Synopsis
Predict, prevent, recognise and treat tumour lysis syndrome before potassium, phosphate, urate and calcium disturbances cause arrhythmia, seizure, acute kidney injury or death.
- TLS releases potassium, phosphate and nucleic acid from malignant cells; phosphate lowers calcium and purines become uric acid, producing arrhythmia, seizure and acute kidney injury.
- Assess risk before treatment from malignancy type, burden, LDH, white-cell count, treatment sensitivity, baseline urate, renal function, hydration, obstruction and nephrotoxic medicines.
- First-line baseline tests are potassium, phosphate, adjusted and preferably ionised calcium when symptomatic, urate, creatinine, urea, bicarbonate, LDH, FBC, ECG and accurate fluid balance.
Key red flags
ECG change, muscle weakness, bradycardia, ventricular arrhythmia or potassium at a severe threshold needs immediate UK Kidney Association hyperkalaemia treatment while tumour lysis is controlled.
Weakness, paraesthesia, bradycardia, broad QRS, loss of P waves, sine-wave change or ventricular arrhythmia is an immediate resuscitation problem.
Investigation priorities
Detect the biochemical pattern and immediately dangerous membrane toxicity.
Management branches
A treatment-responsive malignancy is about to receive systemic therapy, corticosteroid prephase or another rapid tumour-reducing intervention.
- Classify tumour and patient risk using diagnosis, burden, LDH, white-cell count, renal reserve, urate, hydration, obstruction and planned treatment.
- Correct volume depletion, stop avoidable nephrotoxins and potassium or phosphate supplements and choose ward, high-dependency or ambulatory monitoring appropriate to risk.
Key medicines
AllopurinolGive 300 mg orally once daily, or 100 mg three times daily, usually starting 24 to 48 hours before tumour-reducing treatment and continuing until the lysis-risk period has passed; reduce dose for renal impairment under the haematology protocol.
RasburicaseGive 0.2 mg/kg intravenously once daily as a 30-minute infusion for up to 7 days, with duration determined by baseline burden, treatment response and serial urate under the current BSH and product protocol.