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Saglietti F, Girombelli A, Marelli S, Vetrone F, Balzanelli MG, Tabaee Damavandi P. Role of Magnesium in the Intensive Care Unit and Immunomodulation: A Literature Review. Vaccines (Basel) 2023; 11:1122. [PMID: 37376511 DOI: 10.3390/vaccines11061122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
Both the role and the importance of magnesium in clinical practice have grown considerably in recent years. Emerging evidence suggests an association between loss of magnesium homeostasis and increased mortality in the critical care setting. The underlying mechanism is still unclear, but an increasing number of in vivo and in vitro studies on magnesium's immunomodulating capabilities may shed some light on the matter. This review aims to discuss the evidence behind magnesium homeostasis in critically ill patients, and its link with intensive care unit mortality via a likely magnesium-induced dysregulation of the immune response. The underlying pathogenetic mechanisms, and their implications for clinical outcomes, are discussed. The available evidence strongly supports the crucial role of magnesium in immune system regulation and inflammatory response. The loss of magnesium homeostasis has been associated with an elevated risk of bacterial infections, exacerbated sepsis progression, and detrimental effects on the cardiac, respiratory, neurological, and renal systems, ultimately leading to increased mortality. However, magnesium supplementation has been shown to be beneficial in these conditions, highlighting the importance of maintaining adequate magnesium levels in the intensive care setting.
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Affiliation(s)
- Francesco Saglietti
- Santa Croce and Carle Hospital, Department of Emergency and Critical Care, 12100 Cuneo, Italy
| | - Alessandro Girombelli
- Division of Anesthesiology, Department of Anesthesiology, Intensive care and Emergency Medicine, Ospedale Regionale di Lugano, 69000 Lugano, Switzerland
| | - Stefano Marelli
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy
| | - Francesco Vetrone
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy
| | - Mario G Balzanelli
- Department of Prehospital Emergency Medicine, ASL TA, Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
| | - Payam Tabaee Damavandi
- Department of Neurology, Fondazione IRCCS San Gerardo dei Tintori, School of Medicine and Surgery, Milan Center for Neuroscience, University of Milano-Bicocca, 20900 Monza, Italy
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Saillant A, Try M, Laparra A, Lecoq AL, Zaidan M. [Electrolyte disorders in oncological patients]. Bull Cancer 2023:S0007-4551(23)00209-6. [PMID: 37208250 DOI: 10.1016/j.bulcan.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 05/21/2023]
Abstract
Electrolyte disorders (ED) are common in patients with cancer and in most cases, the etiologies do not differ from the general population. They may also be induced by the cancer, its therapy or paraneoplastic syndromes. ED are associated with poor outcomes, increased morbidity and mortality in this population. Hyponatremia is the most common disorder, often multifactorial, iatrogenic or secondary to the syndrome of inappropriate antidiuretic hormone secretion, usually due to small cell lung cancer. More rarely, hyponatremia may reveal adrenal insufficiency. Hypokalemia is generally multifactorial and associated with other ED. Cisplatin and ifosfamide induce proximal tubulopathies with hypokalemia and/or hypophosphatemia. Hypomagnesemia is often iatrogenic, related to cisplatin or cetuximab, but can be prevented by supplementation. Hypercalcemia can impair life quality and be life-threatening in the most severe cases. Hypocalcemia is less common and often of iatrogenic origin. Finally, the tumor lysis syndrome is a diagnostic and therapeutic emergency that affects the prognosis of patients. Its incidence tends to increase in solid oncology, related to the improvement of therapies. Prevention and early diagnosis of ED are essential to optimize the overall management of patients with underlying cancer and cancer therapy. The aim of this review is to synthesize most frequent ED and their management.
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Affiliation(s)
- Arnaud Saillant
- Centre hospitalier universitaire de Poitiers, service d'oncologie médicale, 86021 Poitiers, France; Groupe de recherche interdisciplinaire francophone en onco-néphrologie, Paris, France.
| | - Mélanie Try
- Groupe de recherche interdisciplinaire francophone en onco-néphrologie, Paris, France; Assistance publique-Hôpitaux de Paris (AP-HP), centre hospitalier universitaire de Bicêtre, université de Paris-Saclay, service de néphrologie, dialyse et transplantation, 94270 Le Kremlin-Bicêtre, France
| | - Ariane Laparra
- Assistance publique-Hôpitaux de Paris (AP-HP), centre hospitalier universitaire de Bicêtre, université de Paris-Saclay, service de médecine interne-immunologie, 94270 Le Kremlin-Bicêtre, France
| | - Anne-Lise Lecoq
- Assistance publique-Hôpitaux de Paris (AP-HP), centre hospitalier universitaire de Bicêtre, université de Paris-Saclay, service d'endocrinologie et des maladies de la reproduction, 94270 Le Kremlin-Bicêtre, France
| | - Mohamad Zaidan
- Assistance publique-Hôpitaux de Paris (AP-HP), centre hospitalier universitaire de Bicêtre, université de Paris-Saclay, service de néphrologie, dialyse et transplantation, 94270 Le Kremlin-Bicêtre, France
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Tonai K, Katayama S, Koyama K, Sata N, Tomioka Y, Imahase H, Nunomiya S. Association between hypomagnesemia and coagulopathy in sepsis: a retrospective observational study. BMC Anesthesiol 2022; 22:359. [PMID: 36424547 PMCID: PMC9685885 DOI: 10.1186/s12871-022-01903-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hypomagnesemia reportedly has significant associations with poor clinical outcomes such as increased mortality and septic shock in patients with sepsis. Although the mechanism underlying these outcomes mostly remains unclear, some experimental data suggest that magnesium deficiency could potentiate coagulation activation in sepsis. However, in sepsis, the association between serum magnesium levels and coagulopathy, including disseminated intravascular coagulation (DIC), remains unknown. Thus, we aimed to investigate the relationship between serum magnesium levels and coagulation status and the association between hypomagnesemia and DIC in patients with sepsis. METHODS This retrospective observational study was conducted at the intensive care unit (ICU) of a university hospital from June 2011 to December 2017. Patients older than 19 years who met the Sepsis-3 definition were included. We categorized patients into three groups according to their serum magnesium levels: hypomagnesemia (< 1.6 mg/dL), normal serum magnesium level (1.6-2.4 mg/dL), and hypermagnesemia (> 2.4 mg/dL). We investigated the association between serum magnesium levels and overt DIC at the time of ICU admission according to the criteria of the International Society on Thrombosis and Haemostasis. RESULTS Among 753 patients included in this study, 181 had DIC, 105 had hypomagnesemia, 552 had normal serum magnesium levels, and 96 had hypermagnesemia. Patients with hypomagnesemia had a more activated coagulation status indicated by lower platelet counts, lower fibrinogen levels, higher prothrombin time-international normalized ratios, higher thrombin-antithrombin complex, and more frequent DIC than those with normal serum magnesium levels and hypermagnesemia (DIC: 41.9% vs. 20.6% vs. 24.0%, P < 0.001). The coagulation status in patients with hypomagnesemia was more augmented toward suppressed fibrinolysis than that in patients with normal serum magnesium levels and hypermagnesemia. Multivariate logistic regression revealed that hypomagnesemia was independently associated with DIC (odds ratio, 1.69; 95% confidence interval, 1.00-2.84; P = 0.048) after adjusting for several confounding variables. CONCLUSIONS Patients with hypomagnesemia had a significantly activated coagulation status and suppressed fibrinolysis. Hypomagnesemia was independently associated with DIC in patients with sepsis. Therefore, the treatment of hypomagnesemia may be a potential therapeutic strategy for the treatment of coagulopathy in sepsis.
