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Kidney Case Conference: How I Treat How I Treat Tumor Lysis Syndrome Adrien Joseph 1 and Lara Zafrani1
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Kidney Case Conference: How I Treat How I Treat Tumor Lysis Syndrome Adrien Joseph 1 and Lara Zafrani1
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Kidney Case Conference:How I Treat
How I Treat Tumor Lysis Syndrome
1
Adrien Joseph and Lara Zafrani1,2
CJASN ▪: 1–3, 2023. doi: https://doi.org/10.2215/CJN.0000000000000331
Introduction intensive care unit admission should be considered, 1
Department of
Tumor lysis syndrome results from the spontaneous as well as debulking strategies to gradually reduce medical intensive care
or therapy-induced destruction of malignant cells, re- unit, Saint-Louis
tumor burden, with escalating doses of chemother-
Hospital, Assistance
leasing intracellular content into extracellular space. apy or oral first-line treatments (e.g., hydroxyurea for Publique-Hôpitaux de
Extracellular histones, other damage-associated molec- acute myeloid leukemia). Paris, University of
ular patterns (DAMPs), and excessive inflammatory Paris Cité, Paris,
cytokines may induce endothelial alterations causing France
Hydration 2
INSERM U944, Saint-
AKI1 and sometimes multiple organ failures. Enhanced clearance of electrolytes, DNA, and his- Louis Research
Although guidelines have been published on the tones released by dying tumor cells through volume Institute, University of
classification, grading, and treatment of tumor lysis repletion is the first step in preventing tumor lysis Paris Cité, Paris,
syndrome,2–4 these are mainly on the basis of expert syndrome. Hydration with large volumes of crystal- France
opinions and areas of uncertainty persist. loid fluids is usually proposed,4 with an objective of
Correspondence:
urine output above 100 ml/h. Prof. Lara Zafrani,
Monitoring of urine output, body weight, and echo- Medical Intensive Care
Patient Presentation
cardiography is required regarding the risk of cardiac Unit, Assistance
A 37-year-old woman diagnosed with Burkitt lym- Publique Hôpitaux de
overload, especially in patients with known car-
phoma was admitted in the hematology department Paris, Saint-Louis
diac failure.
for urgent chemotherapy. Her computed tomography Hospital, 1 Avenue
Although urine alkalinization increases the solubil- Claude Vellefaux,
scan revealed enlarged lymph nodes in the cervical,
ity of uric acid, it decreases the solubility of calcium 75010 Paris, France.
axillary, mediastinal, and abdominal regions.
phosphate. Because uric acid nephropathy may now Email: lara.zafrani@
Blood tests before chemotherapy showed a sodium aphp.fr
be treated by using hypouricemic drugs, urinary al-
level of 140 mmol/L (136–145), potassium 4 mmol/L
kalinization is no longer recommended and is poten-
(3.5–4.5), serum creatinine 1.19 mg/dl, lactate dehydro-
tially harmful.2
genase (LDH) 2500 IU/L (125–245), uric acid 7.06 mg/dl
Forced diuresis using loop diuretics has also been
(2.52–6.05), calcium 8.82 mg/dl (8.82–10.22), and phos-
proposed to enhance the urinary flow rate and
phate 4.65 mg/dl (2.48–4.49), and bone marrow aspirate
decrease the risk of crystallization, but this approach
smear showed 6% Burkitt-like cells.
has never been properly evaluated.2 Concomitant
hydration and depletion can be hazardous, and asso-
ciation with cytokine-mediated hemodynamic insta-
Risk Stratification
Evaluating the risk of tumor lysis syndrome before bility seen in tumor lysis syndrome can jeopardize
administration of tumor-specific therapy is of utmost renal hemodynamics.
importance because preventive strategies are a corner-
stone in the management of high-risk patients. The risk Monitoring
of tumor lysis increases with tumor size, spontaneous Clinical and biological monitoring of patients at risk
cell turnover rate, and sensitivity to therapy. More of tumor lysis syndrome depends on risk stratification,
specifically, high-grade lymphomas and hyperleuko- with blood tests and assessments of volume status
cytic acute leukemias represent high-risk situations, several times daily.
whereas solid tumors (with the notable exceptions of Twelve hours after chemotherapy, a new blood
germ-cell tumors and small-cell lung cancers) are at sample revealed AKI with a serum creatinine level
lower risk.3 Apart from tumor-related risk factors, base- of 3.17 mg/dl, potassium 5.5 mmol/L (3.5–4.5), LDH
line kidney function, age, and use of nephrotoxic drugs 8200 IU/L (125–245), uric acid 12.95 mg/dl (2.52–6.05),
further refine risk stratification.3 The emergence of tar- calcium 8.22 mg/dl (8.82–10.22), and phosphate
geted therapies has modified the spectrum of tumor 5.88 mg/dl (2.48–4.49).
lysis syndrome that can occur in a delayed fashion or in
patients otherwise considered at low risk.5 Diagnosis and Pitfalls
The incidence of tumor lysis syndrome can reach A definition of tumor lysis syndrome was published
30% in high-risk patients,6 for whom preemptive in 2004: Laboratory tumor lysis syndrome includes the
www.cjasn.org Vol ▪ ▪▪▪, 2023 Copyright © 2023 by the American Society of Nephrology 1
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