1- Tumor Lysis Syndrome "TLS":
-Expected within 3 days before and 7 days after starting therapy
-High risk factors to develop TLS: Highly proliferative tumors (ALL, AML, NHL, lymphoblastic or Burkhitt's lymphoma), high tumor load, and those tumors most susceptible to therapy.
-Low risk for TLS: Solid tumors in general, MM, AML, CLL, and Hodgkin's
-Best management is prevention with hydration "Maintain U/O 150-200 ml/hr", Close F/U for complications
-Bicarb shown not much helpful and it carries many potential complications including increase chance for phosphate to precipitate in tubules in the alkaline media. Also, Bicarb can increase total body volume "risk for CHF". Best Hydration fluid is 0.9% NS
-start allopurinol early before therapy.
-If uric acid already high, then Rasburicase is indicated "absolute contra-indicated in G6PD!"
Kayexalate for hyperkalemia "remember: 1gm kayexalate binds 1meq of K+"
2-Tubulo-interstitial disease "2ry to chemotherapy":
-Dose dependent, highly concentrated in urine
-causes: non-oliguric bland urine, SIADH, HUS, salt wasting, low Mg and high Na in Urine electrolytes analysis!
-Before starting cisplatin, make sure patient is euvolemc and normal GFR
-Dose dependent, and children 3-5 years are more susceptible!
-can develop CKd in up to 50% of cases of AKI
-Causes proximal tubular injury/Fanconi's syndrome
-95% excreted in urine
-AKI due to crystal deposits/ tubular obstruction, and usually non-oliguric
-treatment: maintain U/O >3 L/day, urine PH >6.5. Leucovorin rescue therapy showed benefit
3- Glomerular toxicity:
-can cause Thrombotic Micro Angiopathic syndrome "TMA", as well as worsening HTN
-No evidence for benefit of using plasma exchange therapy for TMA here. Best is withdrawing therapy.
b- Anti VEGF therapy "Sunitinib, Bivacizumab, etc.."
-TMA, proteinurea "some develops nephrotic syndrome", HTN
-AIN; been described by Dr Jhaveri, Kenar in his case series review of a single center experience of 3 cases developed AIN after introducing Sunitinib.
-Dose dependent TMA "20% develops TMA for dose >100mg/m2 in contrast to 1% only for dose<50mg/m2!"