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Affiliation(s)
- Ken Tonai
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Shinshu Katayama
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Kansuke Koyama
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Naho Sata
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Yoshihiro Tomioka
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Hisashi Imahase
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Shin Nunomiya
- grid.410804.90000000123090000Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
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The addition of sodium thiosulphate to hyperthermic intraperitoneal chemotherapy with cisplatin in ovarian cancer. Gynecol Oncol Rep 2021; 37:100796. [PMID: 34141848 PMCID: PMC8185237 DOI: 10.1016/j.gore.2021.100796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/28/2022] Open
Abstract
Cisplatin chemotherapy is highly nephrotoxic and is a dose limiting side effect. The OVIHIPEC-1 trial employed sodium thiosulphate (ST) as a renal protectant. We analyse the implementation of HIPEC for EOC in a peritoneal malignancy centre. One acute kidney injury (AKI) event was noted when ST was not used with HIPEC. No AKI was observed when sodium thiosulphate was used with cisplatin at 100 mg/m2.
Cisplatin based hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to prolong recurrence free and overall survival of women with ovarian cancer who have responded to neoadjuvant chemotherapy. The aim of this study was to assess the impact of cytoreductive surgery with or without the addition of HIPEC on renal function. Method This is a retrospective case-controlled study at a tertiary teaching hospital in Dublin, Ireland. All patients who had interval cytoreductive surgery (CRS) and HIPEC from October 2017 to October 2020 were included. A cohort of patients who had interval CRS without HIPEC were included as a control. Sodium thiosulphate (ST) was added to the HIPEC protocol in 2019. In order to assess the impact of ST as a renal protectant, renal function and post-operative outcomes were compared between the groups. Results Sixty patients who had interval CRS were included, thirty of whom received cisplatin-based HIPEC. Seven received cisplatin 50 mg/m2 without the addition of ST. Twenty three patients received cisplatin 100 mg/m2 and ST. There were no statistically differences in age, body mass index BMI, American society of anaesthesia score, estimated blood loss or peritoneal cancer index between the cohorts (p > 0.05). The only episode of acute kidney injury (AKI) was within the HIPEC cohort, after cisplatin 50 mg/m2 (without ST) and this was sustained at three months. In contrast, no patients within the CRS cohort or cisplatin 100 mg/m2 that received the addition of ST, sustained a renal injury and all had a creatinine within the normal range at three days post operatively. Conclusion The renal toxicity associated with cisplatin HIPEC and major abdominal surgery can be minimised with careful preoperative optimisation, intra operative fluid management and attention to renal function. The addition of sodium thiosulphate is a safe and effective method to minimise toxicity and should be added to any cisplatin HIPEC protocol.
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Casanova AG, Fuentes-Calvo I, Hernández-Sánchez MT, Quintero M, Toral P, Caballero MT, Martínez-Salgado C, Morales AI, Layton AT, Eleno N, López-Hernández FJ. The furosemide stress test and computational modeling identify renal damage sites associated with predisposition to acute kidney injury in rats. Transl Res 2021; 231:76-91. [PMID: 33253980 DOI: 10.1016/j.trsl.2020.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) diagnosis relies on plasma creatinine concentration (Crpl), a relatively insensitive, surrogate biomarker of glomerular filtration rate that increases only after significant damage befalls. However, damage in different renal structures may occur without increments in Crpl, a condition known as subclinical AKI. Thus, detection of alterations in other aspects of renal function different from glomerular filtration rate must be included in an integral diagnosis of AKI. With this aim, we adapted to and validated in rats (for preclinical research) the furosemide stress test (FST), a tubular function test hitherto performed only in humans. We also tested its sensitivity in detecting subclinical tubular alterations. In particular, we predisposed rats to AKI with 3 mg/kg cisplatin and subsequently subjected them to a triggering insult (ie, 50 mg/kg/d gentamicin for 6 days) that had no effect on nonpredisposed animals but caused an overt AKI in predisposed rats. The FST was performed immediately before adding the triggering insult. Predisposed animals showed a reduced response to the FST (namely, reduced furosemide-induced diuresis and K+ excretion), whereas nonpredisposed animals showed no alteration, compared to the controls. Computational modeling of epithelial transport of solutes and water along the nephrons applied to experimental data suggested that proximal tubule transport was only minimally reduced, the sodium-chloride symporter was upregulated by 50%, and the renal outer medullary potassium channel was downregulated by 85% in predisposed animals. In conclusion, serial coupling of the FST and computational modeling may be used to detect and localize subclinical tubular alterations.
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Affiliation(s)
- Alfredo G Casanova
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Fundación Instituto de Estudios de Ciencias de la Salud de Castilla y León (IECSCYL), Soria, Spain; Department of Physiology and Pharmacology, University of Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain
| | - Isabel Fuentes-Calvo
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Physiology and Pharmacology, University of Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain
| | - María T Hernández-Sánchez
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Fundación Instituto de Estudios de Ciencias de la Salud de Castilla y León (IECSCYL), Soria, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain
| | - Miguel Quintero
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain
| | - Paula Toral
- Department of Physiology and Pharmacology, University of Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain
| | - María T Caballero
- Department of Physiology and Pharmacology, University of Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Martínez-Salgado
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Fundación Instituto de Estudios de Ciencias de la Salud de Castilla y León (IECSCYL), Soria, Spain; Department of Physiology and Pharmacology, University of Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain; Disease and Theranostic Modeling (DisMOD) International Consortium, Salamanca, Spain
| | - Ana I Morales
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Physiology and Pharmacology, University of Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain; Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain; Disease and Theranostic Modeling (DisMOD) International Consortium, Salamanca, Spain
| | - Anita T Layton
- Departments of Applied Mathematics and Biology, and Schools of Computer Science and Pharmacology, University of Waterloo, Waterloo, Ontario, Canada; Disease and Theranostic Modeling (DisMOD) International Consortium, Salamanca, Spain.
| | - Nélida Eleno
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Department of Physiology and Pharmacology, University of Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain.
| | - Francisco J López-Hernández
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Fundación Instituto de Estudios de Ciencias de la Salud de Castilla y León (IECSCYL), Soria, Spain; Department of Physiology and Pharmacology, University of Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain, National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain; Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain; Disease and Theranostic Modeling (DisMOD) International Consortium, Salamanca, Spain.
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Alvarado-Muñoz JF, Falco A, Morales AR, Sánchez NC, Reynoso G, Barillas A, Moreno J, López K, Prestol R, Cabreja A, Nuñez C. Platinum ineligibility in squamous cell carcinoma of the head and neck: consensus from Central America and the Caribbean. Future Oncol 2021; 17:1963-1971. [PMID: 33559505 DOI: 10.2217/fon-2020-0931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The high incidence of head and neck cancer in Central America and the Caribbean, together with limitations in the healthcare system for patients with locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) in this region necessitate a consensus of opinion based on a review of the literature on therapy with cisplatin plus radiation. Such an approach will ensure appropriate selection of patients who can benefit from therapy and reduce the incidence of related adverse events. Therefore, we recorded the opinion of experts in the region in order to identify needs and challenges in the treatment of LA SCCHN.
