Tumor lysis syndrome medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamad Alkateb, MBBCh [2] Nazia Fuad M.D.

Tumor lysis syndrome is a medical emergency and requires prompt treatment. Patients who develop TLS should receive intensive care with continuous cardiac monitoring and measurement of electrolytes, creatinine, and uric acid every four to six hours. Special attention should be given to correct the electrolyte abnormalities. Hyperurecemia should be treated with rasburicase at 0.2 mg/kg with repeated doses as needed, to wash out the obstructing uric acid crystals with fluids with or without a loop diuretic, and then the appropriate use of renal replacement therapy is also required.

The treatment of tumor lysis syndrome is a multidisciplinary effort between nephrologist, hematologist, and intensivist:^[1][2][3]

• Intravenous fluids:

• Aggressive hydration 3 l/m2/d

• Maintain urine output 4ml/kg/h for infants and 100ml/m2/h for adults.
• Avoid adding potassium in hydration fluids.
• Fluid loss should be measured, such as vomiting and diarrhea.
• Elderly, infants, and patients with cardiac disease are at high risk of developing hypervolemia.

• Diuretics:

• Mannitol 0·5 mg/kg
• Furosemide 0·5–1·0 mg/kg; 2–4 mg/kg in case of severe oliguria or anuria.

• Note: alkalization of urine is not recommended to increase the excretion of uric acid (the use of sodium bicarbonate is controversial).^[4]

• Electrolytes disturbance:

• Hyperphosphataemia: treatment should be initiated if phosphorus levels are ≥2·1 mmol/l.

• Avoid intravenous phosphate
• Aluminium hydroxide; poorly tolerated

• Hypocalcemia: treatment should be initiated if calcium levels are ≤1·75 mmol/l.

• Asymptomatic: no treatment needed
• Symptomatic: calcium gluconate 50–100 mg/kg IV
• Cardiac monitoring is recommended if calcium level drops below ≤1.75mmol/l

• Hyperkalemia:

• Asymptomatic (≥6·0 mmol/l):

• Avoid potassium administration
• Cardiac monitoring
• Sodium polystyrene sulfonate

• Symptomatic (>7·0 mmol/l):

• Cardiac monitoring
• Calcium gluconate 100–200 mg/kg IV and/or
• Regular insulin 0·1 unit/kg IV + D25 2 ml/kg IV
• Dialysis

• Hyperuricemia:

• Allopurinol 10 mg/kg/d divided q8 h, reduce the dose by 50% in renal failure.
• Rasburicase 0·05–0·20 mg/kg IV over 30 min; contraindicated in patients with glucose 6 phosphate dehydrogenase (G6PD) deficiency.
• Note: the duration of treatment depends on the clinical response.

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