Excessive elevation of serum phosphate during tumor lysis syndrome: Lessons from a particularly challenging case.

Burkitt's lymphoma is a common cause of tumor lysis syndrome (TLS) and, in the era of aggressive utilization of prophylactic allopurinol and recombinant uricase enzyme, nephrologists are increasingly witnessing monovalent or divalent cation abnormalities without marked uric acid elevation. An 18-year-old male received his 1st cycle of intensive chemotherapy for Burkitt's lymphoma and developed TLS as defined by the Cairo Bishop criteria. Lactate dehydrogenase peaked at 9,105 U/L (range: 130 - 250) and was accompanied by acute kidney injury, including serum creatinine 2.2 mg/dL on the 4th day with oliguria, hyperkalemia, extreme hyperphosphatemia (21.4 mg/dL), hypermagnesemia, and hypocalcemia. Renal replacement therapy decision was made based on life-threatening electrolyte disturbances. The competing necessity to effectively control hyperphosphatemia and avoid the complication of dialysis disequilibrium syndrome prompted us to perform an initial intermittent hemodialysis with simultaneous intravenous mannitol administration, followed by continuous hemodialysis to manage the continued production of phosphorus from cell lysis. Osmotic stability during the therapy session was affirmatively demonstrated (322, 319 mOsm/kg, respectively). The patient showed excellent tolerance for these therapies and eventually recovered renal function as demonstrated during follow-up visits.

Clinical Outcomes of Older Kidney Transplant Recipients.

BACKGROUND: Older kidney transplant recipients (OKTR) are vulnerable to infections and AKI, often prompting hospitalization. This study elucidates etiology of hospitalizations, AKI, and outcomes in OKTR. METHODS: Retrospective study of 500 patients age ≥ 60, who underwent kidney transplantation from 2005-2015. Demographic, transplant, and outcomes data were collected. RESULTS: OKTR had mean age 66 years; 59% males and 50% African Americans. 62% had at least one hospitalization post-transplant. Predictors of hospitalization were DGF, DM, panel reactive antibodies (PRA), dialysis duration. Hospitalization was mostly due to infection and surgical complications. Average length of stay was 6.4 days. OKTR with at least one hospitalization had 84% higher risk for graft loss (p=0.001). 56% of older kidney transplant recipients had at least one AKI episode post-transplant. Predictors of AKI included DGF, older, African American donor, and tacrolimus variability. The most common etiologies for AKI were infection, dehydration, and GI complications. OKTR with at least one AKI episode had 2.6-fold higher risk for graft loss (p<0.001). CONCLUSIONS: Post-transplant hospitalization and AKI in OKTR significantly impact graft survival. Addressing comorbidities and risks in the pre-transplant and outpatient setting may help alleviate burden of hospitalization and risk of AKI in OKTR and improve graft outcomes.