Pediatric emergency medicine trisk 2740 2740
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multifactorial and may relate to chemotherapy, transfusion, or subclinical liver
injury. Unexpected moderate or severe hyperbilirubinemia should be fully assessed.
Diarrhea in an oncology patient may be triggered by a variety of causes including
radiation injury, chemotherapy, and C. difficile colitis due to prolonged
hospitalizations and/or use of broad-spectrum antibiotics.
Venoocclusive disease (VOD) of the liver is a rare but important complication to
recognize. Risk factors include exposure to actinomycin-D chemotherapy and liver
radiation. Manifestations include hepatomegaly, transaminitis, thrombocytopenia,
and ascites. The thrombocytopenia is frequently more than what would be expected
from the chemotherapy alone or may occur at the wrong timing relative to
chemotherapy. Once the diagnosis is suspected, a hepatic ultrasound with Doppler
assessment of hepatic vein flow should be performed. Reversal of flow in the small
hepatic veins establishes the diagnosis in the appropriate clinical setting.
Management is supportive until the problem resolves on its own. Most patients will
require admission for both observation and support.
For a discussion of typhlitis, see section on “Infectious Complications of Cancer
Treatment.”
RENAL COMPLICATIONS OF CANCER THERAPY
Renal injury from cancer treatment is very common and some degree of renal
dysfunction is frequently present even in patients with normal creatinine for age.
Other patients will have documented renal dysfunction based on elevated creatinine,
decreased glomerular filtration rate (GFR), or decreased 24-hour creatinine
clearance. Renal complications may also lead to metabolic disturbances (see
“Metabolic Complications of Cancer Treatment” section).
Uric-acid nephropathy can occur in patients with very high cell turnover (see
“Leukemia” section). Drug-induced renal injury is common in oncology patients (
Table 98.8 ). Radiation injury to the kidney may cause renal insufficiency as well as
radiation nephritis, 3 to 6 months after treatment. Typical findings include the
manifestations of vasculitis with hemolytic uremic syndrome (HUS).
Oncology patients are also at risk for medical renal disease associated with poor
perfusion, exposure to multiple nephrotoxic agents, and hypertension.
Since renal injury is common, it is appropriate to check BUN, creatinine,
electrolytes, calcium, magnesium, and phosphate in all ill oncology patients. If
significant abnormalities are noted, the oncology-specific history should be
reviewed to determine specific risk factors or exposures that may help explain the
problem. In general, the management of significant abnormalities is not unique in
patients with cancer and should follow the guidelines in Chapter 100 Renal and
Electrolyte Emergencies . Consider the possibility of a decreased GFR (whether
