From the Guidelines
Tumor lysis syndrome (TLS) should be managed with aggressive IV hydration and rasburicase in high-risk patients, as this approach has been shown to effectively prevent and treat the condition, reducing morbidity, mortality, and improving quality of life 1.
Symptoms and Pathophysiology
TLS presents with symptoms including nausea, vomiting, lethargy, edema, fluid overload, cardiac arrhythmias, seizures, and acute kidney injury, resulting from rapid breakdown of cancer cells releasing intracellular contents, causing hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.
Prevention and Treatment
For prevention in high-risk patients, aggressive IV hydration with normal saline at 2-3 L/m²/day should be initiated 24-48 hours before chemotherapy, along with rasburicase (0.1-0.2 mg/kg IV as a single dose) for rapid uric acid reduction 1. Allopurinol (100-300 mg orally three times daily or 200-400 mg/m²/day in children) may be used as an alternative or in addition to rasburicase in some cases 1. Electrolyte abnormalities require specific management, including:
- Hyperkalemia: calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium binders
- Hyperphosphatemia: phosphate binders like aluminum hydroxide (300-600 mg orally with meals)
- Symptomatic hypocalcemia: calcium gluconate
Severe Cases and Monitoring
Severe cases may require hemodialysis, particularly with persistent hyperkalemia, severe acidosis, or symptomatic hypocalcemia 1. Continuous cardiac monitoring is essential during treatment, and nephrology consultation should be obtained early for patients with significant kidney dysfunction 1.
Key Recommendations
- Hydration and rasburicase should be administered to adult cancer patients who are candidates for tumor-specific therapy and who carry a high risk of tumor lysis syndrome 1
- Cancer patients with a low-risk of tumor lysis syndrome should receive hydration along with oral allopurinol 1
- Rasburicase is preferred for rapid uric acid reduction in patients at very high risk or with established TLS 1
From the FDA Drug Label
Tumor Lysis Syndrome (TLS) Clinical TLS was defined by changes in at least two or more laboratory parameters for hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia and at least one of the following events occurring within 7 days of treatment: renal failure/injury, need for renal dialysis, and/or serum creatinine increase >1.5 ULN, arrhythmia or seizure. Clinical TLS occurred in 3% of Elitek-treated patients, 3% of Elitek/allopurinol-treated patients, and 4% of allopurinol-treated patients.
The symptoms of Tumor Lysis Syndrome (TLS) include:
- Hyperuricemia
- Hyperkalemia
- Hyperphosphatemia
- Hypocalcemia
- Renal failure/injury
- Need for renal dialysis
- Serum creatinine increase >1.5 ULN
- Arrhythmia
- Seizure
The therapy for TLS includes the use of rasburicase (Elitek), which can be administered alone or in combination with allopurinol. The incidence of clinical TLS was lower in patients treated with Elitek (3%) compared to those treated with allopurinol (4%) 2.
From the Research
Tumor Lysis Syndrome Symptoms
- Hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia, and uremia are characteristic findings of tumor lysis syndrome (TLS) 3, 4, 5
- These metabolic derangements can lead to cardiac arrhythmia, seizures, renal failure, and sudden death 3, 5
- Clinical presentation is characterized by hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia 5
Tumor Lysis Syndrome Therapy
- Established TLS requires early, aggressive intervention with intravenous hydration, electrolyte management, and the use of hypouricemic agents 3, 6
- Management includes intravenous hydration to maintain urine flow, medications targeting hyperuricemia including rasburicase and allopurinol 5
- In severe cases, renal replacement therapy may be required 5
- Aggressive hydration, possible use of loop diuretics, possible use of phosphate binders, use of uric acid lowering agents and dialysis in refractory cases are also part of the treatment 7
- Prevention is critical and includes adequate hydration, use of uric acid lowering therapies, use of phosphate binders and minimization of potassium intake 7