Cisplatin is a coordinate metal complex with significant antineoplastic activity and various effects, including acute anc chronic renal insufficiency and renal magnesium wasting. Nephrotoxicity may occur in as many as 50% to 75% of patients receiving the drug, and is apparently due to renal tubular injury. Although controlled, prospective clinical trials are lacking, the available data indicate that the frequency and severity of cisplatin nephrotoxicity may be reduced by slow infusion rates; hydration before, during, and immediately after administration of cisplatin; and concomitant administration of mannitol. Preliminary animal studies indicate that chloride-containing vehicles such as 0.9% sodium chloride may prevent the aquation or hydroxylation of cisplatin and reduce its toxicity. No information is available on th prevention of cisplatin associated renal magnesium wasting. However, frequent measurement of serum cations and appropriate replacement are recommended.

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To clarify the mechanisms involved in the stability of blood pressure during ultrafiltration (UF) alone versus regular dialysis, this study systematically examined the importance of changes in serum potassium, osmolality, and plasma norepinephrine during several dialysis maneuvers. Six stable, normotensive chronic dialysis patients were subjected to a uniform 2 to 3% decrease in body weight during the 2 hours of each dialysis maneuver. Supine to upright mean blood pressure (MBP) decreased (90 to 75 mm Hg, P less than 0.05), and three patients became symptomatic after weight loss during regular dialysis, but orthostatic blood pressure was stable (89 to 86 mm Hg, NS) and the patients were asymptomatic after UF and weight loss. Isokalemic regular dialysis did not afford hemodynamic stability, as orthostatic MBP declined (85 to 56 mm Hg, P less than 0.02), and four of the patients were again asymptomatic after standing. A continuous hypertonic mannitol (25%) infusion during the 2-hour dialysis, however, kept osmolality from decreasing and was associated with a stable orthostatic MBP (89 to 83 mm Hg, NS). A continuous infusion of isotonic mannitol (5%) given in a volume of five times that of the hypertonic mannitol failed to prevent orthostatic hypotension (80 to 60 mm Hg, P less than 0.005). Plasma norepinephrine concentrations were high in these patients and increased only modestly after weight loss. These results implicate constant plasma osmolality as a critical protective factor of blood pressure during UF and further demonstrate that changes in blood pressure may be associated from changes in both serum potassium and plasma norepinephrine concentration.

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