Correction from The New England Journal of Medicine — The Tumor Lysis Syndrome. Correspondence from The New England Journal of Medicine — The Tumor Lysis Syndrome. N Engl J Med. May 12;(19) doi: /NEJMra The tumor lysis syndrome. Howard SC(1), Jones DP, Pui CH. Author information.

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Tumor lysis syndrome TLS is characterized by a massive tumor cell death leading to the development of metabolic derangements and target organ dysfunction.

Acute Kidney Injury in Patients with Cancer

Administration of loop diuretics may also improve control of hyperkalemia neim patients with TLS. What are some of the renal injuries associated with the newer targeted anticancer agents? Targeted agents, defined as drugs designed to target specific gene mutations in malignant tissue, inhibit oncogenic signaling cascades associated with tumor growth. However, the management of hyperkalemia should always start from a lead ECG.

Also, an alkaline pH promotes calcium binding to albumin, which can be very dangerous in patients with TLS who tend to have lower calcium levels at baseline, leading to neuromuscular and cardiac toxicity. TLS is an oncometabolic emergency resulting from rapid cell death. Phosphate binders include calcium containing medications such as calcium acetate and calcium carbonate, as well as non-calcium phosphate binders such as sevelamer and lanthanum[ 31 ].

However, it is essential to mention that several small studies, most of which are retrospective in nature, have demonstrated that a single dose of rasburicase was effective[ 25 – 27 ]. Nephrotoxic effects often develop from overproduction of monoclonal immunoglobulins and free light chains, leading to cast nephropathy the most common cause of acute kidney injurylight-chain—related proximal tubular injury, and various glomerulopathies such as light-chain deposition disease and amyloid light-chain AL amyloidosis.

Thus, a thorough clinical history is of paramount importance when dealing with a cancer patient who has presented with an acute decline xyndrome kidney function. Another aspect of the risk stratification which we use is the type and burden of malignancy. Rasburicase should be used in individuals who are at high risk of developing TLS and in patients whose baseline uric acid is higher than 7.

Rheumatology Oxford ; Tumor lysis njem can occur as a consequence of tumor targeted therapy or spontaneously.


tumlr Clin J Am Soc Nephrol. Some aspects of prevention include adequate hydration, use of uric acid lowering therapies, use of phosphate binders, and the minimization of potassium intake. Briefly, elevated levels of uric acid should be treated with rasburicase, unless contraindicated, in doses of at least 0. Create your account Back to Social Login. However, the role of loop diuretics is not based on solid data; thus, it should be approached on an individual basis. Log in via Email.

It is reasonable to monitor patients for at least 24 h after discontinuation of TLS prophylaxis to ensure no development of TLS.

One aspect of the management of elevated phosphorus in patients with TLS includes the restriction in phosphorus intake, both in diet and IV fluids.

In conclusion, it is important to note that preexistent renal disease and the characteristics of certain patients increase the risk of full-blown clinical TLS. National Center for Biotechnology SyndrkmeU.

It is also important to note that the use of phosphate binders in the prevention of TLS was not specifically studied in the literature. Neurologic complications of electrolyte disturbances and acid-base balance. Another important aspect which we routinely assess in our patients is the use of medications capable of detrimentally affecting renal function such as non-steroidal anti-inflammatory drugs, inhibitors of the angiotensin converting enzyme, and angiotensin receptor blockers, especially in patients with decreased tuomr status[ 4 ].

A medication mimicking urate oxidase named rasburicase was approved by Food and Drug Association in for use in subjects at risk of TLS[ 21 ]. Request to Join has invited you to join this group. The reader is referred to a detailed review on the management of hyperkalemia[ 32 ]. Established tumor lysis syndrome should lysia treated in the intensive care unit by aggressive hydration, possible use of loop diuretics, possible use of phosphate binders, use of uric acid lowering agents and dialysis in refractory cases.

The tumor lysis syndrome.

However, this approach has not been shown to be superior to the administration sydrome normal saline alone[ 29 ]. Uric acid and evolution. Generally, albuterol should be combined with IV insulin, with or without dextrose. Comparative evaluation of single fixed dosing and weight-based dosing of rasburicase for tumor lysis syndrome.


The choice of the fluid varies and some recommend the use of dextrose in one quarter normal saline as the initial fluid of choice[ 17 ]. Clinicians should stratify every hospitalized cancer patient and especially those receiving chemotherapy for the risk of tumor lysis syndrome. Febuxostat does not require dose modification in patients with renal disease and does not seem to have allergy cross-reactivity with allopurinol[ 20 ].

The clinical effect of cation exchange resins typically lysos within 2 h of administration and lasts up to 6 to syjdrome h. Patients afflicted with cancer often have decreased oral intake due to the decrease in appetite and nausea. In either case, the release of the above mentioned intracellular substances mediates the sydnrome of TLS and its complications.

These factors will be discussed in more detail in the next section. In contrast to uric acid crystal deposition in acidic pH, the crystals of calcium phosphate more readily precipitate in alkaline pH, making this approach to alkalization potentially dangerous[ 30 ].

Acute Kidney Injury in Patients with Cancer | NEJM Resident

Certain patient factors such advanced age and the presence of preexistent renal and cardiac diseases warrant a closer follow up during preventive hydration. Typically, a carbonic anhydrase inhibitor acetazolamide or sodium bicarbonate are used to reach a urine pH of at least 6. Management of established TLS includes intravenous hydration, urate lowering therapies, management of hyperkalemia and hemodialysis in refractory cases.

Cellular death mediated by treatment targeted at cancer chemotherapy or another pharmacological antitumor intervention, embolization of tumor or radiation therapy or spontaneous cellular death in rapidly dividing cancer cells which is known as spontaneous TLS leads to an efflux of cellular material rich in potassium, phosphorus, and uric acid into the bloodstream.

The third option for reducing potassium is the administration of IV sodium bicarbonate in a dose of 50 mEq, which works by pushing potassium into the cells in exchange for hydrogen ions[ 32 ]. A drop of potassium should be expected of up to 1.