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Affiliation(s)
| | - Agustín Falco
- Alexander Fleming Institute of Oncology, Buenos Aires, Argentina
| | | | - Noé C Sánchez
- Guatemalan Social Security Institute, Guatemala City, Guatemala
| | | | - Allan Barillas
- Guatemalan Social Security Institute, Guatemala City, Guatemala
| | | | - Kreilin López
- Heriberto Pieter Cancer Institute, Santo Domingo, Dominican Republic
| | - Rogelio Prestol
- Heriberto Pieter Cancer Institute, Santo Domingo, Dominican Republic
| | - Angela Cabreja
- Regional Oncological Institute Cibao, Santiago de los Caballeros, Dominican Republic
| | - César Nuñez
- Regional Oncological Institute Cibao, Santiago de los Caballeros, Dominican Republic
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Metal element alteration in the lung by cisplatin and CV247 administration. Biomed Pharmacother 2020; 128:110307. [PMID: 32474353 DOI: 10.1016/j.biopha.2020.110307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/14/2020] [Accepted: 05/20/2020] [Indexed: 12/20/2022] Open
Abstract
Despite significant nephrotoxicity, cisplatin is still used in the therapy of various tumors. We were interested in how metal ion composition is altered by cisplatin and whether platinum accumulates in the non-tumorous lung. We also aimed to study metal ion changes after treatment with a veterinary medicament CV247 with antioxidant property (containing Cu and Mn gluconate, ascorbic acid, Na salicylate), and whether CV247 alters pulmonary platinum accumulation in the healthy lung. Male Wistar rats were randomly selected into 4 groups (n = 10/group): control group, cisplatin-treated group, CV247-treated group, cisplatin + CV247-treated group. Inductively coupled plasma optical emission spectrometry and mass spectrometry were used for measuring Al, As, B, Ba, Ca, Cd, Co, Cu, Cr, Fe, K, Li, Mg, Mn, Mo, Na, Ni, P, Pb, Pt, S, Sb, Se, Sn, Sr, and Zn in the lung and the redox state was measured in the plasma. Cisplatin influenced the element homeostasis in the lung. Pt, Mn, Se accumulation and Ca, Mg excretion were observed after treatment with cisplatin. The antioxidant CV247 supplementation modified the Mn concentration; however, the concentration of Cu did not change despite the Cu content of the product, and CV247 did not affect other metal concentrations in the lung of the cisplatin-treated group. In conclusion, cisplatin has a systemic impact on the metal element metabolism, and this effect was demonstrated in the healthy lung, too. The results indicate the importance of supplementing some essential elements, such as Ca and Mg during cisplatin cancer therapy.
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Cheminet G, Clain G, Jannot AS, Ranque B, Passeron A, Michon A, De Luna G, Diehl JL, Oudard S, Cellier C, Karras A, Vedié B, Prot-Bertoye C, Pouchot J, Arlet JB. Extreme hypomagnesemia: characteristics of 119 consecutive inpatients. Intern Emerg Med 2018; 13:1201-1209. [PMID: 29951810 DOI: 10.1007/s11739-018-1898-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/16/2018] [Indexed: 01/24/2023]
Abstract
Extreme hypomagnesemia (hypoMg) can be encountered in many situations, but little data currently exist. Our aim is to describe the epidemiological, clinical, etiological characteristics, and the biological abnormalities of consecutive inpatients with extreme hypomagnesemia. In our observational monocentric study, between 1st July 2000 and April 2015, all inpatients with extreme hypomagnesemia, defined by at least one plasma magnesium concentration (PMg) below 0.3 mmol/L, were included. Demographic, clinical, biological characteristics and the drugs prescribed before the qualifying PMg measurement were retrospectively collected. 41,069 patients had at least one PMg assessment. The prevalence of extreme hypomagnesemia is 0.3% (119 inpatients). The median age is 70 years, 52% are women. The patients were mainly hospitalized in intensive care (n = 37, 31.1%), oncology (n = 21, 17.6%), gastroenterology (n = 18, 15.1%) and internal medicine (n = 16, 13.4%) departments. One hundred patients (84%) had a medical history of gastrointestinal disease (39% with bowel resections, 24% with stoma), and 50 (42%) had a cancer history. The drugs most commonly prescribed (known to induce hypoMg) are proton pump inhibitors (PPI) (n = 77, 70%), immunosuppressive regimens (n = 25, 22.5%), platinum salt-based chemotherapies (n = 19, 17.1%), and diuretics (n = 22, 19.8%). The suspected causes of hypomagnesemia are often multiple, but drugs (46%, including PPI in 19%) and chronic gastrointestinal disorders (37%) are prominent. Associated electrolyte disturbances include hypocalcemia (77%) and mild hypokalemia (51%). The 1-month mortality from all causes is 16%. Extreme hypomagnesemia is rare in inpatients, and is frequently associated with severe hypocalcemia. Digestive disorders and drugs are the main contributory causes.
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Affiliation(s)
- Geoffrey Cheminet
- Service de Médecine Interne, Internal medicine Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Gabrielle Clain
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
- Medical Information Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Anne-Sophie Jannot
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
- Medical Information Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Brigitte Ranque
- Service de Médecine Interne, Internal medicine Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Amélie Passeron
- Service de Médecine Interne, Internal medicine Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Adrien Michon
- Service de Médecine Interne, Internal medicine Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Gonzalo De Luna
- Service de Médecine Interne, Internal medicine Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Jean-Luc Diehl
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
- Medical Intensive Care Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Stéphane Oudard
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
- Oncology Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Christophe Cellier
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
- Gastroenterology Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Alexandre Karras
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
- Nephrology Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Benoit Vedié
- Biochemistry Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Caroline Prot-Bertoye
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
- Renal Physiology Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Jacques Pouchot
- Service de Médecine Interne, Internal medicine Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France
| | - Jean-Benoît Arlet
- Service de Médecine Interne, Internal medicine Department, Georges Pompidou European Hospital, AP-HP, 20 rue Leblanc, 75015, Paris, France.
- Faculté de Médecine Paris Descartes, Sorbonne Paris-Cité, Paris, France.
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Muselin F, Dumitrescu E, Berbecea A, Doma AO, Brezovan D, Savici J, Trif A, Cristina RT. The effect of cisplatin administration on certain trace elements homeostasis in rats and the protective effect of silver birch (Betula pendula) sap. J Trace Elem Med Biol 2018; 50:474-481. [PMID: 29429790 DOI: 10.1016/j.jtemb.2018.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/19/2018] [Accepted: 02/01/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND A clinically active structure with known antitumor activities is cisplatin (CDDP), but this it comes with toxicity characteristics which can be faded by the beneficial effects of Silver birch (Betula pendula) sap. OBJECTIVE We aimed to assess the cisplatin activity on: Mn, Mg, Cu, Fe and Zn homeostasis in rats and to observe the effect of birch sap. METHODS Healthy Wistar rats (n = 10/group) were divided in four groups: Control: receiving 1 mL saline I.P. way + water; E1: cisplatin 20 mg kgbw-1, I.P.; E2: cisplatin 20 mg kgbw-1, I.P. + birch sap and Control sap group: 1 mL saline I.P. + birch sap. Blood was collected: at the trial's start and after 48 h, and blood and organs (liver, kidney and spleen) for the cytoarchitecture investigation and readings were sampled after seven days. Samples were processed in nitric acid by microwave digestion and readings were completed by flame atomic absorption spectroscopy, the outcomes being statistically analyzed by ANOVA. RESULTS Cisplatin produced a significant imbalance in the trace elements homeostasis, the birch sap administration recovering them usual homeostasis status. Comparatively with the Control, rats exposed to cisplatin presented a not significant (p > 0.05) decrease of Zn (-26.74%) and Mg (-10.25%), a significant (p < 0.05) decrease of Cu (-27.73%) at 48 h, a highly significant (p < 0.01) decrease of Cu (-56.08%) and Fe (-85.35%) at seven days after administration and a not significant (p > 0.05) increase of Mn (+28.16%). Birch sap administration after Cisplatin was followed by restoration or nevertheless significant increase (p < 0.05) of the investigated trace elements Zn (+56.88% to 48 h/+89.94% after seven days), Mg (+26.86%/+95.74%), Cu (+23.13%/+74.56%), Fe (+39.64%/+440.11%) and Mn (+4.30%/+15.87%), suggesting them defence against cisplatin. Histology revealed the order of main altered organs after the CDDP exposure: kidney, spleen and liver. CONCLUSIONS The study recommended the important protective role of Betula pendula sap against diverse cisplatin deleterious side-effects.
