What is the management of tumor lysis syndrome?

Management of Tumor Lysis Syndrome

Tumor lysis syndrome (TLS) requires aggressive hydration starting 48 hours before tumor-specific therapy, rasburicase administration at 0.20 mg/kg/day for 3-5 days, and careful electrolyte management to prevent life-threatening complications. 1

Risk Assessment

• TLS is a potentially life-threatening complication occurring in rapidly proliferating, bulky, or highly chemo-radiosensitive cancers 1
• High-risk patients include those with:
  • Host-related factors: dehydration, hyponatremia, pre-existing renal impairment, obstructive uropathy, and hyperuricemia 1
  • Disease-related factors: bulky disease, high-grade lymphomas, acute lymphoblastic leukemia, and elevated LDH 1
  • Therapy-related factors: intensive polychemotherapy including cisplatin, cytosine arabinoside, etoposide, and methotrexate 1

Prevention and Treatment Algorithm

Step 1: Hydration

• Begin aggressive hydration 48 hours before tumor-specific therapy when possible 1
• Target urine output ≥100 mL/hour in adults 1

Step 2: Hyperuricemia Management

• Administer rasburicase at 0.20 mg/kg/day, infused over 30 minutes, continued for 3-5 days 1
• Rasburicase rapidly reduces uric acid levels, with 96% of patients achieving levels ≤2 mg/dL within 4 hours of the first dose 2
• Rasburicase is indicated for initial management of plasma uric acid levels in patients with leukemia, lymphoma, and solid tumor malignancies receiving anticancer therapy expected to result in TLS 2
• Important: Do not administer allopurinol concurrently with rasburicase to avoid xanthine accumulation 1

Step 3: Electrolyte Management

• Hyperphosphatemia: Treat with aluminum hydroxide at 50-100 mg/kg/day divided in 4 doses 1, 3
• Hypocalcemia: Only treat if symptomatic with calcium gluconate 50-100 mg/kg 1
• Hyperkalemia: Treat with hydration, loop diuretics, and sodium polystyrene; severe cases require insulin and glucose, calcium carbonate, and sodium bicarbonate 1, 3

Monitoring Protocol

High-Risk Patients (Pre-TLS)

• Monitor every 12 hours for the first three days, then every 24 hours 1
• Measure: LDH, uric acid, sodium, potassium, creatinine, BUN, phosphorus, and calcium 1

Patients with Established TLS

• Monitor every 6 hours for the first 24 hours, then daily 1
• Measure: vital parameters, serum uric acid, electrolytes, and renal function 1

Indications for Renal Replacement Therapy

• Severe oliguria or anuria 1
• Persistent hyperkalemia 1, 4
• Hyperphosphatemia with symptomatic hypocalcemia 1
• Hyperuricemia not responding to rasburicase 1
• Severe volume overload 1
• Hemodialysis can reduce plasma uric acid levels by approximately 50% with each 6-hour treatment 1, 3

Important Considerations and Pitfalls

• Do not use urine alkalinization in patients receiving rasburicase therapy 1
• Do not administer calcium gluconate for mild asymptomatic hypocalcemia as it may lead to increased tissue and renal precipitation of calcium phosphate 1
• Rasburicase allows for earlier administration of chemotherapy due to rapid degradation of uric acid 1, 2
• Monitor for hypersensitivity reactions to rasburicase, which can include allergic reactions, bronchospasm, chest pain, dyspnea, hypoxia, hypotension, shock, or urticaria 2
• Rasburicase is indicated only for a single course of treatment 2
• Early collaboration between oncologists and nephrologists improves assessment of kidney function and risk factors, facilitating timely interventions 4