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This study aimed to identify predictive parameters for renal and hematological adverse events.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Twenty-six patients undergoing [\n                      <jats:sup>225<\/jats:sup>\n                      Ac]Ac-PSMA-I&amp;T RLT (mean 3\u2009\u00b1\u20091 cycles) were retrospectively included. All patients received pretherapeutic Fluor-18 ([\n                      <jats:sup>18<\/jats:sup>\n                      F]F)-PSMA-1007 positron emission tomography\/computed tomography (PET\/CT) to quantify renal standardized uptake values (SUV) through manual segmentation of both kidneys. Total and osseous PSMA-tumor volume (TV) were also calculated. Additionally, Technetium-99m ([\n                      <jats:sup>99m<\/jats:sup>\n                      Tc]Tc)-mercaptoacetyltriglycine (MAG3) renal scintigraphy was performed to assess tubular extraction rates (TER). Standard laboratory values were evaluated at baseline, at and between treatment cycles, including estimated glomerular filtration rate (eGFR) and hemoglobin (Hb). Renal events were defined as an eGFR decline\u2009\u2265\u200920% (\n                      <jats:italic>Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group<\/jats:italic>\n                      recommendations), while anemia was classified according to common terminology criteria of adverse events (CTCAE) version 5.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Both eGFR (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.0018) and Hb (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.0002) declined during therapy. Eight patients (31%) experienced renal events, and ten subjects (38%) developed grade 3 anemia. Renal SUV on [\n                      <jats:sup>18<\/jats:sup>\n                      F]F-PSMA-1007 PET\/CT correlated with both eGFR and TER (\n                      <jats:italic>r<\/jats:italic>\n                      \u2009\u2265\u20090.413,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009\u2264\u20090.036), suggesting that PET-based renal quantification may reflect renal function. SUV emerged as the strongest predictor of renal events (Odds Ratio [OR]\u2009=\u20090.095,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.011) outperforming TER (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.165) and baseline eGFR (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.245). Based on Kaplan Meier analysis, low SUV was also associated with shorter renal event-free survival (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.001). Baseline Hb (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.002) was the strongest predictor of grade 3 anemia, while additional markers (platelets, white blood cell count, alkaline phosphatase, osseous PSMA-TV and lactate dehydrogenase; each\n                      <jats:italic>P<\/jats:italic>\n                      \u2009\u2264\u20090.037) also contributed. In line, baseline Hb emerged as the strongest predictor of anemia-free survival (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.0007; osseous TV,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.024).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>\n                      PET-derived renal SUV and osseous tumor volume are promising predictive markers for renal and hematological adverse events during [\n                      <jats:sup>225<\/jats:sup>\n                      Ac]Ac-PSMA-I&amp;T RLT. These findings may support pretherapeutic risk stratification in this vulnerable patient population.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00259-026-07788-4","type":"journal-article","created":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T00:23:06Z","timestamp":1770596586000},"page":"4360-4373","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["PET-based risk stratification for adverse events under [225Ac]Ac-PSMA radioligand therapy"],"prefix":"10.1007","volume":"53","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0243-9338","authenticated-orcid":false,"given":"Liam","family":"Widjaja","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sophie C.","family":"Siegmund","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Franz J.","family":"Gildehaus","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina-Sophie","family":"Schmidt-Hegemann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin G.","family":"Pomper","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven P.","family":"Rowe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ralph A.","family":"Bundschuh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vera","family":"Wenter","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gabriel T.","family":"Sheikh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Konrad","family":"Klimek","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian G.","family":"Stief","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mathias J.","family":"Zacherl","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rudolf A.","family":"Werner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jozefina","family":"Casuscelli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,9]]},"reference":[{"key":"7788_CR1","doi-asserted-by":"publisher","first-page":"327","DOI":"10.1038\/s41391-023-00725-8","volume":"27","author":"SJ Freedland","year":"2024","unstructured":"Freedland SJ, Davis M, Epstein AJ, Arondekar B, Ivanova JI. 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The study was approved by the ethical committee of Ludwig-Maximilians University (#25\u20130130).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval"}},{"value":"All participants consented to imaging and subsequent therapy, as well as to potential scientific analysis.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}},{"value":"RAW has received speaker honoraria from Novartis\/AAA and PentixaPharm, reports advisory board work for Novartis\/AAA and Bayer.RAB is Consultant for and has received speaker\u00b4s honoraria from Bayer Healthcare (Leverkusen, Germany), Novartis (N\u00fcrnberg, Germany), Terumo GmbH (Eschborn, Germany), and Eisai GmbH (Frankfurt, Germany) and has received travel expenses from Blue Earth Therapeutics (Oxford, UK).JC has received speaker honoraria, travel expenses and reports advisory board work from Astellas, Astra Zeneca, Bayer, BMS, Eisai, Ipsen, Johnson&Johnson, Merck, MSD, and Novartis.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}]}}