Prevention of Cisplatin Nephrotoxicity
Adequate hydration with isotonic saline (1-2 L pre-hydration and post-hydration continuing for several hours), along with magnesium supplementation (8-16 mEq) and monitoring of renal function before each cycle, is essential to prevent cisplatin-induced nephrotoxicity. 1
Key Prevention Strategies
Hydration Protocol
- Pre-hydration: 1-2 L of isotonic saline prior to cisplatin administration 1
- Post-hydration: Continue IV fluids for several hours after cisplatin infusion 1
- Some patients may require continued IV fluids for 5-7 days in outpatient settings to prevent dehydration 1
- Short-duration, low-volume hydration regimens have been shown to be effective and safe for outpatient management 2, 3
Electrolyte Management
- Add 8-16 milliequivalents of magnesium to the hydration regimen for nephroprotection 1, 2
- Monitor electrolytes regularly, particularly magnesium, calcium, and potassium levels 1
- Magnesium supplementation has consistently shown to reduce nephrotoxicity risk 3
Monitoring Requirements
- Check renal function before each cycle of cisplatin therapy 1, 4
- Blood urea nitrogen (BUN)
- Creatinine
- Serum uric acid
- Creatinine clearance
- Renal function must return to normal before administering another dose of cisplatin 4
- Monitor for myelosuppression, dehydration, and electrolyte imbalances 1, 4
Diuretics and Additional Measures
- Mannitol may be beneficial for forced diuresis, especially with high-dose cisplatin 2, 3
- Consider dose reduction (75 mg/m² vs 100 mg/m²) to decrease toxicity 1
- Elderly patients require closer monitoring due to higher susceptibility to nephrotoxicity 1, 4
Clinical Considerations
Impact of Nephrotoxicity
- Cisplatin-induced nephrotoxicity is dose-related and cumulative, affecting 28-36% of patients receiving a single dose of 50 mg/m² 4
- Long-term nephrotoxicity may reduce glomerular filtration rate (GFR) by up to 30%, often asymptomatic 1
- Even small reductions in GFR adversely impact cardiovascular disease and all-cause mortality 1
Special Populations
- Elderly patients are more susceptible to nephrotoxicity and require more vigilant monitoring 1, 4
- Cisplatin is contraindicated in patients with pre-existing renal impairment 4
- Renal function typically decreases in a dose-dependent pattern after cisplatin therapy 1
Emerging Evidence
- Oral hydration after IV pre-hydration may be safe in some patients, though this approach should be used cautiously 5, 3
- Short-duration hydration regimens appear to be as effective as traditional longer hydration protocols 3, 6
Pitfalls and Caveats
- Renal toxicity typically manifests during the second week after cisplatin dose 4
- Despite appropriate hydration protocols, renal toxicity can still occur and requires vigilant monitoring 4
- Cisplatin can cause hypomagnesemia that may persist long-term, necessitating ongoing electrolyte management 1
- Drug interactions may occur; monitor plasma levels of anticonvulsants which may become subtherapeutic during cisplatin therapy 4