Electrolytic Abnormalities Related to Phosphate in Critically Ill Cancer Patients

  • Agamenón Quintero
  • Jorge RacedoEmail author
  • Roger de Jesús Durante Flórez
Reference work entry


Phosphate plays a critical role in physiological processes such as mitochondrial respiration, cellular metabolism, and energy production (glycolysis, gluconeogenesis, and ammoniagenesis). It is also a significant constituent of cell membranes in the form of phospholipids. Hyperphosphatemia and hypophosphatemia are common electrolyte disorders in critically ill patients because of several factors. Both are associated with higher mortality in the ICU. However, most patients remain asymptomatic or do not receive an early management due to serum phosphate that is not routinely measured in ICU. Critically ill patients with cancer have a high risk of phosphate abnormalities because of chemotherapeutical drugs, surgery, tumor-related complications (tumor lysis syndrome), or comorbidities such as renal insufficiency, acid-base balance disorders, and intestinal malabsorption. Critical care physicians must be aware of potentially life-threatening complications due to phosphate abnormalities and identify the underlying etiology to make appropriate decisions. This chapter presents the diagnostic and therapeutic approach of hyperphosphatemia and hypophosphatemia in critically ill patients with cancer.


Hyperphosphatemia Hypophosphatemia Phosphate absorption Phosphate excretion Phosphate homeostasis Oncologic emergency Renal insufficiency Tumor lysis syndrome 


