Management of Tumor Lysis Syndrome with Diabetic Ketoacidosis
The management of tumor lysis syndrome (TLS) with diabetic ketoacidosis (DKA) requires aggressive hydration, rasburicase administration, insulin therapy, and careful electrolyte management, with early consideration of renal replacement therapy if needed. 1
Initial Assessment and Management
Hydration Strategy
- Initiate aggressive IV hydration through central venous access at 200-300 mL/hour with normal saline
- Target urine output of at least 100 mL/hour in adults (3 mL/kg/hour in children <10 kg) 2, 1
- Balance hydration needs carefully due to competing concerns:
- TLS requires aggressive hydration
- DKA requires careful fluid replacement to avoid cerebral edema
- Monitor for signs of fluid overload, especially in patients with compromised cardiac function
Rasburicase Administration
- Administer rasburicase to all patients with clinical TLS 2, 1
- Standard dose is 0.2 mg/kg/day as a 30-minute infusion 3
- Rasburicase rapidly reduces uric acid levels, with 96% of patients achieving uric acid levels ≤2 mg/dL within 4 hours 3
Insulin Therapy for DKA
- Start insulin infusion at 0.1 units/kg/hour
- Monitor blood glucose hourly and adjust insulin rate accordingly
- Continue insulin infusion until ketoacidosis resolves
- Avoid rapid correction of hyperglycemia to prevent cerebral edema
Electrolyte Management
Hyperkalemia Management
- Mild hyperkalemia (<6 mmol/L): Hydration, loop diuretics, sodium polystyrene 1 g/kg 2, 1
- Severe hyperkalemia: Rapid insulin (0.1 units/kg) plus glucose (25% dextrose 2 mL/kg) 2
- Additional measures: Calcium gluconate for cardiac membrane stabilization, sodium bicarbonate for acidosis correction
- Continuous ECG monitoring for all patients with hyperkalemia 1
Phosphate and Calcium Management
- Mild hyperphosphatemia (<1.62 mmol/L): No treatment or aluminum hydroxide 50-100 mg/kg/day 2, 1
- Asymptomatic hypocalcemia: No treatment (treating may worsen calcium phosphate deposition) 2
- Symptomatic hypocalcemia (tetany, seizures): Calcium gluconate 50-100 mg/kg as single dose 2
Acidosis Management
- TLS-related acidosis: Correct with bicarbonate if severe
- DKA-related acidosis: Will improve with insulin therapy and hydration
- Monitor arterial blood gases to guide therapy
Renal Replacement Therapy
Indications for Dialysis
Initiate renal replacement therapy when any of the following occur 2, 1:
- Persistent hyperkalemia unresponsive to medical management
- Severe metabolic acidosis
- Volume overload unresponsive to diuretic therapy
- Overt uremic symptoms
- Severe progressive hyperphosphatemia (>6 mg/dL)
- Severe symptomatic hypocalcemia
Dialysis Modality Selection
- Intermittent hemodialysis (IHD): Effective for rapid correction of electrolyte abnormalities; uric acid clearance approximately 70-100 mL/min 2
- Continuous renal replacement therapies (CRRT): Preferred for hemodynamically unstable patients 1
- Daily dialysis is recommended for patients with TLS and oliguria 2
Monitoring and Follow-up
- Monitor serum electrolytes, renal function, and urine output every 4-6 hours
- Regular assessment of serum calcium, phosphate, and magnesium
- Continuous cardiac monitoring for patients with significant electrolyte abnormalities
- Monitor acid-base status with serial arterial blood gases
- Assess for signs of tumor lysis progression or resolution
Common Pitfalls to Avoid
- Treating asymptomatic hypocalcemia, which may worsen calcium phosphate deposition 1
- Inadequate monitoring of electrolyte abnormalities during treatment 1
- Using diuretics before correcting hypovolemia
- Failing to balance the fluid needs of both TLS and DKA
- Delaying rasburicase administration in high-risk patients
- Overlooking the need for early renal replacement therapy in severe cases
- Correcting hyperglycemia too rapidly in DKA patients