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tumor lysis syndrome

Etiology: 1) rapid tumor cell turnover or necrosis a) secondary to chemotherapy or radiation b) occasionally occurs spontaneously in patients with high tumor burden 2) susceptible tumors a) high-grade lymphomas 1] Burkitt's lymphoma* 2] lymphoblastic lymphoma - diffuse large B-cell lymphoma b) acute leukemia* -acute myeloid leukemia* c) chronic lymphocytic leukemia c) less frequently solid tumors 3) risk factors a) bulky disease b) leukemias with high leukocyte count c) high pretreatment levels of 1] serum lactate dehydrogenase 2) serum uric acid d) renal insufficiency e) use of nephrotoxic agents [1] * may occur spontaneously [1] Pathology: - massive release of uric acid, potassium & phosphate into the blood from rapid lysis of malignant cells [1] - deposition of uric acid crystals & calcium phosphate crystals in renal tubules Clinical manifestations: 1) occurs within 1-5 days of chemotherapy 2) cardiac arrhythmias 3) acute renal failure 4) muscle cramps 5) tetany Laboratory: 1) electrolytes, serum creatinine, serum uric acid every 4-6 hours 2) serum uric acid a) hyperuricemia b) serum uric acid levels may reach 20-90 mg/dL 3) serum K+: hyperkalemia 4) serum phosphate: hyperphosphatemia 5) serum creatinine & serum urea nitrogen: azotemia 6) metabolic acidosis 7) serum calcium: hypocalcemia 8) serum lactate dehydrogenase Special laboratory: - continuous cardiac monitoring [1] Management: 1) adequate hydration with normal saline [1,3] up to 3 L/m2/day 2) allopurinol [3,6] &/or rasburicase [8,9] prior to chemotherapy - rasburicase preferred vs allopurinol for patients at high risk [1] - patients with baseline hyperuricemia &/or renal insufficiency should receive rasburicase [1] 3) patients on allopurinol with uric acid nephropathy (tumor lysis syndrome) require rasburicase to reduce serum urate [1] - rasburicase has faster onset of action than allopurinol; can reduce serum urate levels within 4 hours [1] 4) furosemide for volume overload [1] 5) management of hyperkalemia & hyperphosphatemia [1] 6) alkalinization of urine with NaHCO3 a) maintain urine pH > 7 b) can increase uric acid clearance c) increases risk of calcium phosphate precipitation - not appropriate for patients with high serum phosphorus [1] - not appropriate for treatment of tumor lysis syndrome 7) hemodialysis a) may be necessary with acute renal failure secondary to urate nephropathy b) indications include oliguria or anuria, hyperkalemia, calcium-phosphate product >= mg2/dL2 c) prognosis for restoration of renal function is good

Related

hyperuricemia uric acid stone (urate nephropathy, gouty nephropathy)

General

syndrome cancer complication

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 681
  3. Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011 May 12;364(19):1844-54 PMID: 21561350
  4. Abu-Alfa AK, Younes A. Tumor lysis syndrome and acute kidney injury: evaluation, prevention, and management. Am J Kidney Dis. 2010 May;55(5 Suppl 3):S1-13 PMID: 20420966
  5. Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008 Jun 1;26(16):2767-78 PMID: 18509186
  6. Rampello E, Fricia T, Malaguarnera M. The management of tumor lysis syndrome. Nat Clin Pract Oncol. 2006 Aug;3(8):438-47. PMID: 16894389
  7. Galardy PJ, Hochberg J, Perkins SL et al Rasburicase in the prevention of laboratory/clinical tumour lysis syndrome in children with advanced mature B-NHL: a Children's Oncology Group Report. Br J Haematol. 2013 Nov;163(3):365-72 PMID: 24032600
  8. Lopez-Olivo MA, Pratt G, Palla SL, Salahudeen A. Rasburicase in tumor lysis syndrome of the adult: a systematic review and meta-analysis. Am J Kidney Dis. 2013 Sep;62(3):481-92 PMID: 23684124
  9. Wilson FP, Berns JS. Onco-nephrology: tumor lysis syndrome. Clin J Am Soc Nephrol. 2012 Oct;7(10):1730-9. Review. PMID: 22879434 Free Article