Management of Tumor Lysis Syndrome in Lymphoma Patient on B-CHOP
This patient has tumor lysis syndrome (TLS) and requires immediate aggressive IV hydration PLUS rasburicase—both therapies together, not one or the other. 1, 2
Understanding the Clinical Scenario
The presence of hyperkalemia and hypocalcemia in a lymphoma patient receiving B-CHOP chemotherapy indicates laboratory TLS (defined as at least 2 biochemical abnormalities among hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia). 1
Laboratory TLS requires the same aggressive treatment as clinical TLS in all adults. 2 This means both hydration AND rasburicase must be administered immediately. 1, 2
Core Treatment Algorithm
Immediate Interventions (Both Required)
Start aggressive IV hydration through central venous access to maintain urine output at minimum 100 mL/hour. 1, 2
Administer rasburicase 0.2 mg/kg IV over 30 minutes immediately to rapidly degrade uric acid and prevent acute renal failure. 2, 3, 4
Loop diuretics (furosemide/Lasix) may be added to achieve target urine output if hydration alone is insufficient, but only if the patient is not oliguric or hypovolemic. 1, 2
Management of Hyperkalemia
The severity of hyperkalemia determines additional interventions beyond hydration:
For mild hyperkalemia (<6 mmol/L): Hydration plus loop diuretics plus sodium polystyrene sulfonate 1 g/kg orally or by enema. 1, 2
For severe hyperkalemia (≥6 mmol/L or ECG changes): Add calcium gluconate 50-100 mg/kg IV over 2-5 minutes to stabilize myocardial membrane, plus insulin 0.1 units/kg IV with 25% dextrose 2 mL/kg IV. 1, 2, 3
Continuous ECG monitoring is mandatory for all hyperkalemic patients. 1
Management of Hypocalcemia
Only administer calcium gluconate 50-100 mg/kg IV if the patient develops tetany, seizures, or prolonged QT interval. 1, 2, 3
Why the Answer is NOT Just One Option
Looking at the multiple choice options provided:
Lasix (A) alone is insufficient because it only addresses volume management and mild hyperkalemia, but does not prevent the life-threatening complications of TLS including acute renal failure from uric acid nephropathy. 1, 2
Thiazide (B) is incorrect because thiazides are not recommended in TLS management; loop diuretics are preferred when diuretics are needed. 1, 2
Rasburicase (C) alone is insufficient because hydration is equally critical to maintain renal perfusion and urine flow. 1, 2
Hydration (D) alone is insufficient because it does not address the rapid accumulation of uric acid that leads to acute renal failure. 1, 2
The correct answer requires BOTH hydration AND rasburicase together. 1, 2 If forced to choose a single answer from the options, hydration (D) would be the foundation, but rasburicase must be added immediately. 2, 3
Critical Pitfalls to Avoid
Never delay rasburicase administration while waiting to see if hydration alone works—this increases mortality risk from acute renal failure and cardiac arrhythmias. 2, 3
Never give calcium gluconate for hypocalcemia in the presence of hyperphosphatemia unless the patient is symptomatic—this causes metastatic calcification and worsens renal function. 3
Never use thiazide diuretics in TLS—only loop diuretics (furosemide) are appropriate when diuretics are needed. 1, 2
Never alkalize urine when using rasburicase—this increases calcium phosphate precipitation risk without benefit since rasburicase rapidly degrades uric acid. 3
Monitoring Requirements
Recheck potassium every 2-4 hours after initial treatment. 2, 3
Obtain comprehensive metabolic panel, phosphate, calcium, uric acid, and LDH every 4-6 hours. 3