H endemic malaria [58]. In these individuals the unchecked oxidative potential of hydrogen peroxide can lead to methemoglobinemia and hemolytic anemia [59]. Particularly in patients of African, Mediterranean, or Southeast Asian ancestry, testing for G6PD deficiency is warranted before the administration of potent oxidizing agents (e.g., rasburicase). Acute phosphate AKI can also be part of TLS and it has been suggested that wide use of rasburicase and urine alkalinization has resulted in a paradigm shift towards acute phosphate nephropathy in TLS-induced AKI [60]. TLS patients may develop a first episode of AKI secondary to spontaneous TLS-induced acute urate nephropathy, GW 4064 site treated with rasburicase and allopurinol, and a second episode due to chemotherapy-induced TLS with acute phosphate nephropathy.Established TLSSeveral features of the preventive management of TLS remain the mainstay also for the treatment of established TLS. RRT should be considered for all critically ill patients with TLS having persistent metabolic abnormalities or renal failure in spite of fluid replacement. Between 40 and 71 of patients suffering from TLS develop a need for RRT [61]. The selection of RRT in established TLS is briefly discussed in the next section.RRT modality in critically ill patients with cancer with AKI Older studies on dialysis in patients with cancer were discussed extensively in a previous review [10]. As indicated in Table 1, various acute dialysis modalities are used in critically ill cancer patients. Continuous dialysis modalities are often preferred over intermittent therapies to start PubMed ID:http://www.ncbi.nlm.nih.gov/pubmed/27597769 RRT in hypotensive oliguric patients who require vasopressors and large volumes of fluids. In an earlier study in our unit, continuous renal replacement therapy (CRRT) was initially used in 71.4 vs 43.1 of AKI patients with vs without hematological malignancies [9]. Many ICU centers start with CRRT and switch afterwards to intermittent hemodialysis (IHD) when the hemodynamic situation of the patient has stabilized. A hybrid therapy called sustained low-efficiency dialysis (SLED) or extended dialysis (EDD) has emerged as an alternative to CRRT in the management of hemodynamically unstable patients with AKI [62]. Salahudeen et al. [63] retrospectively assessed 199 ICU cancer patients requiring RRT. Most patients (62 ) had hematological cancers,sepsis was present in 27 of the cases, and 30-day mortality was 65 . All patients received “continuous” SLED (sustained low-efficiency extended dialysis). Although 75 of the patients were on vasopressors before dialysis initiation, satisfactory ultrafiltration with acceptable hemodynamic stability were achieved. This study was the first to describe the technical characteristics of SLED in patients with cancer in the ICU. In a recent study with mainly solid cancer patients, IHD was the initial RRT modality in 108 (72.5 ) patients [64]. The other 27.5 were transferred to IHD after 4.0 (2.0?.0) days of CRRT. Thirty-eight (25.5 ) patients were transferred from IHD to CRRT due to hemodynamic instability. Fifty (34.1 ) of the patients received both IHD and CRRT modalities during their ICU stay. Overall, in these critically ill patients with cancer and AKI, IHD offered acceptable hemodynamic stability and provided adequate metabolic control. It is the author’s opinion that irrespective of the etiology of AKI the choice of intermittent vs continuous RRT should be based on the experience of the ICU and nephrolog.
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