Tumor lysis syndrome medical therapy

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

Overview

Tumor lysis syndrome is a medical emergency and requires prompt treatment.

Medical Therapy

• Intra venous fluids:

• Aggressive hydration (3 l/m2/d)
• Diuretics:

• Mannitol (0·5 mg/kg)
• Furosemide (0·5–1·0 mg/kg)

• Alkalization of urine is recommended to increase the excretion of uric acid (the use of sodium bicarbonate is controversial)

• Electrolytes disturbance:

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

• Avoid intra venous phosphate
• Aluminium hydroxide (15 ml q6h)

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

• Asymptomatic: not treatment needed
• Symptomatic: calcium gluconate (50–100 mg/kg IV)

• Hyperkalemia:

• Asymptomatic (≥6·0 mmol/l): avoid potassium administration, ECG, sodium polystyrene sulphonate
• Symptomatic (>7·0 mmol/l): add calcium gluconate (100–200 mg/kg) IV and/or regular insulin (0·1 unit/kg IV) + D25 (2 ml/kg) IV, and 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)

• Acute renal failure prior to chemotherapy. Since the major cause of acute renal failure in this setting is uric acid build-up, therapy consists of rasburicase to wash out excessive uric acid crystals as well as a loop diuretic and fluids. Sodium bicarbonate should not be given at this time. If the patient does not respond, hemodialysis may be instituted, which is very efficient in removing uric acid, with plasma uric acid levels falling about 50% with each six hour treatment.

• Acute renal failure after chemotherapy. The major cause of acute renal failure in this setting is hyperphosphatemia, and the main therapeutic means is hemodialysis. Forms of hemodialysis used include continuous arteriovenous hemodialysis (CAVHD), continuous venovenous hemofiltration (CVVH), or continuous venovenous hemodialysis (CVVHD).