Dialysis and other Treatments

In patients who have cancers that are likely to respond to therapy, but in whom acute or chronic renal failure is present, aggressive saline infusion is not possible. Further, other therapies such as bisphosphonates should be used with caution, if at all. In these circumstances, dialysis against a dialysate containing little or no calcium is a reasonable and highly effective option for selected patients [10]. There are no randomised control trials (RCTs) and only case reports [10] (Level 3).

The receptor activator of nuclear factor-KB ligand (RANKL) system is the molecular pathway that leads to osteoclast recruitment and differentiation and bone resorption in hypercalcaemia associated with cancer. Agents that interfere with the system, such as recombinant osteoprotegerin (a decoy receptor for RANKL) or monoclonal antibodies directed against RANKL, have been proposed as novel treatments for hypercalcaemia associated with malignant disease, as have monoclonal antibodies, which neutralise PTH-rP [10].

A number of randomised clinical trials comparing bisphosphonates to saline and diuretics alone and to other antiresorptive agents such as calcitonin have confirmed the superiority of bisphosphonates [16,17] (Level 1B).