Tumor Lysis Syndrome (TLS) Prevention & Management

Algorithm Steps

1. ▶

   Start

   Patient at Risk for Tumor Lysis Syndrome

   Initiating cytotoxic therapy for malignancy with high tumor burden

   1. ◆

      Decision

      Assess TLS Risk Category

      Based on tumor type, burden, and treatment

      • HIGH RISK: Burkitt lymphoma, ALL with WBC >100k, AML with WBC >100k, bulky NHL with elevated LDH
      • INTERMEDIATE: ALL with WBC 50-100k, AML with WBC 25-100k, DLBCL, CLL treated with venetoclax
      • LOW RISK: Solid tumors, indolent lymphomas, CLL with WBC <50k
      1. ●

         Action

         HIGH RISK: Rasburicase + Aggressive Hydration

         Intensive prophylaxis required

         • Rasburicase 0.2 mg/kg IV single dose (max 7.5mg)
         • May repeat if uric acid remains elevated
         • IV fluids 2.5-3 L/m²/day (avoid K+, phosphate)
         • Monitor labs Q6h during treatment initiation
         • Hold allopurinol (interferes with uric acid monitoring)
         1. ⚠

            Warning

            ⚠️ G6PD Deficiency

            Rasburicase CONTRAINDICATED - causes severe hemolysis

            • Screen all patients before rasburicase
            • Use allopurinol or febuxostat instead
            • Higher risk in African, Mediterranean, Asian descent
         2. ●

            Action

            Laboratory Monitoring

            Check electrolytes and renal function frequently

            • Potassium, Phosphorus, Calcium, Uric acid, Creatinine, LDH
            • High risk: Q4-6h for first 24-48h
            • Intermediate: Q8-12h
            • ECG monitoring for hyperkalemia
            1. ◆

               Decision

               Laboratory TLS Present?

               Cairo-Bishop Criteria (≥2 abnormalities)

               • Uric acid ≥8 mg/dL or 25% increase
               • Potassium ≥6 mEq/L or 25% increase
               • Phosphorus >4.5 mg/dL (adult) or 25% increase
               • Calcium ≤7 mg/dL or 25% decrease
               1. ◆

                  Decision

                  Clinical TLS Present?

                  Lab TLS + End-organ dysfunction

                  • AKI: Creatinine ≥1.5x ULN
                  • Cardiac arrhythmia or sudden death
                  • Seizures
                  • Death attributable to TLS
                  1. ●

                     Action

                     Treat Hyperkalemia

                     Life-threatening - treat immediately

                     • K+ >6 or ECG changes: Calcium gluconate 1-2g IV
                     • Insulin 10U regular + D50 50mL IV
                     • Albuterol nebulized 10-20mg
                     • Kayexalate 30-60g PO/PR (delayed effect)
                     • Dialysis if refractory
                     1. ◆

                        Decision

                        Renal Replacement Therapy Needed?

                        Indications for urgent dialysis

                        • Refractory hyperkalemia despite medical therapy
                        • Severe hyperphosphatemia (>10 mg/dL)
                        • Volume overload unresponsive to diuretics
                        • Symptomatic uremia
                        • Oliguria/anuria with rising creatinine
                        1. ●

                           Action

                           Initiate Renal Replacement Therapy

                           CRRT preferred for hemodynamic instability

                           • CRRT (CVVHD/CVVHDF) for unstable patients
                           • Intermittent HD if hemodynamically stable
                           • High-flux dialyzer for uric acid clearance
                           • May need extended or daily treatments initially
                           1. ●

                              Action

                              Continue Aggressive Monitoring & Hydration

                              Maintain until TLS resolves

                              • Continue IV fluids to maintain UOP >100 mL/m²/hr
                              • Labs Q6-8h until stable
                              • May resume/continue chemotherapy when stable
                              • Typically resolves within 5-7 days
                              1. ✓

                                 Outcome

                                 TLS Resolved - Continue Cancer Treatment

                                 Electrolytes normalized, renal function stable

                  2. ●

                     Action

                     Treat Hyperphosphatemia

                     Reduces calcium and causes precipitation

                     • Phosphate binders: Sevelamer 800mg TID with meals
                     • Aluminum hydroxide (short-term only)
                     • Restrict dietary phosphorus
                     • Dialysis for severe/refractory cases
                  3. ●

                     Action

                     Treat Hypocalcemia

                     Only if symptomatic (tetany, seizures, QTc prolongation)

                     • SYMPTOMATIC: Calcium gluconate 1-2g IV slowly
                     • ASYMPTOMATIC: Monitor only - avoid calcium unless symptomatic
                     • Calcium infusion can worsen calcium-phosphate precipitation
                     • Correct phosphorus first
      2. ●

         Action

         INTERMEDIATE RISK: Allopurinol + Hydration

         Standard prophylaxis

         • Allopurinol 300mg PO BID (start 2-3 days before chemo)
         • IV fluids 2-2.5 L/m²/day
         • Monitor labs Q8-12h initially
         • Escalate to rasburicase if uric acid rises >8 mg/dL
         • Consider rasburicase if baseline uric acid elevated
      3. ●

         Action

         LOW RISK: Hydration + Monitoring

         Minimal prophylaxis

         • Oral hydration 2L/day or IV 2L/m²/day
         • Monitor labs daily
         • Consider allopurinol if any risk factors present
         • Escalate if uric acid rises