Clinical Pathway for Evaluation and Treatment of
Oncology Patients 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
No emergent
TLS signs/symptoms
TLS signs/symptoms
Emergent
TLS signs/symptoms
TLS signs/symptoms
Assign Risk of TLS
- Assess:
- Signs/symptoms of TLS
- Labs for electrolyte derangements
- Tumor Burden
- Comorbidities
- Novel agents associated with increased TLS risk
- Review risk assignment with fellow/attending
Emergent TLS
Signs/Symptoms
Admit/transfer to ICU
Consult nephrology
Consider renal replacement therapy
Signs/Symptoms
Admit/transfer to ICU
Consult nephrology
Consider renal replacement therapy
No concerning
labs or symptoms
labs or symptoms
Concerning
labs or symptoms
labs or symptoms
Possible Comorbidities
- Pre-existing renal conditions
- Dehydration
- Acidosis
- Nephrotoxins
- Mediastinal mass
Assess
Comorbidities
Comorbidities
Assess
Comorbidities
Comorbidities
Not
Present
Present
Present
Not
Present
Present
Present
Low Risk of TLS | Intermediate Risk of TLS | High Risk of TLS/Established Lab TLS | Severe TLS | |
---|---|---|---|---|
|
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 |
Electrolyte Derangement | Medication | Dosing and Contraindications available via CHOP Formulary | |
---|---|---|---|
Hyperuricemia | Allopurinol | Dosing | Contraindications |
Rasburicase Add if uric acid ≥ 8 |
Dosing | 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
- Consult nephrology
- Consider renal replacement therapy
- Consider vascular access
- Admit/transfer to ICU
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
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
Evidence
- Rapid Fire: Tumor Lysis Syndrome
- NEJM: The Tumor Lysis Syndrome
- Arch Pathol Lab Med: Tumor Lysis Syndrome
- Hematological Oncology: Current Understanding of Tumor Lysis Syndrome
- Annals of Hematology: TLS in era of novel and targeted agents
- Cureus: TLS in Solid Tumors
- BJH: TLS – New Therapeutic Strategies and Classification
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