What fluids should be administered for tumor lysis syndrome?

Fluid Management for Tumor Lysis Syndrome

Aggressive intravenous hydration through a central venous access should be administered to all patients with clinical tumor lysis syndrome (TLS), with the goal of maintaining urine output at least 100 mL/hour in adults (3 mL/kg/hour in children <10 kg). 1

Initial Fluid Management Protocol

• Timing: Begin hydration at least 48 hours before tumor-specific therapy when possible 1
• Route: Central venous access preferred 1
• Target:
  • Adults: Maintain urine output ≥100 mL/hour
  • Children <10 kg: Maintain urine output ≥3 mL/kg/hour
• Fluid type: Normal saline (0.9% sodium chloride) is the preferred fluid

Monitoring Parameters During Hydration

• Monitor vital parameters every 6 hours for first 24 hours: heart rate, blood pressure, urine output, respiratory rate 1
• Check electrolytes (potassium, phosphate, calcium) every 6 hours initially 1
• Monitor renal function (serum creatinine, BUN) every 6 hours initially 1
• Track fluid balance carefully to avoid volume overload

Adjunctive Measures

Diuretics

• Loop diuretics (or mannitol) may be required to maintain target urine output 1
• Important caveat: Avoid diuretics in patients with:
  • Obstructive uropathy
  • Hypovolemia

Rasburicase Administration

• Administer rasburicase concurrently with hydration for all patients with clinical TLS 1, 2
• Rasburicase dose: 0.2 mg/kg/day as a 30-minute infusion 1, 2
• Clinical trials show rasburicase rapidly reduces uric acid levels, with 96% of patients achieving uric acid levels ≤2 mg/dL within 4 hours 2

Special Considerations

Electrolyte Management During Hydration

• Hyperkalemia: For mild hyperkalemia (<6 mmol/L), hydration with loop diuretics may be sufficient 1
• Hyperphosphatemia: Mild hyperphosphatemia (<1.62 mmol/L) may not require specific treatment beyond hydration 1
• Hypocalcemia: Asymptomatic hypocalcemia requires no treatment; treat only if symptomatic 1

When to Consider Dialysis

• Oliguria despite adequate hydration and diuretics
• Severe electrolyte abnormalities unresponsive to medical management
• Fluid overload unresponsive to diuretics
• Acute kidney injury with rising creatinine 1, 3

Pitfalls to Avoid

1. Urine alkalinization: Unless specifically indicated for other reasons, avoid urine alkalinization in patients receiving rasburicase 1
2. Volume overload: Careful monitoring of fluid status is essential to prevent pulmonary edema
3. Delayed initiation: Do not delay hydration; early intervention is critical to prevent renal complications
4. Inadequate monitoring: Frequent laboratory monitoring is essential to detect worsening electrolyte abnormalities

Algorithm for Fluid Management in TLS

1. Risk assessment: Determine if patient has clinical TLS or laboratory TLS
2. Initiate hydration: Start IV fluids via central venous access
3. Add rasburicase: Administer concurrently with hydration
4. Monitor response: Check urine output hourly and electrolytes every 6 hours
5. Adjust therapy: Add diuretics if needed to maintain urine output
6. Consider dialysis: For refractory cases with severe electrolyte abnormalities or oliguria

Aggressive hydration remains the cornerstone of TLS management, as it enhances renal blood flow, glomerular filtration, and excretion of uric acid and phosphate, thereby reducing the risk of acute kidney injury 4, 3.