Renal failure is probably the most frequent cause of hyperkalemia, but in cancer management other causes should be considered. Most important, and usually preventable, is the tumour lysis syndrome that accompanies the rapid breakdown of malignant cells in response to effective chemotherapy. Tumour lysis is most likely in the management of high-grade lymphomas, leukaemia, and trophoblastic and germ cell tumours, where the lysis of many millions of cells results in release of intracellular products, notably potassium and phosphate, into the circulation, along with urate generated by the breakdown of cellular proteins. Urate crystals may precipitate in the renal tubules causing acute urate nephropathy if appropriate precautions are not taken.
Prevention of tumour lysis is the key to management and patients who are predicted to respond rapidly to chemotherapy should be vigorously hydrated intravenously, urinary pH should be maintained in the alkaline range by administration of sodium bicarbonate, and urate nephropathy prevented by pre-treatment of the patient with allopurinol.
Severe, and particularly acute, hyperkalaemia may cause cardiac dys-rhythmias and cardiac arrest. Emergency management is required and this should include intravenous rehydration with glucose, insulin, and sodium bicarbonate to correct acidosis and drive potassium into the intracellular space, and intravenous administration of 10% calcium gluconate. In occasional situations, haemodialysis may be necessary.
Other causes of hyperkalaemia in cancer patients include septicaemia, adrenal insufficiency (usually secondary to glucocorticoid withdrawal or adrenal destruction by a tumour), acute graft versus host disease following allogeneic bone marrow transplantation, and drugs (particularly diuretics such as spirinolactone).
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