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Affiliation(s)
- Florin Muselin
- Banat's University of Agriculture and Veterinary Medicine "King Michael I of Romania", from Timisoara (BUAVMT), Faculty of Veterinary Medicine, 119 Calea Aradului, 300645 Timisoara, Romania.
| | - Eugenia Dumitrescu
- Banat's University of Agriculture and Veterinary Medicine "King Michael I of Romania", from Timisoara (BUAVMT), Faculty of Veterinary Medicine, 119 Calea Aradului, 300645 Timisoara, Romania
| | - Adina Berbecea
- Banat's University of Agriculture and Veterinary Medicine "King Michael I of Romania", from Timisoara (BUAVMT), Faculty of Veterinary Medicine, 119 Calea Aradului, 300645 Timisoara, Romania
| | - Alexandru Octavian Doma
- Banat's University of Agriculture and Veterinary Medicine "King Michael I of Romania", from Timisoara (BUAVMT), Faculty of Veterinary Medicine, 119 Calea Aradului, 300645 Timisoara, Romania
| | - Diana Brezovan
- Banat's University of Agriculture and Veterinary Medicine "King Michael I of Romania", from Timisoara (BUAVMT), Faculty of Veterinary Medicine, 119 Calea Aradului, 300645 Timisoara, Romania
| | - Jelena Savici
- Banat's University of Agriculture and Veterinary Medicine "King Michael I of Romania", from Timisoara (BUAVMT), Faculty of Veterinary Medicine, 119 Calea Aradului, 300645 Timisoara, Romania
| | - Alexandra Trif
- Banat's University of Agriculture and Veterinary Medicine "King Michael I of Romania", from Timisoara (BUAVMT), Faculty of Veterinary Medicine, 119 Calea Aradului, 300645 Timisoara, Romania
| | - Romeo Teodor Cristina
- Banat's University of Agriculture and Veterinary Medicine "King Michael I of Romania", from Timisoara (BUAVMT), Faculty of Veterinary Medicine, 119 Calea Aradului, 300645 Timisoara, Romania.
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Crona DJ, Faso A, Nishijima TF, McGraw KA, Galsky MD, Milowsky MI. A Systematic Review of Strategies to Prevent Cisplatin-Induced Nephrotoxicity. Oncologist 2017; 22:609-619. [PMID: 28438887 DOI: 10.1634/theoncologist.2016-0319] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 12/20/2016] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Cisplatin, a platinum-based antineoplastic agent, is the cornerstone for the treatment of many malignancies. Nephrotoxicity is the primary dose-limiting toxicity, and various hydration regimens and supplementation strategies are used to prevent cisplatin-induced kidney injury. However, evidence-based recommendations on specific hydration regimens are limited. A systematic review was performed to evaluate clinical studies that have examined hydration and supplementation strategies to prevent cisplatin-induced nephrotoxicity. MATERIALS AND METHODS PubMed and Excerpta Medica databases were searched from 1966 through October 2015 for clinical trials and other studies focused on hydration regimens to prevent nephrotoxicity in cancer patients treated with cisplatin. The University of Oxford Centre for Evidence-Based Medicine criteria were used to grade level of evidence. RESULTS Among the 1,407 identified studies, 24 were included in this systematic review. All studies differed on type, volume, and duration of hydration. Among the 24 studies, 5 evaluated short-duration hydration, 4 evaluated low-volume hydration, 4 investigated magnesium supplementation, and 7 reviewed forced diuresis with hydration. Short-duration and lower-volume hydration regimens are effective in preventing cisplatin-induced nephrotoxicity. Magnesium supplementation may have a role as a nephroprotectant, and forced diuresis may be appropriate in some patients receiving cisplatin. CONCLUSION Hydration is essential for all patients to prevent cisplatin-induced nephrotoxicity. Specifically, short-duration, low-volume, outpatient hydration with magnesium supplementation and mannitol forced diuresis (in select patients) represent best practice principles for the safe use of cisplatin. The Oncologist 2017;22:609-619 IMPLICATIONS FOR PRACTICE: The findings contained within this systematic review show that (a) hydration is essential for all patients to prevent cisplatin-induced nephrotoxicity, (b) short-duration, low-volume, outpatient hydration regimens appear to be safe and feasible, even in patients receiving intermediate- to high-dose cisplatin, (c) magnesium supplementation (8-16 milliequivalents) may limit cisplatin-induced nephrotoxicity, and (d) mannitol may be considered for high-dose cisplatin and/or patients with preexisting hypertension. These findings have broad implications for clinical practice and represent best practice principles for the prevention of cisplatin-induced nephrotoxicity.
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Affiliation(s)
- Daniel J Crona
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Department of Pharmacy, University of North Carolina Hospital and Clinics, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Aimee Faso
- Department of Pharmacy, University of North Carolina Hospital and Clinics, Chapel Hill, North Carolina, USA
| | - Tomohiro F Nishijima
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kathleen A McGraw
- Department of Library Sciences, Health Sciences Library, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew D Galsky
- Division of Hematology & Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew I Milowsky
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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11
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Muggia FM, Bonetti A, Hoeschele JD, Rozencweig M, Howell SB. Platinum Antitumor Complexes: 50 Years Since Barnett Rosenberg's Discovery. J Clin Oncol 2015; 33:4219-26. [PMID: 26503202 DOI: 10.1200/jco.2015.60.7481] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Franco M Muggia
- Franco M. Muggia, New York University School of Medicine, New York, NY; Andrea Bonetti, Mater Salutis Hospitaļ Legnago, Italy; James D. Hoeschele, Eastern Michigan University, Ypsilanti, MI; Marcel Rozencweig, Innate Pharma, Marseille, France; and Stephen B. Howell, University of California San Diego (UCSD) and Moores UCSD Cancer Center, La Jolla, CA.
