What is the treatment for tumor lysis syndrome?

Treatment of Tumor Lysis Syndrome

The treatment of tumor lysis syndrome requires aggressive hydration through central venous access and rasburicase administration for all patients with clinical TLS, along with specific management of electrolyte abnormalities and renal replacement therapy when indicated. 1, 2

Initial Management

Hydration and Uric Acid Management

• Aggressive IV hydration:

  • Start 48 hours before chemotherapy when possible
  • Target urine output: ≥100 mL/hour in adults (3 mL/kg/hour in children <10 kg)
  • Use central venous access 1
  • Loop diuretics (or mannitol) may be needed to maintain urine output, except in patients with obstructive uropathy or hypovolemia 1

• Rasburicase administration:

  • Dose: 0.20 mg/kg/day IV 2
  • Rapidly degrades uric acid (96% of patients achieve uric acid levels ≤2 mg/dL within 4 hours) 3
  • Contraindicated in patients with G6PD deficiency, metahemoglobinemia, or other metabolic disorders that can potentially cause hemolytic anemia 2

Electrolyte Management

Hyperkalemia

• Mild hyperkalemia (<6 mmol/L):

  • Hydration
  • Loop diuretics
  • Sodium polystyrene 1 g/kg orally or by enema 1

• Severe hyperkalemia:

  • Rapid insulin (0.1 units/kg) plus glucose (25% dextrose 2 mL/kg)
  • Calcium carbonate 100-200 mg/kg/dose
  • Sodium bicarbonate to stabilize myocardial cell membrane and correct acidosis
  • Continuous ECG monitoring 1

Hyperphosphatemia

• Mild hyperphosphatemia (<1.62 mmol/L):
  • Aluminum hydroxide 50-100 mg/kg/day divided in 4 doses (oral or nasogastric) 1

Hypocalcemia

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

Renal Replacement Therapy

Indications for Dialysis

• Acute renal failure
• Severe electrolyte disturbances unresponsive to medical treatment
• Refractory volume overload
• Excessively elevated uric acid or phosphorus levels
• Severe metabolic acidosis 1, 2

Dialysis Efficacy

• Hemodialysis reduces uric acid levels by approximately 50% with each 6-hour treatment
• Uric acid clearance: approximately 70-100 mL/min 1
• Oliguria due to acute uric acid nephropathy often responds rapidly to hemodialysis, restarting diuresis as plasma uric acid falls to 10 mg/dL 1

Monitoring

• First 24 hours: Monitor vital signs, uric acid, electrolytes, and renal function every 6 hours 2
• Every 24 hours: Assess blood cell count, serum LDH, albumin, serum osmolality, blood gases, acid-base equilibrium, ECG, and body weight 2

Important Considerations and Pitfalls

• Do not use urine alkalinization with rasburicase as it provides no benefit and may worsen calcium phosphate precipitation 2
• Avoid calcium administration for asymptomatic hypocalcemia as it increases the risk of calcium phosphate tissue deposition 2
• Watch for hypersensitivity reactions to rasburicase (occurs in 4.3% of patients) 3
• Be vigilant for early signs of renal failure and initiate renal replacement therapy promptly when indicated 1
• Recognize high-risk patients: Those with hematologic malignancies (especially ALL, Burkitt's lymphoma), high tumor burden, pre-existing renal dysfunction, and elevated baseline uric acid levels 2, 4, 5

By following this structured approach to TLS management, focusing on aggressive hydration, rasburicase administration, careful electrolyte management, and timely initiation of renal replacement therapy when needed, the potentially life-threatening complications of TLS can be effectively managed.