loss of DPD activity. Of note, the excellent tolerance upon standard dosing strongly suggests that this patient was actually not DPD-deficient, despite U values always above normal concentrations. This case report highlights how critical is the information regarding the renal function of patients with cancer when phenotyping DPD using U plasma as a surrogate, and that U accumulation in patients with such condition is likely to yield false-positive results.