| | - Andrea Bonetti
- Franco M. Muggia, New York University School of Medicine, New York, NY; Andrea Bonetti, Mater Salutis Hospitaļ Legnago, Italy; James D. Hoeschele, Eastern Michigan University, Ypsilanti, MI; Marcel Rozencweig, Innate Pharma, Marseille, France; and Stephen B. Howell, University of California San Diego (UCSD) and Moores UCSD Cancer Center, La Jolla, CA
| | - James D Hoeschele
- Franco M. Muggia, New York University School of Medicine, New York, NY; Andrea Bonetti, Mater Salutis Hospitaļ Legnago, Italy; James D. Hoeschele, Eastern Michigan University, Ypsilanti, MI; Marcel Rozencweig, Innate Pharma, Marseille, France; and Stephen B. Howell, University of California San Diego (UCSD) and Moores UCSD Cancer Center, La Jolla, CA
| | - Marcel Rozencweig
- Franco M. Muggia, New York University School of Medicine, New York, NY; Andrea Bonetti, Mater Salutis Hospitaļ Legnago, Italy; James D. Hoeschele, Eastern Michigan University, Ypsilanti, MI; Marcel Rozencweig, Innate Pharma, Marseille, France; and Stephen B. Howell, University of California San Diego (UCSD) and Moores UCSD Cancer Center, La Jolla, CA
| | - Stephen B Howell
- Franco M. Muggia, New York University School of Medicine, New York, NY; Andrea Bonetti, Mater Salutis Hospitaļ Legnago, Italy; James D. Hoeschele, Eastern Michigan University, Ypsilanti, MI; Marcel Rozencweig, Innate Pharma, Marseille, France; and Stephen B. Howell, University of California San Diego (UCSD) and Moores UCSD Cancer Center, La Jolla, CA
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Faienza MF, Delvecchio M, Giordano P, Cavallo L, Grano M, Brunetti G, Ventura A. Metabolic syndrome in childhood leukemia survivors: a meta-analysis. Endocrine 2015; 49:353-60. [PMID: 25154516 DOI: 10.1007/s12020-014-0395-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/12/2014] [Indexed: 01/05/2023]
Abstract
A significant number of long-term complications have been described in childhood leukemia survivors. In particular, these patients may present features of metabolic syndrome (MetS), and therefore increased risk for cardiovascular diseases. The aim of this meta-analysis is to evaluate the prevalence and the risk of MetS in survivors of childhood leukemia. Two authors independently performed a systematic literature search in PubMed and EMBASE to March 2014, reviewed and selected articles, based on pre-determined selection criteria. Twelve articles, comprising 2,337 participants (1,462 cases and 875 controls), were included in the meta-analysis. Only three of them were case-control studies eligible for the meta-analysis. The childhood leukemia survivors showed an increased risk of MetS as compared to healthy controls (OR = 4.36; 95 % CI 1.19-16.22). The risk was significantly increased only in patients treated with chemotherapy and radiotherapy (OR = 7.79; 95 % CI 1.27-47.77), and not in patients treated with only chemotherapy (OR = 2.35; 95 % CI 0.40-13.78). Childhood leukemia survivors, in particular if treated also with radiotherapy, are prone to develop MetS more than healthy controls. Monitoring of MetS components in these patients is necessary to avoid cardiovascular consequences later in life.
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Affiliation(s)
- Maria Felicia Faienza
- Department of Biomedical Sciences and Human Oncology, Pediatrics Unit, University of Bari 'A. Moro', Piazza G. Cesare, 11, 70124, Bari, Italy,
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13
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Lin YJ, Cheng FC, Chien LS, Lin JC, Jiang RS, Liu SA. Expression of magnesium transporter genes in head and neck cancer patients underwent neoadjuvant cisplatin-based chemotherapy. Eur Arch Otorhinolaryngol 2015; 272:3051-7. [PMID: 25726166 DOI: 10.1007/s00405-015-3563-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 02/14/2015] [Indexed: 11/29/2022]
Abstract
We aimed to investigate expression of magnesium transporter genes in patients with head and neck cancer who underwent cisplatin-based neoadjuvant chemotherapy and their association with serum magnesium level. Head and neck cancer patients scheduled to undergo neoadjuvant cisplatin-based chemotherapy were eligible for enrollment. Blood samples were obtained at three time points: prior to, during, and after completion of chemotherapy. Expression levels of magnesium transporter genes were determined by quantitative real-time PCR. A total of 23 patients were included in the final analysis. The average serum magnesium levels dropped 6.98 and 5.20% during and after completion of chemotherapy. There were neither significant associations between serum magnesium level and demographic variables nor tumor-related variables. SLC41A1 expression level was positively correlated with serum magnesium whereas TRPM6 expression level was negatively correlated with serum magnesium. Serum magnesium level decreased during cisplatin-based chemotherapy in head and neck cancer patients. Further studies are warranted to investigate optimal magnesium measurement and substitution protocol.
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Affiliation(s)
- Yu-Jung Lin
- Department of Otolaryngology, Taichung Veterans General Hospital, No. 1650, Sec 4, Taiwan Boulevard, Taichung, Taiwan
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14
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Li C, Liu P, Liu L, Zhang X, Yang P, Sheng H, Bu L, Li H, Qu S. Metabolic syndrome in hematologic malignancies survivors: a meta-analysis. Med Oncol 2014; 32:422. [DOI: 10.1007/s12032-014-0422-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 11/27/2014] [Indexed: 12/26/2022]
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De las Peñas R, Escobar Y, Henao F, Blasco A, Rodríguez CA. SEOM guidelines on hydroelectrolytic disorders. Clin Transl Oncol 2014; 16:1051-9. [PMID: 25304221 PMCID: PMC4239780 DOI: 10.1007/s12094-014-1234-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 09/20/2014] [Indexed: 11/25/2022]
Abstract
Hydroelectrolytic disorders are one of the most common metabolic complications in cancer patients. Although often metabolic alterations affecting various ions are part of the manifestations of the oncological disease, even in the form of paraneoplastic syndrome, we must not forget that very often, these disorders could be caused by various drugs, including some of the antineoplastic agents most frequently used, such as platin derivatives or some biologics. These guidelines review major management of diagnosis, evaluation and treatment of the most common alterations of sodium, calcium, magnesium and potassium in cancer patients. Aside from life-sustaining treatments, we have reviewed the role of specific drug treatments aimed at correcting some of these disorders, such as intravenous bisphosphonates for hypercalcemia or V2 receptor antagonists in the management of syndrome of inappropriate antidiuretic hormone secretion-related hyponatremia.
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Affiliation(s)
- R. De las Peñas
- Consorcio Hospitalario Provincial de Castellón, Castellón, Spain
| | - Y. Escobar
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - F. Henao
- Hospital Universitario Virgen de la Macarena, Sevilla, Spain
| | - A. Blasco
- Hospital General Universitario de Valencia, Valencia, Spain
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Jung HS, Myung SK, Kim BS, Seo HG. Metabolic syndrome in adult cancer survivors: a meta-analysis. Diabetes Res Clin Pract 2012; 95:275-82. [PMID: 22078073 DOI: 10.1016/j.diabres.2011.08.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 08/04/2011] [Accepted: 08/08/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cross-sectional studies have reported inconsistent findings on whether the risk of metabolic syndrome is high among cancer survivors. We conducted a meta-analysis of cross-sectional studies. METHODS We searched MEDLINE (PubMed) and EMBASE in April 2010. Two evaluators independently reviewed and selected articles, based on pre-determined selection criteria. RESULTS Out of 257 articles meeting our initial criteria, 9 cross-sectional studies, which involved 6763 participants (1762 cases and 5001 controls) were included in the final analysis. Compared with the healthy control groups, the cancer survivors were at an increased risk of metabolic syndrome, in the random-effects meta-analysis of all 9 cross-sectional studies (OR=1.84; 95% CI=1.14-2.97; I(2)=80.5). In the subgroup meta-analysis by cancer type, a significant positive association was observed for hematologic malignancies, including ALL (acute lymphoblastic leukemia), AML (acute myelogenous leukemia), NHL (non-Hodgkin's lymphoma), and CML (chronic myelogenous leukemia) (OR=1.94; 95% CI=1.06-3.55; I(2)=68.1%), whereas no significant association was found for non-hematologic malignancies, including testicular tumor, prostate cancer, sarcoma, and epithelial ovarian cancer. CONCLUSIONS Our meta-analyses of cross-sectional studies found that adult cancer survivors with hematologic malignancies were at an increased risk of metabolic syndrome.
