Tumor lysis syndrome medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Tumor lysis syndrome}} | {{Tumor lysis syndrome}} | ||
{{CMG}} {{AE}} {{MJK}} | {{CMG}} {{AE}} {{MJK}} {{N.F}} | ||
==Overview== | ==Overview== | ||
Tumor lysis syndrome is a medical emergency and requires prompt treatment. | 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 [[Electrolyte|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. | ||
==Medical Therapy== | ==Medical Therapy== | ||
The treatment of tumor lysis syndrome is a multidisciplinary effort between nephrologist, hematologist, and intensivist.<ref name="pmid15384972">{{cite journal| author=Cairo MS, Bishop M| title=Tumour lysis syndrome: new therapeutic strategies and classification. | journal=Br J Haematol | year= 2004 | volume= 127 | issue= 1 | pages= 3-11 | pmid=15384972 | doi=10.1111/j.1365-2141.2004.05094.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15384972}}</ref><ref name="JonesWill2015">{{cite journal|last1=Jones|first1=Gail L|last2=Will|first2=Andrew|last3=Jackson|first3=Graham H|last4=Webb|first4=Nicholas J A|last5=Rule|first5=Simon|title=Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology|journal=British Journal of Haematology|volume=169|issue=5|year=2015|pages=661–671|issn=00071048|doi=10.1111/bjh.13403}}</ref> | The treatment of tumor lysis syndrome is a multidisciplinary effort between [[nephrologist]], [[hematologist]], and intensivist:<ref name="pmid11694945">{{cite journal| author=Jeha S| title=Tumor lysis syndrome. | journal=Semin Hematol | year= 2001 | volume= 38 | issue= 4 Suppl 10 | pages= 4-8 | pmid=11694945 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11694945 }} </ref><ref name="pmid15384972">{{cite journal| author=Cairo MS, Bishop M| title=Tumour lysis syndrome: new therapeutic strategies and classification. | journal=Br J Haematol | year= 2004 | volume= 127 | issue= 1 | pages= 3-11 | pmid=15384972 | doi=10.1111/j.1365-2141.2004.05094.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15384972}}</ref><ref name="JonesWill2015">{{cite journal|last1=Jones|first1=Gail L|last2=Will|first2=Andrew|last3=Jackson|first3=Graham H|last4=Webb|first4=Nicholas J A|last5=Rule|first5=Simon|title=Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology|journal=British Journal of Haematology|volume=169|issue=5|year=2015|pages=661–671|issn=00071048|doi=10.1111/bjh.13403}}</ref> | ||
*Intravenous fluids: | *Intravenous fluids: | ||
:*Aggressive hydration 3 l/m2/d | |||
::*Maintain [[urine output]] 4ml/kg/h for infants and 100ml/m2/h for adults | :*Aggressive [[hydration]] 3 l/m2/d | ||
::*Avoid adding [[potassium]] in hydration fluids | ::*Maintain [[urine output]] 4ml/kg/h for infants and 100ml/m2/h for adults. | ||
::*Fluid loss should be measured, such as vomiting and diarrhea | ::*Avoid adding [[potassium]] in hydration fluids. | ||
::*Elderly, infants, and patients with cardiac disease are at high risk of developing [[hypervolemia]] | ::*Fluid loss should be measured, such as [[vomiting]] and [[diarrhea]]. | ||
::*Elderly, infants, and patients with [[Heart disease|cardiac disease]] are at high risk of developing [[hypervolemia]]. | |||
:*[[Diuretics]]: | :*[[Diuretics]]: | ||
::*[[Mannitol]] 0·5 mg/kg | ::*[[Mannitol]] 0·5 mg/kg | ||
::*[[Furosemide]] 0·5–1·0 mg/kg; 2–4 mg/kg in case of severe [[oliguria]] or [[anuria]] | ::*[[Furosemide]] 0·5–1·0 mg/kg; 2–4 mg/kg in case of severe [[oliguria]] or [[anuria]]. | ||
