• Be wary of hyperkalemia.
• Continuous cardiac monitoring is necessary.
• Involve intensivist, hematologist, oncologist, and nephrologist early

• Tumor lysis syndrome (TLS) is a life-threatening condition that occurs when malignant cells break down rapidly.
• TLS can occur spontaneously or as a result of a recently started cancer therapy (chemotherapy, radiation, targeted therapy, steroids, hormonal therapy).
• Mortality rates are up to 20%.
• TLS risk factors:
  • Tumours with higher turnover, and those with higher responsiveness to therapy.
  • High burden of tumours.
  • Renal impairment.
  • Treatment with cancer therapies.
  • Use of medications/substances that increase uric acid levels (e.g., alcohol, vitamin C, aspirin, caffeine, epinephrine, thiazide diuretics, levadopa).
• Higher risk malignancies:
  • Acute lymphocytic leukemia (ALL).
  • Acute myeloid leukemia (AML).
  • Burkitt lymphoma.
  • large B-cell lymphoma.
  • T-cell non-Hodgkins lymphoma.

• Presentation of TLS is non-specific and may include:
  • Nausea, vomiting, diarrhea, anorexia, seizures, muscle weakness and cramps, tetany, cramps, pain, oliguria/anuria, confusion, kidney injury/failure, abnormal heart rhythms, palpitations.
  • TLS can lead to hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and acute kidney injury (AKI).
• To diagnose TLS, need 2 or more of the following:
  • Uric acid (≥ 476 μmol/L or 25% increase from baseline).
  • Potassium (≥ 6.0 mmol/L or 25% increase).
  • Phosphate (≥ 1.45 mmol/L [adults] or ≥ 2.1 mmol/l [children] or 25% increase).
  • Calcium (≤ 1.75 mmol/L or 25% decrease).

• Goal is to manage electrolyte imbalances, improve volume status, and excrete uric acid/phosphate.
• Aggressive IV fluid hydration (normal saline)
  • Aim for urine output of 100 mL/m²/hr in adults or >4 ml/kg/hr in infants.
  • Deliver fluid at rate of 3 L/m² per 24 h in adults.
  • Do not add potassium to hydration fluid.
• Rasburicase if uric acid is elevated
  • 2 mg/kg/day given as a 30-min infusion daily for 3-7 days with electrolyte monitoring.
  • Use allopurinol if patient has G6PD deficiency.
• Hyperkalemia:
  • See Hyperkalemia Clinical Summary: https://emergencycarebc.ca/clinical_resource/hyperkalemia-diagnosis-and-treatment/
• • Infusion of calcium gluconate
    • Hyperkalemic adults with EKG changes (prolonged PR or QRS) related to hyperkalemia may be given 1000 mg/kg; 100-200 mg/kg for children over 2-3 minutes.
  • IV insulin + glucose can be used for temporary stabilization.
  • NaHCo3.
  • Recommended to administer oral potassium-lowering agents such or AKI and TLS
    • Avoid sodium polystyrene sulfonate (Kayexelate) unless no other options due to adverse effects reported of colonic necrosis.
• Phosphate binders for hyperphosphatemia
  • 50–150 mg/kg/day PO.
  • Not recommended if poorly tolerated by patient.
• Calcium for symptomatic hypocalcemia (seizures, arrhythmias, tetany)
  • Calcium administration at lowest possible dose to alleviate symptoms.
  • Do not treat if asymptomatic hypocalcemia.
  • If a patient has hyperphosphatemia and hypocalcemia, do not treat hypocalcemia until hyperphosphatemia is corrected unless there are severe arrhythmias or tetany due to hypocalcemia.

Hemodialysis is indicated if there is: severe AKI, persistent hyperkalemia, symptomatic hypocalcemia secondary to hyperphosphatemia, calcium-phosphate product ≥70 mg²/dL² uncontrolled fluid overload.

1. • https://www.uptodate.com/contents/tumor-lysis-syndrome-pathogenesis-clinical-manifestations-definition-etiology-and-risk-factors?sectionName=Hyperphosphatemia&topicRef=17050&anchor=H491579&source=see_link#H491579
   • https://www.uptodate.com/contents/treatment-and-prevention-of-hyperkalemia-in-adults?topicRef=17050&source=see_link
   • https://www.uptodate.com/contents/overview-of-the-causes-and-treatment-of-hyperphosphatemia?topicRef=17050&source=see_link
   • https://www.uptodate.com/contents/treatment-of-hypocalcemia?topicRef=17050&source=see_link
   
   

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5. Larson RA, Pui C-H. Tumor lysis syndrome: Prevention and Treatment [Internet]. 2023 [cited 2024 Jan 2]. Available from: https://www.uptodate.com/contents/tumor-lysis-syndrome-prevention-and-treatment#H21712100