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Affiliation(s)
- Hyun-Suk Jung
- Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea
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17
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Travis LB, Beard C, Allan JM, Dahl AA, Feldman DR, Oldenburg J, Daugaard G, Kelly JL, Dolan ME, Hannigan R, Constine LS, Oeffinger KC, Okunieff P, Armstrong G, Wiljer D, Miller RC, Gietema JA, van Leeuwen FE, Williams JP, Nichols CR, Einhorn LH, Fossa SD. Testicular cancer survivorship: research strategies and recommendations. J Natl Cancer Inst 2010; 102:1114-30. [PMID: 20585105 DOI: 10.1093/jnci/djq216] [Citation(s) in RCA: 230] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Testicular cancer represents the most curable solid tumor, with a 10-year survival rate of more than 95%. Given the young average age at diagnosis, it is estimated that effective treatment approaches, in particular, platinum-based chemotherapy, have resulted in an average gain of several decades of life. This success, however, is offset by the emergence of considerable long-term morbidity, including second malignant neoplasms, cardiovascular disease, neurotoxicity, nephrotoxicity, pulmonary toxicity, hypogonadism, decreased fertility, and psychosocial problems. Data on underlying genetic or molecular factors that might identify those patients at highest risk for late sequelae are sparse. Genome-wide association studies and other translational molecular approaches now provide opportunities to identify testicular cancer survivors at greatest risk for therapy-related complications to develop evidence-based long-term follow-up guidelines and interventional strategies. We review research priorities identified during an international workshop devoted to testicular cancer survivors. Recommendations include 1) institution of lifelong follow-up of testicular cancer survivors within a large cohort setting to ascertain risks of emerging toxicities and the evolution of known late sequelae, 2) development of comprehensive risk prediction models that include treatment factors and genetic modifiers of late sequelae, 3) elucidation of the effect(s) of decades-long exposure to low serum levels of platinum, 4) assessment of the overall burden of medical and psychosocial morbidity, and 5) the eventual formulation of evidence-based long-term follow-up guidelines and interventions. Just as testicular cancer once served as the paradigm of a curable malignancy, comprehensive follow-up studies of testicular cancer survivors can pioneer new methodologies in survivorship research for all adult-onset cancer.
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Affiliation(s)
- Lois B Travis
- Department of Radiation Oncology, James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY 14642, USA.
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19
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Greystoke AP, Jodrell DI, Cheung M, Rivans I, Mackean MJ. How many cisplatin administration protocols does your department use? Eur J Cancer Care (Engl) 2009; 19:80-90. [PMID: 19708939 DOI: 10.1111/j.1365-2354.2007.00908.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The introduction, 30 years ago, of the co-administration of appropriate hydration and ensuring a diuresis occurs during the administration of cisplatin was important in its development, allowing clinically significant doses to be given with acceptable rates of toxicity. The clinical usage of cisplatin has increased and hydration protocols have been amended to increase patient comfort and reduce resource utilization. We suspected that this had led to unnecessary variations in practice both in clinical trials and subsequently in the clinic. Therefore, we reviewed practice in the Edinburgh Cancer Centre and discovered that 25 different hydration protocols were in use, with wide variation in dilution of cisplatin, total fluid administered, use of electrolyte (potassium and magnesium) supplementation and diuretics. These differences are a reflection of adoption of variations in hydration regimes published in pivotal clinical trials. A review of the available evidence relating to cisplatin associated hydration regimens was performed and recommendations will be made for the future design of evidence-based protocols.
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Affiliation(s)
- A P Greystoke
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, UK
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Bashir H, Crom D, Metzger M, Mulcahey J, Jones D, Hudson MM. Cisplatin-induced hypomagnesemia and cardiac dysrhythmia. Pediatr Blood Cancer 2007; 49:867-9. [PMID: 16619211 DOI: 10.1002/pbc.20804] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We describe a case of a patient with cisplatin-induced hypomagnesemia who suffered brief asystole during an episode of gastroenteritis. Structural heart disease was excluded. The patient achieved complete clinical recovery after short-term administration of intravenous magnesium supplementation. Cisplatin should be considered a cause of hypomagnesemic-related cardiac dysrhythmia. Magnesium deficit may increase myocardial electrical instability and thus, the risk of life-threatening arrhythmias and sudden death. Long-term serum electrolyte measurement and appropriate replacement of magnesium are recommended.
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Affiliation(s)
- Hamid Bashir
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, USA
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Kaufman MR, Chang SS. Short- and long-term complications of therapy for testicular cancer. Urol Clin North Am 2007; 34:259-68; abstract xi. [PMID: 17484931 DOI: 10.1016/j.ucl.2007.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We review the treatments used for testicular cancer and the complications associated with each modality of therapy. It is imperative the clinician recognize possible treatment-related morbidity when counseling and monitoring testicular cancer patients.
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Affiliation(s)
- Melissa R Kaufman
- Vanderbilt University, Department of Urologic Surgery, A-1302 Medical Center North, Nashville, TN 37232, USA
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Lanvers-Kaminsky C, Krefeld B, Dinnesen AG, Deuster D, Seifert E, Würthwein G, Jaehde U, Pieck AC, Boos J. Continuous or repeated prolonged cisplatin infusions in children: a prospective study on ototoxicity, platinum concentrations, and standard serum parameters. Pediatr Blood Cancer 2006; 47:183-93. [PMID: 16302218 DOI: 10.1002/pbc.20673] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND To overcome the ototoxicity of cisplatin, single bolus infusions were replaced by repeated prolonged infusions of lower doses or by continuous infusions at still lower infusion rates. However, considering ototoxicity little is, in fact, known about the tolerance of repeated prolonged or continuous infusion in children. PROCEDURE Auditory function was monitored along with plasma concentrations of free and total platinum (Pt), and with standard serum parameters (sodium, potassium, calcium, magnesium, phosphate, chloride, and creatinine) in 24 children receiving cisplatin by continuous infusion for the treatment of neuroblastoma and osteosarcoma or by repeated 1 or 6 hr infusions for the treatment of germ cell tumors. RESULTS Hearing deteriorated in 10/15 osteosarcoma patients, 2/3 neuroblastoma patients, and 1/6 patients with germ cell tumors. Ototoxicity occurred after cumulative doses between 120 and 360 mg/m(2) cisplatin. In osteosarcoma patients, ototoxicity was associated with a comparatively higher mean plasma concentration of free Pt. However, Pt plasma concentrations did not discriminate between patients with or without ototoxicity. In patients experiencing ototoxicity serum creatinine increased by 45% compared to pre-treatment levels (mean). Serum creatinine increased by 26% in patients without ototoxicity (P < 0.05, Mann-Whitney Rank sum test). Despite standardized hydration, discrete but significant changes of potassium, sodium, magnesium, and phosphate were observed during and/or after cisplatin infusion, which, however, did not discriminate between patients with and without ototoxicity. CONCLUSIONS While continuous cisplatin infusions are less nephrotoxic than repeated prolonged infusions, we observed considerable ototoxicity in patients treated with continuous cisplatin infusions, which necessitates further evaluations on the tolerance of continuous cisplatin infusions in children.
