Tumor Lysis Syndrome
Tumor lysis syndrome is an oncological emergency. The massive turnover of tumor cells leads to accumulation of electrolytes and uric acid that could lead to renal failure and cardiac arrhythmias. There are clinical and laboratory classifications of tumor
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Himaja Koneru and Paul D. Bozyk
Case Presentation A 72 year old woman with no significant past medical history presented with abnormal labs from an urgent care facility. Her initial labs showed marked absolute lymphocyte leukocytosis of 1789.4 × 106 cells/mm3 with morphology suggesting Chronic Lymphocytic Leukemia. There was no evidence of acute tumor lysis syndrome at initial presentation as suggested by a potassium of 4.4 mEq/dL, uric acid of 4.7 mg/dL, calcium of 9.1 mg/dL and phosphorus level of 3.9 mg/dL. She was started on hydroxyurea, intravenous hydration, and allopurinol for prevention of tumor lysis syndrome. Flow cytometry revealed positivity for ATM and MYB gene deletions as well as del(13q) chromosome. Following initiation of therapy, the patient developed hyperkalemia resistant to medical treatment including sodium polystyrene sulfonate, calcium gluconate and insulin with dextrose, and was started on hemodialysis. Due to her confirmed diagnosis of chronic lymphocytic leukemia (CLL), she was started on induction chemotherapy with Rituximab and Bendamustine. A day later, her H. Koneru Internal Medicine, Beaumont Health, Royal Oak, MI, USA P.D. Bozyk (*) Medical Intensive Care Unit, Department of Medicine, Beaumont Health, Royal Oak, MI, USA e-mail: [email protected]
labs demonstrated elevated potassium to 6.7 mEq/ dL, phosphorus to 16.6 mg/dL, and uric acid to 9.0 mg/dL. She also exhibited hypocalcemia, at 6.9 mg/dL. Question What is the cornerstone of management of acute tumor lysis syndrome? Answer Intensive supportive care for renal insufficiency and electrolyte abnormalities. The optimal management of acute tumor lysis syndrome is preservation of renal function and prevention of life threatening cardiac arrhythmias and neuromuscular irritability by providing the best supportive care. The patient was transferred to the medical ICU for management of acute tumor lysis syndrome. She was given aggressive fluid hydration. Continuous renal replacement therapy was considered, though deferred given normal hemodynamics. Her potassium, phosphate, calcium and uric acid levels were monitored every 6 h and were managed appropriately. No significant dysrhythmias occurred during her course. Her electrolyte abnormalities subsequently resolved. She was transferred back to the general medical floor. Her renal function completely recovered eliminating the need for further renal replacement and she was subsequently discharged home and therapy. She was continued on allopurinol as an outpatient and has not had a recurrent episode of tumor lysis syndrome.
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_75
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Principles of Management here Are Laboratory and Clinical T Classifications of Tumor Lysis Syndrome (TLS) There are several different definitions of TLS which contain laboratory and clinical classifications, as can be found here [1]. According to Cairo and Bishop [2] laboratory TLS is diagnosed when two or more
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