:*Note: | :*Note: alkalization of urine is not recommended to increase the excretion of [[uric acid]] (the use of [[sodium bicarbonate]] is controversial).<ref name="pmid9607427">{{cite journal| author=Ten Harkel AD, Kist-Van Holthe JE, Van Weel M, Van der Vorst MM| title=Alkalinization and the tumor lysis syndrome. | journal=Med Pediatr Oncol | year= 1998 | volume= 31 | issue= 1 | pages= 27-8 | pmid=9607427 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9607427 }} </ref> | ||
*Electrolytes disturbance: | *Electrolytes disturbance: | ||
:*[[Hyperphosphataemia]]: treatment should be initiated if [[phosphorus]] levels are ≥2·1 mmol/l | |||
::*Avoid | :*[[Hyperphosphataemia]]: treatment should be initiated if [[phosphorus]] levels are ≥2·1 mmol/l. | ||
::*Aluminium hydroxide; poorly tolerated | ::*Avoid [[intravenous]] [[phosphate]] | ||
:*[[Hypocalcemia]]: treatment should be initiated if [[calcium]] levels are ≤1·75 mmol/l | ::*[[Aluminium hydroxide]]; poorly tolerated | ||
:*[[Hypocalcemia]]: treatment should be initiated if [[calcium]] levels are ≤1·75 mmol/l. | |||
::*Asymptomatic: no treatment needed | ::*Asymptomatic: no treatment needed | ||
::*Symptomatic: [[calcium gluconate]] 50–100 mg/kg IV | ::*Symptomatic: [[calcium gluconate]] 50–100 mg/kg IV | ||
::*Cardiac monitoring is recommended if calcium level drops below ≤1.75mmol/l | ::*Cardiac monitoring is recommended if [[calcium]] level drops below ≤1.75mmol/l | ||
:*[[Hyperkalemia]]: | :*[[Hyperkalemia]]: | ||
::*Asymptomatic (≥6·0 mmol/l): | ::*Asymptomatic (≥6·0 mmol/l): | ||
:::*Avoid potassium administration | :::*Avoid [[potassium]] administration | ||
:::*Cardiac monitoring | :::*[[Cardiac monitoring]] | ||
:::*Sodium polystyrene | :::*[[Sodium polystyrene sulfonate]] | ||
::*Symptomatic (>7·0 mmol/l): | ::*Symptomatic (>7·0 mmol/l): | ||
:::*[[Cardiac monitoring]] | :::*[[Cardiac monitoring]] | ||
| Line 35: | Line 37: | ||
:::*[[Dialysis]] | :::*[[Dialysis]] | ||
:*[[Hyperuricemia]]: | :*[[Hyperuricemia]]: | ||
::*[[Allopurinol]] 10 mg/kg/d divided q8 h, reduce the dose by 50% in renal failure | ::*[[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 | ::*[[Rasburicase]] 0·05–0·20 mg/kg IV over 30 min; contraindicated in patients with [[Glucose-6-phosphate dehydrogenase deficiency|glucose 6 phosphate dehydrogenase (G6PD) deficiency]]. | ||
::*Note: the duration of treatment depends on the clinical response. | ::*Note: the duration of treatment depends on the clinical response. | ||
==References== | ==References== | ||
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[[Category:Blood]] | [[Category:Blood]] | ||
[[Category:Hematology]] | [[Category:Hematology]] | ||
[[Category:Up-To-Date]] | |||
[[Category:Oncology]] | |||
[[Category:Medicine]] | |||
Latest revision as of 13:16, 1 July 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamad Alkateb, MBBCh [2] Nazia Fuad M.D.
Overview
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.
Medical Therapy
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.
- 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
- 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
- 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.
References
- ↑ Jeha S (2001). "Tumor lysis syndrome". Semin Hematol. 38 (4 Suppl 10): 4–8. PMID 11694945.
- ↑ Cairo MS, Bishop M (2004). "Tumour lysis syndrome: new therapeutic strategies and classification". Br J Haematol. 127 (1): 3–11. doi:10.1111/j.1365-2141.2004.05094.x. PMID 15384972.
- ↑ Jones, Gail L; Will, Andrew; Jackson, Graham H; Webb, Nicholas J A; Rule, Simon (2015). "Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology". British Journal of Haematology. 169 (5): 661–671. doi:10.1111/bjh.13403. ISSN 0007-1048.
- ↑ Ten Harkel AD, Kist-Van Holthe JE, Van Weel M, Van der Vorst MM (1998). "Alkalinization and the tumor lysis syndrome". Med Pediatr Oncol. 31 (1): 27–8. PMID 9607427.