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Affiliation(s)
- C Lanvers-Kaminsky
- Department of Paediatric Haematology and Oncology, University Children's Hospital, Albert-Schweitzer Street 33, Muenster, Germany.
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Duke AM, Hopkins PM, Halsall PJ, Steele DS. Mg2+ dependence of Ca2+ release from the sarcoplasmic reticulum induced by sevoflurane or halothane in skeletal muscle from humans susceptible to malignant hyperthermia. Br J Anaesth 2006; 97:320-8. [PMID: 16849381 DOI: 10.1093/bja/ael179] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In normal resting muscle, cytosolic Mg(2+) exerts a potent inhibitory influence on the sarcoplasmic reticulum (SR) Ca(2+) release channel (ryanodine receptor, RyR1). Impaired Mg(2+)-regulation of RyR1 has been proposed as a causal factor in malignant hyperthermia (MH). The aim of this study was to compare the effects of cytosolic Mg(2+) on SR Ca(2+) release induced by halothane or sevoflurane in normal (MHN) and MH susceptible (MHS) human skeletal muscle fibres. METHODS Samples of vastus medialis muscle were obtained from patients under investigation for MH susceptibility. Single fibres were mechanically skinned and perfused with solutions mimicking the intracellular milieu. Changes in [Ca(2+)](i) were detected using fura-2 fluorescence after application of equimolar halothane or sevoflurane. RESULTS In MHN fibres, concentrations of sevoflurane or halothane as high as 10 mM typically failed to induce SR Ca(2+) release at physiological free [Mg(2+)] (1 mM). However, when [Mg(2+)] was decreased to 0.4 mM, SR Ca(2+) release occurred in 51% (16/33) and 6% (2/33) of MHN fibres after the addition of 1 mM halothane or 1 mM sevoflurane, respectively. Further decreases in [Mg(2+)] increased the proportion of responsive fibres. In the presence of 0.1 mM [Mg(2+)], Ca(2+) release occurred in all fibres (33/33) after the introduction of 1 mM halothane or 1 mM sevoflurane. In MHS fibres, 1 mM halothane or 1 mM sevoflurane-induced Ca(2+) release in 54% (7/13) or 15% (2/13) of fibres, respectively, at 1 mM Mg(2+). A decrease in [Mg(2+)] to 0.2 mM Mg(2+) was sufficient to render 100% of MHS fibres (13/13) responsive to 1 mM halothane or 1 mM sevoflurane. CONCLUSIONS In both MHS and MHN fibres (i) halothane is a more potent activator of SR Ca(2+) release than sevoflurane and (ii) as with halothane, the efficacy of sevoflurane-induced SR Ca(2+) release exhibits a marked dependence on cytosolic [Mg(2+)]. The marked potentiation of SR Ca(2+) release after a moderate reduction in cytosolic [Mg(2+)] suggests that conditions which cause hypomagnesaemia will increase the probability and possibly severity of an MH event. Conversely, maintenance of a normal or slightly increased cytosolic [Mg(2+)] may reduce the probability of MH.
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Affiliation(s)
- A M Duke
- Institute of Membrane and Systems Biology, University of Leeds Woodhouse Lane, Leeds LS2 9JT, UK
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Steele DS, Duke AM. Defective Mg2+ regulation of RyR1 as a causal factor in malignant hyperthermia. Arch Biochem Biophys 2006; 458:57-64. [PMID: 16620769 DOI: 10.1016/j.abb.2006.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Revised: 03/01/2006] [Accepted: 03/02/2006] [Indexed: 11/27/2022]
Abstract
In skeletal muscle, Mg(2+) exerts a dual inhibitory effect on RyR1, by competing with Ca(2+) at the activation site and binding to a low affinity Ca(2+)/Mg(2+) inhibitory site. Pharmacological activators of RyR1 must overcome the inhibitory action of Mg(2+) before Ca(2+) efflux can occur. In normal muscle, where the free [Mg(2+)](i) is approximately 1mM, even prolonged exposure to millimolar levels of volatile anesthetics does not initiate SR Ca(2+) release. However, when the cytosolic [Mg(2+)] is reduced below the physiological range, low levels of volatile anesthetic within the clinically relevant range (1mM) can initiate SR Ca(2+) release, in the form of a propagating Ca(2+) wave. In human muscle fibers from malignant hyperthermia susceptible patients, such Ca(2+) waves occur when 1mM halothane is applied at physiological [Mg(2+)](i). There is increasing evidence to suggest that defective Mg(2+) regulation of RyR1 confers susceptibility to malignant hyperthermia. At the molecular level, interactions between critical RyR1 subdomains may explain the clustering of RyR1 mutations and associated effects on Mg(2+) regulation.
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Affiliation(s)
- Derek S Steele
- Institute of Membrane and Systems Biology, University of Leeds, Leeds LS29JT, UK.
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Lajer H, Kristensen M, Hansen HH, Nielsen S, Frøkiaer J, Ostergaard LF, Christensen S, Daugaard G, Jonassen TEN. Magnesium depletion enhances cisplatin-induced nephrotoxicity. Cancer Chemother Pharmacol 2005; 56:535-42. [PMID: 15947931 DOI: 10.1007/s00280-005-1010-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2004] [Accepted: 01/07/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Nephrotoxicity and magnesium (Mg)-depletion are well-known side effects to cisplatin (CP) treatment. The purpose of this present study was to investigate the role of Mg on CP induced changes in renal function. CP induced renal dysfunction was achieved by treatment with CP or vehicle (2.5 mg/kg) once weekly for 3 weeks. Since the CP-induced renal damage, including tubular reabsorption defects, is most prominent within the outer medulla (OM), changes in the expression pattern of OM aquaporins and sodium transporters including the Na,K-ATPase (alpha-subunit), type III Na,H-exchanger (NHE3), aquaporin 1 (AQP1) and 2 (AQP2) and the Na,K,2Cl-cotransporter (NKCC2) were investigated by semi-quantitative Western blotting. EXPERIMENTAL DESIGN Rats had access to either a diet with standard Mg or to a Mg-depleted diet. Cisplatin was administered to female Wistar rats once a week for 3 weeks according to four regimens: (1) Cisplatin 2.5 mg/kg body weight i.p., to rats on a diet with standard Mg, (2) Cisplatin 2.5 mg/kg body weight i.p., to rats on a diet with low Mg, (3) Isotonic NaCl 2.5 ml/kg body weight i.p., to rats on a diet with standard Mg, (4) Isotonic NaCl 2.5 ml/kg body weight i.p., to rats on a diet with low Mg. RESULTS CP had no effect on plasma creatinine or urea in rats with standard Mg intake, but the expression of all five transporters was significantly reduced when compared to vehicle treated rats on standard Mg-intake. Vehicle treated rats on low Mg-intake had a significant reduction in the expression of Na,K-ATPase, NHE3 and NKCC2, but unchanged expression levels of AQP1 or AQP2 when compared to standard treated controls. Forty percent of the CP-treated rats on low Mg-intake died during the experiment and the remaining animals had marked increased plasma creatinine and urea. Furthermore, the Western blot analysis revealed an almost complete disappearance of all four transporters, suggesting a dramatic synergistic effect of CP and Mg-depletion on renal function including the expression pattern of outer medullary sodium transporters and aquaporins. CONCLUSIONS This study indicates a substantial additive effect of Mg-depletion on cisplatin induced renal toxicity as evidenced by significant changes in plasma creatinine and urea, renal failure induced mortality and loss of renal transporters. This should give cause for concern since the nephrotoxicity observed during cisplatin treatment might be substantiated by the known Mg-loss associated with cisplatin treatment especially in patients suffering from intense gastro-intestinal side effects.
