What is the treatment for suspected tumor lysis syndrome?

Treatment of Tumor Lysis Syndrome

The treatment of suspected tumor lysis syndrome requires immediate aggressive hydration through central venous access, administration of rasburicase, management of electrolyte disturbances, and early initiation of renal replacement therapy when indicated. 1

Initial Management

Hydration and Diuresis

• Start aggressive IV hydration at 200-300 mL/hour through central venous access 1
• Target urine output: ≥100 mL/hour in adults (3 mL/kg/hour in children <10 kg) 2, 1
• When possible, begin hydration 48 hours before anticancer therapy 2
• Loop diuretics (or mannitol) may be necessary to maintain adequate urine output, except in patients with obstructive uropathy or hypovolemia 2, 1

Rasburicase Administration

• Administer rasburicase to all patients with clinical TLS, adults with laboratory TLS, children at high risk of TLS, or children with rapidly worsening biochemical parameters 2, 1
• Standard dose: 0.2 mg/kg/day as a 30-minute infusion 1
• Rasburicase rapidly reduces uric acid levels, with 96% of patients achieving uric acid levels ≤2 mg/dL within 4 hours of the first dose 3
• Allows earlier administration of chemotherapy if necessary 2

Electrolyte Management

Hyperkalemia

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

Hyperphosphatemia

• Mild hyperphosphatemia (<1.62 mmol/L): May not require treatment or can be treated with aluminum hydroxide 50-100 mg/kg/day divided in 4 doses 2
• Severe progressive hyperphosphatemia may require renal replacement therapy 1

Hypocalcemia

• Asymptomatic hypocalcemia: Does not require treatment 2
• Symptomatic hypocalcemia (tetany, seizures): Calcium gluconate 50-100 mg/kg as a single dose, cautiously repeated if necessary 2
• Calculate corrected calcium using: Total calcium (mg/dL) + 0.8 × [4 - Serum albumin (g/dL)] 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 requiring rapid correction of electrolyte abnormalities 1
• Continuous renal replacement therapy (CRRT): For hemodynamically unstable patients 1
• Daily dialysis: Recommended for patients with TLS and oliguria 1

Monitoring and Follow-up

• Monitor serum electrolytes, renal function, and urine output every 4-6 hours 1
• Regular assessment of serum calcium, phosphate, and magnesium 1
• Continuous cardiac monitoring for patients with significant electrolyte abnormalities 1
• Monitor acid-base status with serial arterial blood gases 1

Common Pitfalls to Avoid

• Delaying treatment of severe TLS
• Inadequate monitoring of electrolyte disturbances
• Using diuretics before correcting hypovolemia
• Treating laboratory values without addressing the underlying cause
• Failing to monitor for hypocalcemia after treatment 1
• Inadequate hydration before rasburicase administration 1
• Failing to correct calcium for albumin 1

Special Considerations

• Rasburicase is contraindicated in patients with G6PD deficiency due to risk of hemolysis 3
• Patients with TLS may rapidly develop acute kidney injury requiring prompt intervention 4
• Even patients with solid tumors can develop TLS, particularly with highly effective chemotherapy regimens 5