Patients should avoid foods high in potassium, phosphorous, and uric acid; health care practitioners should avoid administering medications in fluids high in those components. Renal consultation should also be done early in the patient’s care to assist in the electrolyte management.

Hyperphosphatemia, which is associated with TLS, can be treated using binders such as lanthanum, sevelamer, calcium carbonate, and aluminum hydroxide. Moderate hyperkalemia (potassium between 5 and 7 mEq/L) can be treated with a binder such as sodium polystyrene sulfonate, though only if there are no significant ECG changes.


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Hyperkalemic patients who are symptomatic, who have significant ECG changes, or who have a level greater than 7 mEq/L require more aggressive therapy, including intravenous calcium gluconate and an agent aimed at shifting the potassium intracellularly. This intracellular shift is only temporary, so these patients require close cardiac monitoring, frequent labs, and fluid hydration. Hyperkalemia has the most potential for causing deleterious effects because of its potential to induce life-threatening arrhythmias.

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Patients with hypocalcemia should have their hyperphosphatemia corrected before calcium is administered to avoid binding and precipitation leading to further kidney injury. If, however, the patient is acutely hypocalcemic and symptomatic, she/he should receive intravenous calcium gluconate to avoid the development of cardiac or neurologic sequelae. Patients who have low calcium levels and no symptoms are typically not treated.

Rasburicase is an intravenous medication that promotes the conversion of uric acid to allantoin, an inactive soluble metabolite that assists in lowering uric acid levels.4 It can be used in patients with high-risk malignancies to prevent TLS and for TLS treatment.

Although rasburicase has data to support preventive and treatment indications in TLS, its cost and unclear impact on direct clinical outcomes make routine use challenging.5 Rasburicase has, furthermore, several black box warnings, including methemoglobinemia, hypersensitivity reactions, and hemolysis in patients with glucose-6-phosphate dehydrogenase deficiency. These warnings may preclude some patients from initiating therapy.

References

  1. Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011;364(19):1844-54. doi: 10.1056/NEJMra0904569
  2. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127(1):3-11.
  3. Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008;26(16):2767-78. doi: 10.1200/JCO.2007.15.0177
  4. Elitek prescribing information. Sanofi website. http://products.sanofi.us/elitek/elitek.html. Accessed January 2018.
  5. Lopez-Olivo MA, Pratt G, Palla SL, Salahudeen A. Rasburicase in tumor lysis syndrome of the adult: a systematic review and meta-analysis. Am J Kidney Dis. 2013;62(3):481-92. doi: 10.1053/j.ajkd.2013.02.378