What is the treatment for tumor lysis syndrome?

Treatment of Tumor Lysis Syndrome

Aggressive hydration through a central venous access and rasburicase administration should be the cornerstone of treatment for all patients with clinical tumor lysis syndrome (TLS). 1

Initial Management

Hydration and Urine Output

• Start IV hydration through central venous access at least 48 hours before tumor-specific therapy when possible 1
• Target urine output of at least 100 mL/hour in adults (3 mL/kg/hour in children <10 kg) 1
• Use normal saline at 200-300 mL/hour initially 1
• Loop diuretics (or mannitol) may be required to maintain adequate urine output, except in patients with:
  • Obstructive uropathy
  • Hypovolemia 1

Hyperuricemia Management

• Administer rasburicase to all patients with clinical TLS 1
• Also administer rasburicase to:
  • Adults with laboratory TLS
  • Children with high risk of TLS
  • Children with rapidly worsening biochemical parameters 1
• Rasburicase rapidly degrades uric acid, allowing earlier administration of chemotherapy if needed 1, 2
• Clinical data shows rasburicase significantly lowers serum uric acid compared to allopurinol, with 96% of patients achieving uric acid levels ≤2 mg/dL within 4 hours of the first dose 2

Electrolyte Management

Hyperphosphatemia

• Mild hyperphosphatemia (<1.62 mmol/L): No treatment needed or use aluminum hydroxide at 50-100 mg/kg/day divided in 4 doses (oral or nasogastric) 1

Hypocalcemia

• Asymptomatic hypocalcemia: No treatment required 1
• Symptomatic hypocalcemia (tetany, seizures): Administer calcium gluconate 50-100 mg/kg as a single dose, cautiously repeating if necessary 1

Hyperkalemia

• Mild (<6 mmol/L) asymptomatic hyperkalemia: Correct with hydration, loop diuretics, and sodium polystyrene 1 g/kg (oral or enema) 1
• Severe hyperkalemia: Administer rapid insulin (0.1 units/kg) plus glucose (25% dextrose 2 mL/kg) 1
• Additional interventions:
  • Calcium carbonate 100-200 mg/kg/dose to stabilize myocardial cell membrane
  • Sodium bicarbonate to correct acidosis
  • Continuous ECG monitoring for hyperkalemic patients 1

Renal Replacement Therapy

Indications for Dialysis

• Oliguria/anuria due to acute uric acid nephropathy
• Severe acid-base and electrolyte abnormalities
• Extracellular fluid volume overload 1

Dialysis Options

• Intermittent hemodialysis (IHD): Uric acid clearance approximately 70-100 mL/min; plasma uric acid level falls by about 50% with each 6-hour treatment 1
• Continuous renal replacement therapies (CRRT) for hemodynamically unstable patients 1
• Early initiation of renal replacement therapy is advised to remove purine by-products and improve hyperphosphatemia, hyperkalemia, and hypocalcemia 1

Monitoring and Common Pitfalls

Essential Monitoring

• Regular assessment of serum calcium, phosphate, magnesium, and renal function 1
• Calculate corrected calcium: Total calcium (mg/dL) + 0.8 × [4 - Serum albumin (g/dL)] 3
• ECG monitoring for patients with hyperkalemia 1

Common Pitfalls to Avoid

• Using diuretics before correcting hypovolemia
• Failing to correct calcium for albumin
• Inadequate hydration before rasburicase administration
• Treating laboratory values without addressing the underlying cause
• Delaying treatment of severe TLS
• Failing to monitor for hypocalcemia after treatment 3

Special Considerations

Rasburicase Adverse Effects

• Hypersensitivity reactions (incidence <1%) including anaphylaxis
• Hemolysis (incidence <1%)
• Methemoglobinemia (incidence <1%) 2

Contraindications to Rasburicase

• G6PD deficiency (risk of hemolysis)
• History of allergic reactions to rasburicase 2

By following this algorithmic approach to TLS management, focusing on aggressive hydration, rasburicase administration, electrolyte correction, and timely initiation of renal replacement therapy when indicated, mortality and morbidity from this oncologic emergency can be significantly reduced.