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Affiliation(s)
- H Lajer
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Denmark.
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Infusionstherapie und Ernährung von Risikogruppen. INFUSIONSTHERAPIE UND DIÄTETIK IN DER PÄDIATRIE 2005. [PMCID: PMC7136897 DOI: 10.1007/3-540-27897-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Besondere Situationen erfordern ein besonderes Vorgehen. Während bisher das »Standardvorgehen« bezüglich der Ernährung von pädiatrischen Patienten dargestellt wurde, beschäftigt sich das vorliegende Kapitel mit »Sondersituationen« der pädiatrischen Infusionstherapie und Ernährung. Behandlungssituationen, die ein besonderes Vorgehen bei der Therapie oder spezielle Aufmerksamkeit bei der Anpassung der Ernährung erfordern, entstehen in der Regel durch 4 mögliche Situationen:
spezifische Physiologie von Patientengruppen (z. B. Früh- oder Neugeborene), Auswirkungen von therapeutischen Maßnahmen (z. B. Operationen), Pathophysiologie von Erkrankungen (z. B. angeborene Stoffwechselerkrankungen, Erkrankungen des onkologischen, rheumatischen oder atopischen Formenkreises, Anorexia nervosa, Bulimie oder Adipositas) oder besondere körperliche Belastungen [z. B. (Leistungs-)Sport].
Bekannte Strategien werden systematisch und prägnant dargestellt und diskutiert. Die Beschäftigung mit der Ernährung von »Risikogruppen« übt das Erkennen und den Umgang von potenziellen Gefahrensituationen bei der Verordnung von bilanzierter Ernährung. So sollte auch derjenige von dem Kapitel profitieren, der sich mit den behandelten Patientengruppen, Situationen, Erkrankungen üblicherweise nicht beschäftigen muss.
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Lajer H, Kristensen M, Hansen HH, Christensen S, Jonassen T, Daugaard G. Magnesium and potassium homeostasis during cisplatin treatment. Cancer Chemother Pharmacol 2004; 55:231-6. [PMID: 15619138 DOI: 10.1007/s00280-004-0899-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2004] [Accepted: 07/19/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE Administration of cisplatin causes changes in magnesium and potassium metabolism. The purpose of this study was to investigate day-to-day changes in renal and intestinal homeostasis of magnesium (Mg) and potassium (K) during repeated cisplatin treatments in rats to provide guidelines for human supplementation studies. EXPERIMENTAL DESIGN Rats were housed in metabolic cages with access to a diet containing excess Mg and K. Treatment was administered once a week for 3 weeks and comprised either cisplatin 2.5 mg/kg body weight i.p or, as sham treatment, isotonic NaCl 2.5 ml/kg body weight i.p. Urine and feces were collected every 24 h. Blood samples for measurement of plasma Mg and K were obtained from a permanent arterial catheter prior to each treatment cycle and at the termination of the study. RESULTS Cisplatin exerted a significant negative effect on total Mg balance. This effect was cumulative with repeated doses of cisplatin. The observed difference was mainly due to the difference in Mg balance between the treatment day and the following 2-3 days. The cumulated urinary excretion of Mg did not differ significantly between the two groups at the end of follow-up. A significant decrease was observed in cumulated intestinal absorption in treated rats compared to control rats at the end of follow-up. Lowered intestinal absorption accounted for 90% of the difference in total Mg balance between the two groups as compared to the renal loss. Cisplatin treatment also exerted a negative effect on total K balance, although the difference between cisplatin-treated and control rats was not significant at the end of follow-up. CONCLUSIONS The Mg loss associated with cisplatin treatment was mainly the result of lowered intestinal absorption and not, as presently thought, the result of increased renal elimination. Instead, an increased renal reabsorption capacity was observed in response to decreased intestinal absorption. The study further showed that Mg and K metabolism are subject to predictable changes in intestinal absorption and renal excretion with each cisplatin treatment, and that knowledge of these changes can be used in planning supplementation. Thus, the experimental observations support intravenous supplementation on the day of treatment and 2-3 days after treatment followed by oral supplementation until the next treatment.
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Affiliation(s)
- H Lajer
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
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Kjeldsen K. Myocardial Na,K-ATPase: Clinical aspects. Exp Clin Cardiol 2003; 8:131-133. [PMID: 19641704 PMCID: PMC2716273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The specific binding of digitalis glycosides to Na,K-ATPase is used as a tool for Na,K-ATPase quantification with high accuracy and precision. In myocardial biopsies from patients with heart failure, total Na,K-ATPase concentration is decreased by around 40%; a correlation exists between a decrease in heart function and a decrease in Na,K-ATPase concentration. During digitalization, around 30% of remaining pumps are occupied by digoxin. Myocardial Na,K-ATPase is also influenced by other drugs used for the treatment of heart failure. Thus, potassium loss during diuretic therapy has been found to reduce myocardial Na,K-ATPase, whereas angiotensin-converting enzyme inhibitors may stimulate Na,K pump activity. Furthermore, hyperaldosteronism induced by heart failure has been found to decrease Na,K-ATPase activity. Accordingly, treatment with the aldosterone antagonist, spironolactone, may also influence Na,K-ATPase activity. The importance of Na,K pump modulation with heart disease, inhibition in digitalization and other effects of medication should be considered in the context of sodium, potassium and calcium regulation. It is recommended that digoxin be administered to heart failure patients who, after institution of mortality-reducing therapy, still have heart failure symptoms, and that the therapy be continued if symptoms are revealed or reduced. Digitalis glycosides are the only safe inotropic drugs for oral use that improve hemodynamics in heart failure.An important aspect of myocardial Na,K pump affection in heart disease is its influence on extracellular potassium (K(e)) homeostasis. Two important aspects should be considered: potassium handling among myocytes, and effects of potassium entering the extracellular space of the heart via the bloodstream. It should be noted that both of these aspects of K(e) homeostasis are affected by regulatory aspects, eg, regulation of the Na,K pump by physiological and pathophysiological conditions, as well as by medical treatments. Digitalization has been shown to affect both parameters. Furthermore, in experimental animals, potassium loading and depletion are found to significantly affect K(e) handling. The effects of potassium depletion are of special interest because this condition often occurs in patients treated with diuretics. In human congenital long QT syndrome caused by mutations in genes coding for potassium channels, exercise and potassium depletion are well known for their potential to elicit arrhythmias and sudden death. There is a need for further evaluation of the dynamic aspects of potassium handling in the heart, as well as in the periphery. It is recommended that resting plasma potassium be maintained at around 4 mmol/L.
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Affiliation(s)
- Keld Kjeldsen
- Correspondence: Keld Kjeldsen, Medical Department B 2142, The Heart Centre, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark. Telephone 45-35452628, fax 45-35452648, e-mail
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