Tumor Lysis Syndrome
Carol S. Viele RN, MS
Clinical Nurse Specialist
Hematology-Oncology-Bone Marrow
Transplant
Definition


Potentially fatal metabolic complication
that occurs in some patients with
cancer
Can result in potentially life threatening
metabolic and electrolyte abnormalities
Pathophysiology

Involves a complex series of events
related to the liberation of intracellular
contents from tumor cells and inability
of the kidneys to excrete and maintain
normal serum composition
Manifestations


Usually occurs within 24-48 hours after
initiation of chemotherapy and may
persist for 5-7 days post therapy
May occur as early as 6 hours post
chemotherapy administration
Tumor Types

Non-Hodgkins lymphoma
– Burkitt’s
– High grade T-cell

Acute Leukemia’s
– Acute Promyelocytic leukemia
– Acute lymphoblastic leukemia


Chronic Lymphoblastic leukemia
Solid tumors
– Small cell lung cancer
– Breast cancer
Symptoms

Cardiac:
– Presence of S3
– Bradycardia
– Heart Block
– Cardiac Arrest
Symptoms

Neuromuscular:
– Weakness
– Lethargy
– Cramping
– Tetany
– Chvostek’s sign
– Trousseau’s sign
– Convulsions
Symptoms

Renal:
– Oliguria
– Renal Insufficiency
– Flank pain
– Weight gain
– Edema
– Renal failure
Symptoms

Gastrointestinal:
– Nausea
– Vomiting
– Diarrhea
– Constipation
Hyperuricemia


Results from tumor cell destruction
Most common signs and symptoms:
– Nausea and vomiting
– Azotemia
– Oliguria
– Anuria
– Decreased urine pH
– Uric acid crystals found in urinalysis
Hyperkalemia


Results from rapid destruction of cells
Most common signs and symptoms
– EKG changes
Peaked t waves
 Flat p waves
 Wide QRS complexes
 Bradycardia
 Ventricular tachycardia
 Ventricular fibrillation
 Asystole
 Pulseless electrical activity

Hyperkalemia


Results from rapid destruction of cells
Most common signs and symptoms
– Weakness
– Twitching
– Increased bowel sounds
– Nausea
– Diarrhea
Hyperphosphatemia

Most common signs and symptoms
– Hypocalcemia
– Renal failure
Azotemia
 Ologuria
 Anuria

– Hypertension
– Edema
Hypocalcemia


Results from hyperphosphatemia and
the inverse relationship between
calcium and phosphorous
Most common signs and symptoms
– EKG changes
Prolonged QT
 Inverted T waves
 Ventricular dysrhythmias
 Heart block
 Cardiac arrest

Hypocalcemia

Neuromuscular signs and symptoms
– Tetany
– Twitching
– Paresthesias
– Seizures

GI Symptoms
– Diarrhea
Diagnostic Tests

Chvostek
– Tapping the cheek below the temple
where the facial nerve emerges
Diagnostic Tests

Trousseau Sign
– Occluding the arterial blood flow in the
arm with the blood pressure cuff for one
to five minutes, if the thumb adducts and
the phalangeal joints extend the test is
positive
Prevention



Identify patients at risk
Monitor for all electrolyte abnormalities
Administer allopurinol,
– Decrease uric acid levels by interfering with purine
metabolism through the inhibition of the enzyme xanthine
oxidase that is essential for the conversion of nucleic acids
to uric acid

Alkalinization of the urine
– Prevent as much as possible renal damage

Sodium bicarbonate solution
– Decreases the risk of renal obstruction, however urinary
alkalinization should be used cautiously because of risk of
precipitation in the kidneys of calcium-phosphorous binding
and the risk of hypocalcemic induced neuromuscular
irritability
Prevention

Rasburicase- recombinant urate oxidase– Reduces the uric acid pool
– Reduces existing uric acid
– Prevents the accumulation of xanthines and
hypoxanthine
– Does not require alkalinization
– Facilitates phosphorous excretion
– Dosing:
– IV over 30 minutes
– 0.2 mg/kg IV QD or BID
Management

Hydration
– 3 Liters daily
– Aggressive hydration starting 1-2 days
prior to chemotherapy and continuing for
a few days post chemotherapy
Management

Diuretics:
– Furosemide


Renal dose Dopamine- 2-4 mcg/kg
Prevents:
– Fluid overload
– Electrolyte imbalance
– Complications of uric acid buildup
Management

Hyperkalemia
– Kayexalate with sorbitol
PO
 Rectal

– Calcium Gluconate
– Sodium bicarbonate
– Hypertonic dextrose and regular insulin
– Albuterol (Ventolin) or another beta
stimulant
Management

Dialysis: Hemodialysis/CVVH/CRRT(
Requires ICU Care)
– Used for patients unresponsive to preventive
measures and electrolyte corrections
– Used to remove uric acid
– Used in patients with:





Serum potassium >6 mEq/L
Uric acid >10 mg/dl
Phosphorous > 10 mg/dl
Symptomatic hypocalcemia
Presence of volume overload
Medication Management


Avoid nephrotoxic medications
Avoid agents which block tubular
reabsorption of uric acid
– Aspirin
– Probencid
– Thiazide diuretics
– Radiographic contrast containing iodine
Nursing Interventions



Symptom management
Maintenance of fluid status
Review of systems
– Cardiac via EKG
– Neurologic
– Neuromuscular
– Gastrointestinal
– Renal
Nursing Interventions






Monitor weights at least daily
Daily EKG’s
Monitor for altered level of
consciousness
Strict I&O
Check pH of urine with each void, goal
is to keep pH >7.0
Monitor for signs and symptoms of
nausea and vomiting, administer
antiemetics as ordered
References

Jeha,S., Pui, C. ‘Recombinant Urate
Oxidase (Rasburicase) in the
Prophylaxis and Treatment of Tumor
Lysis Syndrome, Ronco,R.
Rodeghiero, F. (eds) Hyperuricemic
Syndrome: Pathophysiology and
Therapy, Contrib Nephrol,
Basel,Karger,2005,Vol 147,pp69-79
References


Reid-Finlay,M. Kaplow, R. ‘Leukemia
and Bone Marrow Transplantation’,
Schell,H., Puntillo, K., Critical Care
Nursing Secrets, Hanley and Belfus,
Inc, Philadelphia 2001,p. 209-215
Zobec,A., ‘Tumor Lysis Syndrome’,
Oncology Nursing Secrets, Hanley and
Belfus, 2008, p. 557-560