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
  • Laryngospasm, bronchospasm
  • Hypotension  , 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
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

 

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
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