How is tumor lysis syndrome treated in pediatric non-Hodgkin lymphoma (NHL)?

Updated: Jun 14, 2018
  • Author: J Martin Johnston, MD; Chief Editor: Max J Coppes, MD, PhD, MBA  more...
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Answer

Before and during the initial induction phase of chemotherapy, patients may develop tumor lysis syndrome, a condition that can result from the rapid destruction of a large number of neoplastic cells. This destruction causes intracellular ions and metabolic byproducts to be released into the systemic circulation, which can lead to the rapid development of hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. (Renal involvement by lymphoma is an additional risk factor.)

Hyperuricemia or tubular obstruction may lead to acute renal failure, requiring dialysis. In general, this is not a contraindication to continuing chemotherapy. However, some protocols now include a preliminary phase of relatively gentle cytoreductive chemotherapy designed to avoid these metabolic complications.

With all patients, administer intravenous fluids at twice the maintenance rates, usually without potassium. Add sodium bicarbonate to the intravenous fluid to achieve moderate alkalinization of the urine (pH of approximately 7). This measure enhances the excretion of tumor metabolites. For example, the solubility of uric acid is 10-12 times higher at a pH of about 7 than it is at a pH of 5, and the solubility of xanthine is doubled. Avoid a urine pH higher than this to prevent crystallization of hypoxanthine or calcium phosphate.

Administer allopurinol to prevent or correct hyperuricemia. In high-risk situations (extreme elevations of lactate dehydrogenase [LDH] and/or uric acid or evidence of impaired renal function at presentation), consider administration of recombinant urate oxidase (rasburicase [Elitek]). [59]

Follow up the patient's laboratory values to monitor tumor lysis syndrome throughout initial therapy. Testing may be needed as often as 2-4 times per day. This follow-up is especially important during the first 48-72 hours of therapy in a patient with bulky disease.


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