How to prevent renal failure after Hyperthermic Intraperitoneal Chemotherapy (HIPEC)?

Prevention of Renal Failure After HIPEC

Adequate intravenous hydration before, during, and after HIPEC is the cornerstone of preventing renal failure, with sodium thiosulfate administration providing significant nephroprotection when cisplatin is used. 1, 2

Risk Factors for Renal Failure in HIPEC

• Cisplatin-containing HIPEC regimens (highest risk factor) 3
• Pre-existing elevated creatinine and urea levels 3
• Use of angiotensin receptor blockers 3
• Low intraoperative urine output 4
• Hypertension 4

Prevention Strategies

Pre-HIPEC Assessment

• Ensure normal renal function before starting HIPEC 5
• Temporarily discontinue nephrotoxic medications, particularly angiotensin receptor blockers 3
• Assess for pre-existing conditions that could worsen during treatment (hypertension, diabetes) 5

Intraoperative Management

1. Aggressive Hydration Protocol

   • Administer adequate intravenous fluids before and after IP chemotherapy 5
   • Maintain urine output at approximately 3 ml/kg/hour 6
   • Average fluid administration rate of 9 ml/kg/hour (crystalloid and colloid) 6
   • Use goal-directed fluid therapy to optimize volume status and hemodynamic parameters 5

2. Nephroprotective Agents

   • Sodium thiosulfate administration:
     • 9 mg/m² prior to HIPEC procedure
     • 12 mg/m² at the end of the procedure 2
     • Reduces renal impairment rate from 31.4% to 0% when using cisplatin 2, 7

3. Monitoring

   • Close monitoring of urine output during the procedure 4
   • Maintain optimal blood pressure to ensure adequate renal perfusion 4

Post-HIPEC Management

1. Continued Hydration

   • Provide intravenous fluids for 5-7 days post-procedure in the outpatient setting 5
   • Prevent or treat dehydration aggressively 5

2. Monitoring

   • Regular monitoring of serum creatinine and electrolytes 5
   • Monitor for electrolyte imbalances, particularly hypomagnesemia (occurs in up to 30% of patients by day 30) 4
   • Assess acid-base status regularly 5

3. Medication Management

   • Avoid nephrotoxic agents for at least 48 hours post-procedure 5
   • Continue to hold angiotensin-converting enzyme inhibitors and angiotensin II antagonists for 48 hours 5

Special Considerations

• Patients receiving cisplatin-based HIPEC are at highest risk for nephrotoxicity and require more aggressive preventive measures 3
• Hyperthermia alone does not appear to induce or aggravate renal injury; the nephrotoxicity is primarily related to the chemotherapeutic agents 3
• Patients with pre-existing renal dysfunction require more careful monitoring and may need dose adjustments of chemotherapeutic agents 5

Effectiveness of Prevention Strategies

• Sodium thiosulfate has been shown to reduce the incidence of renal impairment from 31.4% to 0% in patients receiving cisplatin during HIPEC 2
• Without preventive measures, acute kidney injury occurs in approximately 31.8% of patients undergoing HIPEC 3
• Maintaining adequate hydration and urine output significantly reduces the risk of permanent renal dysfunction 5, 6

By implementing these preventive strategies, the risk of renal failure after HIPEC can be significantly reduced, improving patient outcomes and reducing the likelihood of long-term renal complications.