  1. 1.
    Amanzadeh J, Reilly RF. Hypophosphatemia: an evidence-based approach to its clinical consequences and management. Nat Clin Pract Nephrol. 2006;2(3):136–48. Scholar
  2. 2.
    Berman E, et al. Altered bone and mineral metabolism in patients receiving imatinib mesylate. N Engl J Med. 2006;354(19):2006–13. Scholar
  3. 3.
    Brandão LR, et al. Hematology and oncology in critical illness. In: Lucking SE, et al., editors. Pediatric critical care study guide: text and review. London: Springer; 2012. p. 801–50. Scholar
  4. 4.
    Broman M, Hansson F, Klarin B. Analysis of hypo- and hypermagnesemia in an intensive care unit cohort. Acta Anaesthesiol Scand. 2018;62(5):648–57. Scholar
  5. 5.
    Buysschaert M, et al. Pamidronate-induced tubulointerstitial nephritis with Fanconi syndrome in a patient with primary hyperparathyroidism. Nephrol Dial Transplant. 2003;18(4):826–9. Scholar
  6. 6.
    Camp MA, Allon M. Severe hypophosphatemia in hospitalized patients. Miner Electrolyte Metab. 1990;16(6):365–8. Scholar
  7. 7.
    Darmon M, et al. Tumour lysis syndrome and acute kidney injury in high-risk haematology patients in the rasburicase era. A prospective multicentre study from the Groupe de Recherche en Réanimation Respiratoire et Onco-Hématologique. Br J Haematol. 2013;162(4):489–97. Scholar
  8. 8.
    De Angelo DJ. Metabolic emergencies in oncology. In: Chang AE, et al., editors. Oncology: an evidence-based approach. New York: Springer; 2006. p. 1321–31. Scholar
  9. 9.
    Fizazi K, et al. Denosumab treatment of prostate cancer with bone metastases and increased urine N-telopeptide levels after therapy with intravenous bisphosphonates: results of a randomized phase II trial. J Urol. 2013;189(1):S51–8. Scholar
  10. 10.
    François H, et al. Partial fanconi syndrome induced by imatinib therapy: a novel cause of urinary phosphate loss. Am J Kidney Dis. 2008;51(2):298–301.CrossRefGoogle Scholar
  11. 11.
    Gaasbeek A, Meinders AE. Hypophosphatemia: an update on its etiology and treatment. Am J Med. 2005;118(10):1094–101. Scholar
  12. 12.
    Ganda K, Seibel MJ. Rapid biochemical response to denosumab in fibrous dysplasia of bone: report of two cases. Osteoporos Int. 2014;25(2):777–82.CrossRefGoogle Scholar
  13. 13.
    Geerse DA, et al. Treatment of hypophosphatemia in the intensive care unit: a review. Crit Care. 2010;14(4):R147. Scholar
  14. 14.
    Glezerman IG, Kewalramani T, Jhaveri K. Reversible Fanconi syndrome due to lenalidomide. NDT Plus. 2008;1(4):215–7.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Hariri A, Mount DB, Rastegar A. Disorders of calcium, phosphate, and magnesium metabolism. In: Mount DB, Sayegh MH, Singh AK, editors. Core concepts in the disorders of fluid, electrolytes and acid-base balance. Boston: Springer US; 2013. p. 103–46. Scholar
  16. 16.
    Hoffmann M, et al. Hypophosphataemia at a large academic hospital in South Africa. J Clin Pathol. 2008;61(10):1104–7. Scholar
  17. 17.
    Imel EA, Econs MJ. Approach to the hypophosphatemic patient. J Clin Endocrinol Metab. 2012;97(3):696–706. Scholar
  18. 18.
    Izzedine H, et al. Drug-induced Fanconi’s syndrome. Am J Kidney Dis. 2003;41(2):292–309.CrossRefGoogle Scholar
  19. 19.
    Ketteler M, et al. Executive summary of the 2017 KDIGO chronic kidney disease-mineral and bone disorder (CKD-MBD) guideline update: what’s changed and why it matters. Kidney Int. 2017;92(1):26–36.CrossRefGoogle Scholar
  20. 20.
    Lacy MQ, Gertz MA. Acquired Fanconi’s syndrome associated with monoclonal gammopathies. Hematol Oncol Clin North Am. 1999;13(6):1273–80. Scholar
  21. 21.
    Latcha S. Electrolyte disorders in cancer patients. In: Jhaveri KD, Salahudeen AK, editors. Onconephrology: cancer, chemotherapy and the kidney. New York: Springer; 2015. p. 131–62. Scholar
  22. 22.
    Levin A, et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease. Kidney Int. 2007;71(1):31–8. Scholar
  23. 23.
    Marinella MA. Refeeding syndrome: an important aspect of supportive oncology. J Support Oncol. n.d.;7(1):11–6.
  24. 24.
    Miller CJ, et al. Impact of serum phosphate in mechanically ventilated patients with severe Sepsis and septic shock. J Intensive Care Med. 2018.
  25. 25.
    Nácul FE, Vieira JM. Disorders of electrolytes. In: O’Donnell JM, Nácul FE, editors. Surgical intensive care medicine. Cham: Springer; 2016. p. 539–51. Scholar
  26. 26.
    Reddi AS. Disorders of phosphate: hyperphosphatemia. In: Fluid, electrolyte and acid-base disorders: clinical evaluation and management. New York: Springer; 2014a. p. 253–63. Scholar
  27. 27.
    Reddi AS. Disorders of phosphate: hypophosphatemia. In: Fluid, electrolyte and acid-base disorders: clinical evaluation and management. New York: Springer; 2014b. p. 239–52. Scholar
  28. 28.
    Reddi AS. Disorders of phosphate: physiology. In: Fluid, electrolyte and acid-base disorders: clinical evaluation and management. New York: Springer; 2014c. p. 233–8. Scholar
  29. 29.
    Rosner MH, Dalkin AC. Electrolyte disorders associated with cancer. Adv Chronic Kidney Dis. 2014;21(1):7–17. Accessed 26 June 2018CrossRefGoogle Scholar
  30. 30.
    Rosner MH, Capasso G, Perazella MA. Acute kidney injury and electrolyte disorders in the critically ill patient with cancer. Curr Opin Crit Care. 2017;23(6):475–83.CrossRefGoogle Scholar
  31. 31.
    Rostom AY, et al. Tumor lysis syndrome following hemi-body irradiation for metastatic breast cancer. Ann Oncol. 2000;11(10):1349–51. Scholar
  32. 32.
    Tanvetyanon T, Stiff PJ. Management of the adverse effects associated with intravenous bisphosphonates. Ann Oncol. 2006;17(6):897–907.CrossRefGoogle Scholar
  33. 33.
    Tucker JK, Thornley-Brown D. Disorders of calcium, phosphorus, and magnesium. In: Lerma EV, Rosner M, editors. Clinical decisions in nephrology, hypertension and kidney transplantation. New York: Springer; 2013. p. 103–16. Scholar
  34. 34.
    Umeda M, et al. Prognostic significance of the serum phosphorus level and its relationship with other prognostic factors in multiple myeloma. Ann Hematol. 2006;85(7):469–73. Scholar
  35. 35.
    Varon J. Critical care oncology. In: Handbook of critical and intensive care medicine. Cham: Springer; 2016. p. 243–62. Scholar
  36. 36.
    Varon J, Acosta P. Renal and fluid – electrolyte disorders. In: Handbook of critical and intensive care medicine. New York: Springer; 2010. p. 297–333. Scholar
  37. 37.
    Ye Z, et al. Postoperative hyperphosphatemia significantly associates with adverse survival in colorectal cancer patients. J Gastroenterol Hepatol. 2013;28(9):1469–75. Scholar
  38. 38.
    Yeung S-CJ. Endocrine and metabolic emergencies. In: Todd KH, Thomas Jr CR, editors. Oncologic emergency medicine: principles and practice. Cham: Springer; 2016. p. 243–62. Scholar
  39. 39.
    Yoshida T, et al. Incidence of hypophosphatemia in advanced cancer patients: a recent report from a single institution. Int J Clin Oncol. 2017;22(2):244–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Agamenón Quintero
    • 1
  • Jorge Racedo
    • 1
    Email author
  • Roger de Jesús Durante Flórez
    • 1
  1. 1.Department of Critical Care MedicineInstituto Médico de Alta Tecnología IMAT OncomedicaMonteríaColombia

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