From the Guidelines
Tumor Lysis Syndrome (TLS) diagnosis and management involves prompt recognition of risk factors and implementation of prophylactic measures.
Diagnosis and Risk Factors
- TLS is characterized by a group of metabolic derangements caused by the massive and abrupt release of cellular components into the blood after the rapid lysis of malignant cells 1.
- Risk factors include bulky disease at presentation, elevated LDH, oliguria, preexisting renal impairment, dehydration, and evidence of TLS before start of therapy 2.
- High-risk patients should receive increased hydration (3 L/m2 per day), unless there is evidence of renal insufficiency and oliguria, and rasburicase prophylaxis is recommended 3.
Management
- Prophylaxis with allopurinol or rasburicase before start of systemic therapy is indicated for certain patients 2.
- Rasburicase, a recombinant urate-oxidase enzyme, converts existing uric acid to allantoin, which is 5 to 10 times more soluble in urine than uric acid 4.
- Urinary alkalinization is no longer recommended 3.
- Intractable fluid overload, hyperkalemia, hyperuricemia, hyperphosphatemia, or hypocalcemia are indications for renal dialysis 3.
- Management of hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia associated with TLS is crucial to prevent serious and potentially fatal consequences 2, 1.
From the Research
Diagnosis of Tumor Lysis Syndrome (TLS)
- TLS is a clinical condition caused by the massive lysis of tumor cells, leading to hemodynamic disturbances 5
- It is characterized by hyperkalemia, hyperphosphatemia, secondary hypocalcemia, hyperuricemia, and acute renal failure 5, 6
- TLS can occur after any type of neoplasm, but is highly associated with rapidly proliferating tumors such as acute lymphoblastic leukemia and high-grade non-Hodgkin lymphoma 5, 6
- The current diagnostic criteria for TLS have several drawbacks and limitations, and may not accurately diagnose the condition 7
Management of Tumor Lysis Syndrome (TLS)
- Prevention and treatment measures include intravenous hydration, use of allopurinol and rasburicase, management of TLS-associated electrolyte abnormalities, and renal replacement therapy 5, 6
- Vigorous intravenous hydration is the cornerstone of prevention and treatment 6
- Rasburicase has revolutionized the management of TLS, but its cost can be a limiting factor 6
- Dialysis may be required when the metabolic disturbances overwhelm the renal excretion, resulting in renal failure 5, 6
- Management of clinical syndrome requires hydration, fluid balance, electrolytes and hyperuricemia correction, and ultimately dialysis when acute kidney injury is worsening 8