Tumor Lysis Syndrome (Truong, 11/19/2025)

 Thanks so much to our Pharmacy Resident, Lam Truong, who gave an excellent Grand Rounds this week on Tumor Lysis Syndrome.

Recording will be posted HERE when available. 

In the meantime, enjoy the cliff notes (thanks Cherie Green!)

Tumor Lysis Syndrome

• Oncological emergency from rapid breakdown of malignant cells leading to massive release of intracellular contents into bloodstream
• Overall in hospital mortality is 21%
• Most common in NHL(30%) > solid tumors (20%) > AML (19%)> ALL (13%)
• TLS can either present at initial dx with very aggressive tumors (usually lymphomas/leukemias but occasional very aggressive solid tumors), OR onset can be 3-7 days after chemotherapy - so patients with upcoming chemotherapy get labs 3 days prior to chemotherapy both to make sure they are not already in TLS and to compare post-chemo labs

Diagnosis: Prompt recognition and tx are essential….

4 Lab abnormalities for dx: 

Hyperkalemia (tumor cell lysis), Hyperphosphatemia (cell lysis), Hyperuricemia (from breakdown of DNA/RNA-crystal nephropathy), and Hypocalcemia (binds the excess phosphate)

Result:AKI (uric acid crystals, direct cytotoxicity), cardiac arrhythmias (hyperK), and seizures (metabolic disturbances), neuromuscular dysfunction (rigidity)

Symptoms: n/v/d, weakness, muscle cramps, paresthesias, seizures, arrhythmia, hypotension, HF, syncope, oliguria, hematuria, edema, joint pain - so keep your differential broad if patients present with these sxs!

Causes: chemo causing cytotoxic effects, molecular targeted therapies and immunotherapies, can occur spontaneously in setting of large tumor burden even in absence of treatment initiation

Monitor Uric acid, K Phos, Ca, Cr, LDH (high LDH represents rapid cell turnover)

Prevention of Tumor Lysis Syndrome:

Hydration protocol, closely monitor UO, dc nephrotoxins, stop all K agents 

Hypouricemic Agents for prevention and tx

Allopurinol xanthine oxidase inhibitor used in intermediate risk patients, prophylaxis in TLS but has slower onset than…

Rasburicase recombinant urate oxidase inhibitor for high risk patients and tx of active hyperuricemia works rapidly (risks: hemolytic anemia in G6PD deficiency). Loading dose 3 mg IV x 1 

Management: Use Tumor Lysis Order Set 

• Look at criteria and lab monitoring - some need additional doses of rasburicase and q6 hr labs
• HyperK: use protocol
• Hyperphos: treat first with binders and concurrently treat hypocalcemia
• HypoCa: look on the line above, don't treat first. Treat Phos first!
• HD for usual indications (refractory hyperK, fluid overload, etc)