Nephrotoxicity is caused when chemotherapy damages the proximal tubule epithelial cells of the kidney leading to acute tubular necrosis (Naughton [170]). Many chemotherapy drugs are metabolized and excreted by the kidneys; others such as cisplatin are excreted unchanged (Camp‐Sorrell [27], Wilkes [268]). Tumour lysis syndrome (TLS) is a condition caused by high levels of potassium, phosphorus and uric acid being released into the bloodstream. TLS is an oncological emergency because of the life‐threatening complications of hypocalcaemia, hyperkalaemia, hyperuricaemia and hyperphosphataemia (Vioral [262]). Treatment includes hydration with 2–3 litres of sodium chloride or 5% dextrose to stimulate diuresis and administration of allopurinol. Rasburicase is recommended for patients who are at high risk of TLS; this drug can reduce uric acid levels within 4 hours (Polovich et al. [194]).

The dosage of chemotherapy drugs may be reduced in patients with pre‐existing renal disease or if there are signs of early renal toxicity during the chemotherapy treatment schedule (Wilkes [268]). The risk of renal toxicity in elderly patients is higher as they have a lower total body water and glomerular filtration rate (Wilkes [268]). Assessment of renal function should continue throughout chemotherapy treatment. The role of the nurse is pivotal in terms of managing fluid replacement and monitoring urinary output (Wilkes [268]).

Haemorrhagic cystitis is inflammation of the mucosal surface of the bladder and/or ureters with associated haematuria (Polovich et al. [194]). It can present as microscopic haematuria or frank bleeding requiring instillation of sclerosing agents (Wilkes [268]). The risk of haemorrhagic cystitis relates to acrolein, which is a liver metabolite of cyclophosphamide and ifosfamide. Acrolein binds to the bladder mucosa causing ulceration, inflammation, necrosis and haemorrhage. Early diagnosis is vital for bladder preservation. If therapy is not stopped, up to 55% of patients continue to experience persistent symptoms (Wilkes [268]). Protecting the bladder from the harmful effects of acrolein can be achieved by administering mesna. Haemorrhagic cystitis is associated with other chemotherapy agents including paclitaxel and gemcitabine. Bladder preservation focuses on hydration, frequent voiding, mesna administration and diuresis (Wilkes [268]).