Tumour Lysis Syndrome 🧬
Emergency management of tumour lysis syndrome: recognition, prevention, treatment, and monitoring for NCHDs.
🚨 Definition & Recognition
- Metabolic emergency caused by rapid lysis of tumour cells, releasing intracellular contents into circulation
- Typically occurs within 12-72 hours after starting chemotherapy (can occur spontaneously)
- Characterized by: Hyperuricaemia, Hyperkalaemia, Hyperphosphataemia, Hypocalcaemia
- Can lead to acute kidney injury, cardiac arrhythmias, seizures, and death if untreated
- Medical emergency - requires immediate intervention
⚠️ High-Risk Patients
- High tumour burden: Burkitt lymphoma, ALL, AML (especially high WCC >50 x 10⁹/L)
- Aggressive lymphomas: DLBCL, T-cell lymphomas
- Pre-existing renal dysfunction or elevated baseline uric acid
- Dehydration or poor urine output
- High sensitivity tumours: Small cell lung cancer, germ cell tumours
- Patients receiving fludarabine, cladribine, or other high-risk regimens
⚡ Immediate Actions (First Hour)
- ABC assessment and continuous cardiac monitoring (risk of arrhythmias)
- IV access and start aggressive IV hydration: 3L/m²/day minimum
- U&E, uric acid, phosphate, calcium, LDH immediately
- FBC, magnesium, LFTs, coagulation
- ECG (risk of hyperkalaemia-induced arrhythmias)
- Hourly urine output monitoring (target >100ml/hr)
- Notify oncology/haematology team immediately
- Consider ICU admission if severe or worsening
📊 Diagnostic Criteria (Cairo-Bishop)
- Laboratory TLS: 2 or more of the following within 3 days of treatment:
- • Uric acid >476 μmol/L (8mg/dL) or 25% increase
- • Potassium >6.0 mmol/L or 25% increase
- • Phosphate >1.45 mmol/L (adults) or >2.1 mmol/L (children) or 25% increase
- • Calcium <1.75 mmol/L or 25% decrease
- Clinical TLS: Laboratory TLS + one of:
- • Creatinine >1.5x ULN or oliguria (<0.5ml/kg/hr for 6 hours)
- • Cardiac arrhythmia/ sudden death
- • Seizure
💊 Prevention (High-Risk Patients)
- Start 24-48 hours BEFORE chemotherapy:
- • IV hydration: 3L/m²/day (or 125-150ml/hr)
- • Allopurinol: 300mg PO daily (reduce dose if eGFR <30)
- • Consider rasburicase if uric acid >476 μmol/L or high risk
- Monitor U&E, uric acid, phosphate, calcium daily
- Maintain urine output >100ml/hr with IV fluids and diuretics if needed
- Avoid potassium/phosphate supplements
🩺 Treatment (If TLS Develops)
- IV Hydration: Aggressive 3-4L/m²/day (125-200ml/hr) to maintain high urine output
- Rasburicase: 0.15-0.2mg/kg IV once daily (reduces uric acid rapidly)
- • Check G6PD deficiency before use (risk of haemolysis)
- • Usually 1-3 days, monitor uric acid daily
- Allopurinol: 300mg PO daily (if rasburicase not available or as adjunct)
- Hyperkalaemia: Treat aggressively - see hyperkalaemia protocol
- • Calcium gluconate 10ml 10% IV (cardiac protection)
- • Insulin/dextrose, salbutamol, consider dialysis
- Hyperphosphataemia: Phosphate binders (calcium carbonate/sevelamer), restrict phosphate
- Hypocalcaemia: Only treat if symptomatic or severe - avoid overcorrection
- Monitor closely: U&E, uric acid, phosphate, calcium every 6-12 hours initially
📋 Monitoring
- Baseline: U&E, uric acid, phosphate, calcium, LDH, FBC, ECG
- During prophylaxis: Daily U&E, uric acid, phosphate, calcium
- If TLS develops: U&E, uric acid, phosphate, calcium every 6-12 hours
- Continuous cardiac monitoring (hyperkalaemia risk)
- Hourly urine output (target >100ml/hr)
- Daily weight, fluid balance
- Regular ECG (monitor for arrhythmias)
- Continue monitoring for 48-72 hours post-chemotherapy
⚠️ Red Flags - Escalate Immediately
- ECG changes: Peaked T-waves, prolonged PR, wide QRS (hyperkalaemia)
- Cardiac arrhythmias or sudden deterioration
- Seizures or altered consciousness
- Oliguria/anuria or rising creatinine
- Uric acid >600 μmol/L despite treatment
- Severe electrolyte abnormalities not responding to treatment
- Signs of fluid overload (pulmonary oedema)
🏥 Renal Replacement Therapy
- Indications for dialysis:
- • Severe AKI (creatinine >3x baseline or oliguria/anuria)
- • Hyperkalaemia >6.5 mmol/L despite medical treatment
- • Severe hyperphosphataemia causing symptoms
- • Fluid overload with pulmonary oedema
- • Metabolic acidosis refractory to treatment
- Early nephrology consult recommended if AKI developing
- Rasburicase can reduce need for dialysis if given early