Tumor Lysis Syndrome

Leave a comment

May 30, 2017 by dailybolusoflr

By: Shaughn Keating


Most often caused by chemotherapy leading to massive cell turnover; often seen with rapidly proliferative hematologic malignancies such as: AML with WBC >50,000, ALL with WBC >100,000, high grade lymphomas (e.g Burkitt, T cell NHL), ALL

Less common in solid tumors – more likely in those with high tumor burden and high chemo-sensitivity (germ cell tumors, bulky SCLC, large HCC)

Can be seen spontaneously – most often in new diagnoses of hematologic malignancies, almost never with solid tumors

Pathogenesis and Pathophysiology

Lysis of of tumor cells leads to massive release of potassium and phosphate

Hyperkalemia is the most acutely dangerous outcome and can lead to death from cardiac dysrhythmias

Hyperphosphatemia can lead to secondary hypocalcemia, potentiating dysrhythmias, myocardial depression, hypotension, bronchospasm, and seizures

Intratubular crystallization which leads obstruction and AKI


Send: UA, uric acid, phosphorous, magnesium and ionized calcium in addition to standard labs.

Also check EKG for arrhythmias and conduction delays

LDH >2 x upper limit of normal also may suggest a large tumor burden

Given risks of hyperleukocytosis, leukostasis, hyperviscosity syndrome, and DIC as alternative or concomitant diagnoses, also consider sending coagulation studies, type and screen, and plasma viscosity

Laboratory diagnosis: Two of the following 3 days before or 7 days after start of chemo:

  1. Uric acid >8.0 mg/dl
  2. Phosphorus >4.5 mg/dl (or >6.5 mg/dl in children)
  3. Potassium >6.0 mg/dl
  4. Corrected Ca <7.0 or iCal <1.12

Clinical diagnosis: Laboratory features plus one of the following:

  1. AKI (Cr increase by 0.3 mg/dl or Cr 1.5 x the upper limit of normal)
  2. Oliguria (UOP <0.5ml/kg/hr)
  3. Cardiac dysrhythmia (or sudden death from likely dysrhythmia)
  4. Seizures or other signs of symptomatic hypocalcemia (tetany, hypotension, etc)


Hydration: D5 1/4 NS for euvolemic patient with a goal urine output of 100 cc/hr

Rasburicase: for all patients with clinical or laboratory TLS; works by converting uric acid into soluble allantoin. In contrast, allopurinol only prevents formation of uric acid. Dose – 0.15-0.2 mg/kg in 50 mL normal saline IV over 30 minutes daily for 5 days

Urine alkalization: Consider if rasburicase is unavailable. Goal urine pH 7-7.5. Avoid higher pH, which can precipitate xanthine or hypoxanthine

Pearls for treatment: Do not treat asymptomatic hypocalcemia; this may precipitate calcium phosphate and induce kidney injury.


Howard SC, Jones DP, Pui CH. “The tumor lysis syndrome.” New England Journal of Medicine. 2011 May 12;364(19):1844-54


Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: