What are the indications for dialysis in a patient with lymphoma, B symptoms, and impaired renal function?

Indications for Dialysis in Lymphoma Patients with Renal Impairment

In a patient with lymphoma, B symptoms, and impaired renal function, dialysis should be initiated for persistent hyperkalemia, severe metabolic acidosis, volume overload unresponsive to diuretics, or overt uremic symptoms (pericarditis, severe encephalopathy), with consideration for prophylactic dialysis when severe progressive hyperphosphatemia (>6 mg/dL) or severe symptomatic hypocalcemia develops. 1

Primary Indications for Dialysis Initiation

The absolute indications for starting renal replacement therapy in lymphoma patients include:

• Persistent hyperkalemia that is refractory to medical management 1, 2
• Severe metabolic acidosis (not alkalosis, which is NOT a standard dialysis indication) 1, 3, 2
• Volume overload unresponsive to diuretic therapy 1, 2
• Overt uremic symptoms, specifically:
  • Pericarditis 1
  • Severe encephalopathy 1

Prophylactic Dialysis Considerations

Dialysis may be initiated prophylactically before overt uremic symptoms develop in specific metabolic scenarios:

• Severe, progressive hyperphosphatemia >6 mg/dL 1
• Severe symptomatic hypocalcemia 1

The appropriate timing for prophylactic dialysis remains unresolved, but the threshold of phosphate >6 mg/dL provides a practical guideline. 1

Special Considerations for Tumor Lysis Syndrome

Given the context of lymphoma with B symptoms (suggesting high tumor burden), tumor lysis syndrome (TLS) is a critical concern:

• Frequent (daily) dialysis is recommended due to continuous release of purine products, potassium, and other metabolites from lysed tumor cells 1, 4
• Dialysis timing and dose should be linked to the purine generation rate rather than fixed schedules 1
• Additional indications for continuous renal replacement therapy (CRRT) in TLS include:
  • Pulmonary edema 1
  • Need to maintain fluid balance while facilitating nutritional therapy 1
  • Hemodynamic instability (CRRT preferred over intermittent hemodialysis due to less hypotension) 1, 2

Modality Selection

For hemodynamically stable patients: Intermittent hemodialysis or extended daily dialysis is appropriate 1

For hemodynamically unstable patients: CRRT is preferred as it can be performed more safely with diminished tendency to exacerbate hypotension 1, 2

Peritoneal dialysis should be reserved only for situations where other modalities are unavailable, as it has lower efficiency in removing solutes (uric acid, urea) and electrolytes (potassium, phosphate) critical in lymphoma-related renal failure 1

Critical Pitfalls to Avoid

• Do not delay dialysis waiting for "traditional" uremic symptoms in the setting of high tumor burden, as severe hyperphosphatemia and hyperkalemia can be life-threatening before encephalopathy or pericarditis develop 1, 4
• Recognize that lymphomatous infiltration can cause acute kidney injury requiring dialysis as the initial presentation, and early kidney biopsy may be necessary for diagnosis if imaging is unrevealing 5, 6, 7
• Failing to recognize TLS in solid tumor or lymphoma patients can lead to delayed treatment and worse outcomes 4
• In patients already on hemodialysis with lymphoma, daily dialysis with allopurinol (or rasburicase) is preferred over aggressive hydration for TLS management 8