Clinical Pathway for Evaluation and Treatment of
Oncology Patients at Risk for Tumor Lysis Syndrome (TLS)

Goals and Metrics
Patient Education
Provider Resources
New diagnosis/relapse of a hematological malignancy or bulky solid tumor at risk for tumor lysis syndrome (TLS)
History & Physical
  • HPI
  • Vital signs, mental status
  • Review/Obtain Labs
    • CBC, BMP (K, Ca, creatinine), Phos, Uric acid, LDH, G6PD
    • Blood gas, lactate if poor perfusion or respiratory distress
  • Consider CXR
  • Consider 12-lead EKG
    • Electrolyte derangement or dysrhythmia
    • Symptomatic with palpitations/dizziness
    • Other clinical concerns
Tumor Lysis Syndrome (TLS)
  • Classic Electrolyte Derangements
    • Hyperphosphatemia
    • Hyperuricemia
    • Hyperkalemia
    • Hypocalcemia
  • Novel Agents associated with increased risk of TLS
Assess for Emergent TLS Signs/Symptoms
  • Laryngospasm, bronchospasm
  • Hypotension (see BP references for males   and females  )
    • Heart failure due to decreased calcium
  • Seizures
  • Neuromuscular irritability, sensory disturbance
  • Urine output
    • Oliguria: < 0.5 ml/kg/hr x 6 hours
No emergent
TLS signs/symptoms
Emergent
TLS signs/symptoms
Assign Risk of TLS
  • Assess:
  • Review risk assignment with fellow/attending
Emergent TLS
Signs/Symptoms
Admit/transfer to ICU
Consult nephrology
Consider renal replacement therapy
No concerning
labs or symptoms
Concerning
labs or symptoms
Possible Comorbidities
  • Pre-existing renal conditions
  • Dehydration
  • Acidosis
  • Nephrotoxins
  • Mediastinal mass
Assess Tumor Burden
Low
Tumor Burden
Intermediate
Tumor Burden
High
Tumor Burden
Assess
Comorbidities
Assess
Comorbidities
Not
Present
Present
Not
Present
Present
  Low Risk of TLS Intermediate Risk of TLS High Risk of TLS/Established Lab TLS Severe TLS
  • Hydration
    D5NS
    No Phos, K
    Do not alkalinize
Maintenance IVF 1.5x MIVF 2x MIVF 2x MIVF
Monitoring Daily labs
VS q4 hr		 Labs q8-12 hr
VS q4 hr		 Labs q6-8 hr
VS q4 hr
EKG if not previously obtained
Cardiac monitoring if abnormal EKG
Other clinical concerns 		Labs q4-6 hr
VS per ICU care
Cardiac monitoring
Prophylaxis Medications   Allopurinol Allopurinol
Add Rasburicase if uric acid ≥ 8		 Allopurinol
Add Rasburicase if uric acid ≥ 8

 

Ongoing treatment and monitoring
Electrolyte Derangement Medication Dosing and Contraindications available via CHOP Formulary
Hyperuricemia Allopurinol Dosing Contraindications
Rasburicase
Add if uric acid ≥ 8 		Dosing

Contraindications

G6PD deficiency
Hyperphosphatemia Sevelamer
Hold if NPO		 Dosing Contraindications
Aluminum Hydroxide Dosing Contraindications
Hyperkalemia Sodium polystyrene sulfonate (Kayexalate®) Dosing Contraindications
Furosemide Dosing Contraindications
Emergent medications –
Hypocalcemia –

 

Contraindications to Hyperhydration
  • Suspected metabolic disease
  • Hypoglycemia
  • Liver failure
  • Adrenal insufficiency
  • Abnormal renal function
  • Heart failure
  • Neurosurgical patients
  • SIADH
  • Nephrotic syndrome
  • Diabetes insipidus
Assess treatment response
  • TLS Resolved when all are met:
    • Normalized electrolytes
    • Normal BUN, creatinine
    • No evidence of fluid overload
    • Normalized BP, UO
    • No cardiac arrhythmias
    • Clinical symptoms resolved
Resolved TLS
Ongoing TLS
Uncontrolled TLS
  • Discontinue hyper-hydration
      • Decrease lab monitoring
        • Reduce to next lower risk frequency
        • Reassess every 24 hours
        • Off monitoring after 72 hours
      • Discontinue medications
        • Allopurinol when uric acid normalizes
        • Phosphate binders when phosphate normalizes
  • Escalate treatment and monitoring to next level of risk
Posted: May 2021
Revised: September 2021
Authors: A. Reilly, MD; H. Rhodes, RN; V. Batra, MD; C. Croy, PharmD; J. Freedman, MD; B. Laskin, MD; L. Kagami; J. Stundon; K. Takasaki