inpatient / hematology and oncology
Tumor Lysis Syndrome (TLS)
# Tumor Lysis Syndrome
Checklist
-- ABCs: does the patient have severe electrolyte derangements requiring frequent monitoring and telemetry?
-- Chart Check: tumor type, last treatment and date, h/o CKD, baseline LDH and uric acid
-- Can't Miss: hypocalcemia, hyperkalemia, renal failure
-- Admission Orders: strict I/O, telemetry, CBC, BMP, Phos, Uric Acid LDH
-- Initial Treatment to Consider: aggressive fluids, address hyperkalemia, decide on need for rasburicase
Assessment:
-- History: *** tumor type, last treatment and date, CKD, elevated LDH or uric acid at baseline
-- Clinical/Exam: *** hypocalcemia (weakness, tetany, arrythmia), oliguria
-- Data: *** Uric Acid, LDH, creatinine, K, Phos, Calcium - Cairo Bishop - uric acid>8, K>6, Phos>4.5, Ca<7; if 2+ criteria met with 7 days of therapy OR 1 lab value and Cr 1.5x ULN, arrhythmia, seizure
Plan:
Workup
-- EKG - baseline in case of hyperkalemia or other electrolyte disturbances
-- trend q6-8 BMP, Phos, Uric Acid, LDH
-- trend UOP, continuous telemetry
Treatment
-- hydrate with NS - 2-3L per day
-- furosemide PRN for UOP >100cc/hr
-- Allopurinol ppx 300-600mg/day 24-48 hours before chemo, then until hyperuricemia resolved
-- Rasburicase 3-6mg IV in specific situations (high risk by # WBC, renal failure, rising uric acid or creatinine, and can’t hydrate)
-- Dialysis may be needed if Ca x Phos >70
PDF coming soon!
If You Remember Nothing Else
The highest risk tumors are ALL, AML, CLL, and bulky solid tumors (NHL, DLBCL). Trend BMP, Phos, Uric Acid, and LDH. The goal is to avoid dangerous electrolyte derangements (hyperkalemia, severe hypocalcemia), and prevent renal failure. Hydrate aggressively and diurese if need be. Allopurinol is used prophylactically and prevents xanthine and uric acid formation (which are both neprhotoxic) whereas rasburicase turns uric acid into allantoin which is harmlessly excreted.
Clinical Pearls
- The highest risk is with ALL/AML >100k WBC, CLL, stage 3 and 4 NHL, DLBCL
- Uric Acid precipitates in renal tubules, especially in acidic environments
- Need to rule of G6PD deficiency if you plan to use rasburicase (risk of hemolysis)
- Allopurinol used for prophylaxis not treatment, no additional benefit on top of rasburicase; Allopurinol decreased uric acid formation by inhibiting xanthine oxidase, rasburicase increases uric acid clearance by turning it into allantoin
- Urinary alkalinization is no longer recommended - no benefit, possible harms
- LDH is a surrogate for tumor proliferation - the higher it is at baseline, the more at risk the patient is for TLS
Trials and Literature
- Review of TLS - NEJM
- Trial for Rasburicase ppx or treatment for leukemia or lymphoma (JCO 2001)
- Compassionate Use Trial of Rasburicase in Kids and Adults to treat TLS (Leukemia 2005)
Other Resources
- Internet Book of Critical Care (IBCC) - Tumor Lysis Syndrome
- Core EM - Tumor Lysis Syndrome
