Today, Dr. Adrian Garcia presented an interesting case of tumor lysis syndrome in a patient with uncontrolled CML

Tumor lysis syndrome is a constellation of lab abnormalities caused my massive tumor cell lysis and is considered an oncologic emergency.  Classically, it presents soon after the initiation of cytotoxic therapy, but spontaneous TLS can also occur (usually in hematologic malignancies including leukemia and lymphoma).

It’s symptoms are nonspecific, but can include constitutional symptoms (anorexia, lethargy, nausea), symptoms of nephrolithiasis (hematuria, flank pain), and consequences of electrolyte abnormalities (heart failure, arrhythmias, seizures, muscle cramps, tetany, syncope, and sudden death). Lab findings include the following:

• Byproducts of cell-lysis:
  • Hyperphosphatemia
  • Hyperkalemia
  • Hyperuricemia (nucleic acids are broken down into uric acid)
• Secondary hypocalcemia caused by hyperphosphatemia
• Acute kidney injury due to nephrolithiasis from uric acid and calcium phosphate stones

The treatment of tumor lysis syndrome includes:

• High-volume normal saline with a loop diuretic to wash out renal crystals
• Electrolyte correction:
  • Rasburicase for hyperuricemia
  • Phosphate binders for hyperphosphatemia
  • Hyperkalemia treatment: Kayexalate, insulin/D50, bicarb, albuterol, calcium gluconate if EKG changes
  • Do not treat hypocalcemia unless symptomatic due to increased risk of calcium phosphate precipitation in the renal tubules
• Indications for hemodialysis:
  • severe oliguria or anuria
  • intractable fluid overload
  • persistent hyperkalemia
  • hyperphosphatemia-induced symptomatic hypocalcemia
  • calcium-phosphate product >= 70

Thanks so much for following along with our interesting cases.