Renal Replacement Therapy for Malignant Hypercalcemia

First-Line Treatment Approach

• The American College of Physicians recommends initial management includes aggressive intravenous rehydration with normal saline to correct hypovolemia and promote calciuresis in patients with malignant hypercalcemia 2
• The National Comprehensive Cancer Network recommends denosumab as a preferred treatment in patients with renal insufficiency where bisphosphonates may be contraindicated 3

Indications for Renal Replacement Therapy

• The European Renal Association recommends renal replacement therapy should be initiated when severe hypercalcemia persists despite standard medical therapy in patients with malignant hypercalcemia 1
• The European Renal Association recommends renal replacement therapy should be initiated when patient has acute oliguric renal failure or anuria due to calcium-induced nephropathy in patients with malignant hypercalcemia 1
• The European Renal Association recommends renal replacement therapy should be initiated when severe electrolyte abnormalities accompany hypercalcemia in patients with malignant hypercalcemia 1

Optimal Renal Replacement Modality

• The European Renal Association recommends intermittent hemodialysis (IHD) as a highly effective treatment for rapid calcium removal with clearance rates of approximately 70-100 mL/min in patients with malignant hypercalcemia 1
• The European Renal Association recommends continuous renal replacement therapies (CRRT) as a preferred treatment for hemodynamically unstable patients with malignant hypercalcemia 1

Dialysis Prescription for Hypercalcemia

• The European Society of Cardiology recommends using calcium-free or low-calcium dialysate solution in patients with malignant hypercalcemia 4
• The American Society of Nephrology recommends using calcium-free or low-calcium dialysate solution in patients with malignant hypercalcemia 5
• The European Renal Association recommends daily hemodialysis may provide improved outcomes in severe cases of malignant hypercalcemia 1

Special Considerations

• The American Society of Nephrology recommends patients with multiple myeloma and malignant hypercalcemia may benefit from high-flux dialyzers 5
• The European Renal Association recommends monitoring for dialysis disequilibrium syndrome, especially in patients with severe hypercalcemia 1
• The National Comprehensive Cancer Network recommends continuing bisphosphonate therapy after dialysis if renal function improves in patients with malignant hypercalcemia 6

Pitfalls to Avoid

• The European Renal Association recommends not delaying initiation of renal replacement therapy in patients with severe symptomatic hypercalcemia and renal failure 1
• The American Society of Nephrology recommends avoiding calcium-containing phosphate binders in dialysis patients with hypercalcemia 5
• The European Renal Association recommends remembering that rebound hypercalcemia can occur after dialysis, requiring ongoing monitoring and potentially repeated treatments in patients with malignant hypercalcemia 1