Tumor lysis syndrome: Difference between revisions
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==Background== | ==Background== | ||
*Associated w/ treatment of ALL, Burkitt lymphoma, NHL | *Associated w/ treatment of ALL, Burkitt lymphoma, NHL | ||
**Rarely observed in solid | **Rarely observed in solid tumors or without prior therapy | ||
*Rapid turnover of tumor cells (spontaneously or after Rx) leading to release of: | *Rapid turnover of tumor cells (spontaneously or after Rx) leading to release of: | ||
**Potassium | **Potassium |
Revision as of 02:45, 3 March 2015
Background
- Associated w/ treatment of ALL, Burkitt lymphoma, NHL
- Rarely observed in solid tumors or without prior therapy
- Rapid turnover of tumor cells (spontaneously or after Rx) leading to release of:
- Potassium
- Phosphate
- Binds Ca causing hypocalcemia
- Uric acid (converted from nucleic acids)
Risk Factors
- High cell proliferation rate
- Large tumor burden (LDH) > 1500 IU/L, WBC ≥ 50 x 103 cells/L
- Extensive BM involvement
- Tumor infiltration of the kidney
Cairo-Bishop Definition
- Laboratory Tumor Lysis Syndrome
- Abnormality in 2 or more of the following, occurring w/in 3d before or 7d after chemo:
- Uric acid ≥ 8 mg/dL or 25% increase from baseline
- Potassium ≥ 6mEq/L or 25% increase from baseline
- Phosphate ≥ 4.5 mg/dL or 25% increase from baseline (≥ 6.5 for children)
- Calcium ≤ 7 mg/dL or 25% decrease from baseline
- Clinical Tumor Lysis Syndrome
- Laboratory tumor lysis syndrome plus 1 or more of the following:
- Cr > 1.5 times upper limit of age-adjusted reference range
- Cardiac dysrhythmia or sudden death
- Seizure
Clinical Features
- Hyperuricemia
- N/V, lethargy, renal failure
- Hyperkalemia
- Most immediate life-threatening element (due to dysrrhythmias)
- Hyperphosphatemia
- May combine w/ Ca to precipiate in renal tubules
- Hypocalcemia
- Acute Renal Failure
- Most common cause of morbidity
- Usually results from uric acid precipitation within renal tubules
Work Up
- CBC
- Chemistry
- Calcium, phosphate
- Uric Acid
- LDH
- UA
- ECG
- HyperK, hypoCa
Imaging
- Avoid IV contrast
Treatment
- Agressive hydration
- Goal urine output is 3L in 24hr
Hypocalcemia
- ≤7 or 25% dec in baseline
- Treat only if symptomatic (increased Ca leads to increased Ca/phos deposition), such as widened QRS or ventricular arrhythmias
- Calcium gluconate 50-200mg IV
Hyperphosphatemia
- ≥4.5 or 25% increase; ≥ 6.5mg/dL in children
- IV insulin & glucose
- Phosphate Binder - Aluminum hydroxide (50-150mg/kg PO q4-6h) - limited effect
- Dialysis if refractory
Hyperuricemia
- ≥8 or 25% increase
- Allopurinol
- Acts slowly; only helpful for preventing future production of uric acid
- 10mg/kg/d PO q8 OR 200-400 mg/m2 IV q12; renally dosed
- Inhibition of xanthine oxidase can last 18-30h
- Urate Oxidase Rx
- Rasburicase 0.05-0.2mg/kg IV)
- Can be used for BOTH prevention and treatment
- Uric acid final product of purine metabolism
- Urate oxidase converts uric acid to allantoin (5-10x more soluble)
- Allopurinol
Hyperkalemia
- Only give Ca for cardiovascular instability (e.g.ventricular arrhythmias, widened QRS)
- Giving Ca leads to increased Ca/phos deposition which leads to renal failure
- See Hyperkalemia for treatment options
Dialysis (Criteria)
- K >6
- Significant renal insufficiency (Cr >10)
- Uric Acid >10
- Symptomatic hypocalcemia
- Serum phosphorus >10
- Volume overload
Disposition
- Admit (often to ICU)
Source
- Tintinalli
- EM Practice March '10