Outcome of tumor lysis syndrome in pediatric patients with hematologic malignancies – a single-center experience from Pakistan

Abstract

Background Tumor lysis syndrome (TLS) is serious complication of anticancer chemotherapy, leading to substantial morbidity and mortality in adults and pediatric patients. Objective To report the incidence and outcomes of TLS in pediatric patients with hematologic malignancies at a center in Pakistan. Methods Retrospective chart review of 317 pediatric patients with hematologic malignancies during January 2008-December 2013. Demographic features and clinical and laboratory parameters of TLS, with immediate and 6-month outcomes were determined using a semi-structured questionnaire. Results Median age at diagnosis was 9 years, with the 79.2% patients being male. Laboratory TLS was present in 36 patients (11.4%), with 27 (8.5%) developing clinical TLS and 13 (4.1%) requiring intensive care support. Hyperphosphatemia was the most frequent metabolic abnormality (14.2%), followed by hypocalcemia (13.9%), hyperuricemia (12.6%), and hyperkalemia (1.3%). 45 patients (14.2%) developed acute kidney injury (AKI). Patients who developed TLS had a signi cantly higher white blood cell count at initiation of chemotherapy (142.0 x 10 9 /L [SD, 173.1] vs 31.5 x 10 9 /L [SD, 58.0]; P = .01) and a higher incidence of AKI (58.3% vs 8.5% of patients; P < .001). Limitations Retrospective design of study, high rate of loss to follow-up, and unavailability of lactate dehydrogenase levels in a majority of patients. Conclusion The incidence of TLS pediatric hematologic malignancies was 11.4% at our center. The main cause of death was sepsis. Hyperphosphatemia was the common metabolic derangement and hyperkalemia was the least common. TLS warrants intensive supportive care to prevent further morbidity and decrease mortality.

Tumor lysis syndrome in pediatric acute lymphoblastic leukemia at tertiary care center

“…Almost all children with high risk stratification (n=56) and pre-B cell leukemia had developed TLS in our study. Similar prevalence of TLS in high risk ALL (all 36 patients) and pre-B cell phenotyping has been reported by Mansoor et al and Saeed F et al (37%) recently 20,23…”

“…19 In local studies on various aspects of childhood ALL, the reported frequency of TLS varies from 10-39%. 7,10,20 This wide variation in range of incidence of TLS could be explained on lack of standard criteria for diagnosis of TLS, variation in prophylaxis protocol and patients cohort, age difference and stage of disease, delayed diagnosis ,delay in initiation of chemotherapy and lack of use of effective preventive therapy (like rasburicase) particularly in developing countries. 14,15,21 Considering the biochemical abnormalities in children with TLS, most common abnormality was hyperuricemia (59.3%) followed by hyperphosphatemia (53.8%).…”

“…Similar prevalence of TLS in high risk ALL (all 36 patients) and pre-B cell phenotyping has been reported by Mansoor et al and Saeed F et al (37%) recently. 20,23 The prevalence of AKI in different studies varies from 5-40% but more recent reports suggest that incidence of AKI varies from14.2-75% depending upon type of patients more in aggressive lymphomas and leukemias. Khalil and colleagues reported AKI in 31.8% in adults with lymphoma whereas Waseem et al has shown AKI in 40% cases.…”

Risk factors of acute kidney injury in pediatric acute lymphoblastic leukemia with hyperleukocytosis ymphoblastic Leukemia

“…Hyperphosphatemia increases the formation of calcium phosphate crystals, increasing the risk of AKI. 16 This finding could be of substantial help to clinicians who are considering aggressive hyperphosphatemia therapy to reduce phosphate levels in pediatric ALL patients with hyperleukocytosis, either using aggressive fluid therapy or with phosphate binders.…”

“…10 Hyperuricemia was found to increase the risk of AKI by 4.32-fold in children with hematologic malignancies (OR 4.32; 95%CI 1.60 to 11.67). 16 The increment of calcium phosphate solubility to more than 60 mg/dL increases precipitation risk in microvascularization and renal tubules. 10 A study in adult patients at Seoul National University Bundang Hospital showed that a patient group with phosphate concentration > 3.8 mg/dL had 2.8 times the risk of developing AKI (OR 2.8; 95%CI 2.44 to 3.22).…”