What is the treatment for tumor lysis syndrome?

Treatment for Tumor Lysis Syndrome

The definitive treatment for tumor lysis syndrome (TLS) includes aggressive hydration, rasburicase administration, management of electrolyte disturbances, and early initiation of renal replacement therapy when indicated. 1

Initial Management

Aggressive Hydration

• Start IV hydration through central venous access at 200-300 mL/hour
• Begin 48 hours before anticancer treatment when possible
• Target urine output: ≥100 mL/hour in adults (3 mL/kg/hour in children <10 kg)
• Use normal saline as the fluid of choice 1
• Loop diuretics may be necessary to maintain adequate urine output, except in patients with obstructive uropathy or hypovolemia 1

Rasburicase Administration

• Standard dose: 0.2 mg/kg/day as a 30-minute infusion 1
• Indicated for:
  • All patients with clinical TLS
  • Adults with laboratory TLS
  • Children at high risk of TLS
  • Children with rapidly worsening biochemical parameters 1
• Clinical trials show rasburicase rapidly reduces uric acid levels to ≤2 mg/dL in 96% of patients within 4 hours of the first dose 2
• Allows earlier administration of chemotherapy if necessary 1

Electrolyte Management

Hyperkalemia

• For mild hyperkalemia (<6 mmol/L) without symptoms:
  • Hydration
  • Loop diuretics
  • Polystyrene sulfonate 1 g/kg orally or by enema 1
• For severe hyperkalemia:
  • Insulin (0.1 units/kg) plus glucose (dextrose 25% 2 mL/kg)
  • Calcium carbonate 100-200 mg/kg/dose to stabilize myocardial membrane
  • Sodium bicarbonate to correct acidosis 1
  • Continuous ECG monitoring 1

Hyperphosphatemia and Hypocalcemia

• Mild hyperphosphatemia (<1.62 mmol/L) may not require treatment
• Calculate corrected calcium: Total calcium (mg/dL) + 0.8 × [4 - Serum albumin (g/dL)]
• Asymptomatic hypocalcemia should not be treated
• Symptomatic hypocalcemia: calcium gluconate 50-100 mg/kg as a single dose 1

Renal Replacement Therapy

Initiate renal replacement therapy when patients present with:

• Persistent hyperkalemia
• Severe metabolic acidosis
• Volume overload
• Evident uremic symptoms
• Severe progressive hyperphosphatemia
• Severe symptomatic hypocalcemia 1

Types of Renal Replacement Therapy

• Intermittent Hemodialysis (IHD): For hemodynamically stable patients; rapidly corrects electrolyte abnormalities
• Continuous Renal Replacement Therapy (CRRT): For hemodynamically unstable patients; better fluid overload control
• Daily Dialysis: Recommended for patients with TLS and oliguria 1

Monitoring

• 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 1

Common Pitfalls to Avoid

1. Inadequate hydration before rasburicase administration
2. Using diuretics before correcting hypovolemia
3. Failing to correct calcium for albumin
4. Treating laboratory values without addressing the underlying cause
5. Failing to monitor for hypocalcemia after treatment 1
6. Delaying treatment of severe TLS
7. Inadequate monitoring of electrolyte disturbances during treatment 1

Special Considerations

• Rasburicase can cause serious hypersensitivity reactions including anaphylaxis, hemolysis, and methemoglobinemia in <1% of patients 2
• Patients with G6PD deficiency should not receive rasburicase due to risk of hemolysis 2
• Early recognition of patients at risk for TLS is essential for preventing life-threatening complications 3, 4