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Tumor lysis syndrome

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of tumor lysis syndrome are prepared by our editorial team based on guidelines from the British Society for Haematology (BSH 2015) and the Clinical Pharmacogenetics Implementation Consortium (CPIC 2014). ...
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Classification and risk stratification

Risk stratification: as per BSH 2015 guidelines, evaluate the risk of risk of TLS in all patients who are due to receive chemotherapy for a hematological malignancy.
B
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Medical management

Intravenous fluids
As per BSH 2015 guidelines:
Administer balanced or isotonic crystalloid solutions to maintain urine output > 100 mL/m²/hour (target > 4 mL/kg/hour for infants).
B
Avoid adding potassium to the hydration fluid.
D

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  • Urine alkalinization

  • Rasburicase

  • Allopurinol

  • Management of hypocalcemia

Inpatient care

Cardiac monitoring: as per BSH 2015 guidelines, provide cardiac monitoring for patients with potassium levels ≥ 6 mmol/L or a ≥ 25% increase from baseline.
B

Therapeutic procedures

Dialysis: as per BSH 2015 guidelines, initiate RRT in patients with intractable fluid overload, hyperkalemia, hyperuricemia, hyperphosphatemia, or hypocalcemia.
A
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Specific circumstances

Patients with G6PD deficiency: as per CPIC 2014 guidelines, avoid withholding rasburicase based on G6PD status in patients with a normal G6PD phenotype with low or reduced risk of hemolytic anemia.
D
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Preventative measures

Urinary alkalinization: as per BSH 2015 guidelines, avoid performing urinary alkalinization as a prophylactic measure for TLS.
D

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  • Primary prophylaxis (low-risk patients)

  • Primary prophylaxis (intermediate-risk patients)

  • Primary prevention (high-risk patients)

Follow-up and surveillance

Multidisciplinary management
As per BSH 2015 guidelines:
Manage patients with established TLS in a multidisciplinary setting including a team of hematologists, nephrologists and intensive care physicians.
B
Transfer patients to an intensive care/high-dependency unit, if local facilities are not available for intensive management and monitoring.
B