Tumor lysis syndrome in the emergency department: challenges and solutions

Abstract

Tumor lysis syndrome (TLS) is the most common oncologic emergency. It is caused by rapid tumor cell destruction and the resulting nucleic acid degradation during or days after initiation of cytotoxic therapy. Also, a spontaneous form exists. The metabolic abnormalities associated with this syndrome include hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and acute kidney injury. These abnormalities can lead to life-threatening complications, such as heart rhythm abnormalities and neurologic manifestations. The emergency management of overt TLS involves proper fluid resuscitation with crystalloids in order to improve the intravascular volume and the urinary output and to increase the renal excretion of potassium, phosphorus, and uric acid. With this therapeutic strategy, prevention of calcium phosphate and uric acid crystal deposition within renal tubules is achieved. Other measures in the management of overt TLS are prescription of hypouricemic agents, renal replacement therapy, and correction of electrolyte imbalances. Hyperkalemia should be treated quickly and aggressively as its presence is the most hazardous acute complication that can cause sudden death from cardiac arrhythmias. Treatment of hypocalcemia is reserved for patients with electrocardiographic changes or symptoms of neuromuscular irritability. In patients who are refractory to medical management of electrolyte abnormalities or with severe cardiac and neurologic manifestations, early dialysis is recommended.

Tumor Lysis Syndrome Rare Presentation As Uremic Pericarditis: A Case Report

“…It might increase serum levels of the purine precursors hypoxanthine and xanthine, which may lead to xanthinuria, deposition of xanthine crystals in the renal tubules, and aggravation of AKI. Concomitantly, in the face of worsening AKI and severe hydro electrolytic alterations refractory to medical therapy, it may be necessary to institute a renal replacement technique (RRT) [5]. RRT was considered, but ultimately not necessary in the present case, since the patient improved with increased diuresis and slowly reestablished kidney function.…”

“…According to the Cairo&Bishop Classification, it is defined by the presence of two or more laboratory criteria (hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia), in the period between three days before and seven days after the start of chemotherapy; and clinical criteria: worsening renal function (AKI), convulsions, arrhythmias or death [3]. This definition has several limitations: it implies the initiation of chemotherapy, not considering situations of spontaneous TLS, uses a serum creatinine value greater than 1.5 times the normal as a diagnostic criterion for AKI, and does not mention the need for simultaneous occurring metabolic changes [4,5]. However, it remains the most used classification.…”

Dialysis as a Novel Adjuvant Treatment for Malignant Cancers

“…Ingestion or infusion of bicarbonate may lead to life-threatening adverse side effects such as hypokalemia, and the risk-to-benefit ratio for such an action may be too high [ 37 , 117 ]. During dialysis, the ion composition in the blood is controlled and severe side effects from ion imbalances from the raised bicarbonate are actively avoided [ 118 ].…”

The intersection of oncology, nephrology, and palliative care

“…Larger disease burden and efficacy is associated with the development of TLS; however the complication of AKI is a strong predictor of death in TLS. 17,[40][41][42] The 6 month mortality of TLS dramatically increases in the presence of AKI (66% versus 21% without), 43 while inpatient mortality approaches 21%. 44 Thrombotic microangiopathy (TMA) from chemotherapy can be caused by a variety of agents, most notably by cisplatin, gemcitabine, mitomycin-C and VEGF inhibitors.…”