Management of Hyperphosphatemia in Tumor Lysis Syndrome

Introduction to Treatment

For mild hyperphosphatemia in tumor lysis syndrome (TLS), aluminum hydroxide (50-100 mg/kg/day) is recommended as first-line treatment, while sevelamer is an effective alternative, especially when aluminum toxicity is a concern or in cases requiring longer treatment, as per the American Society of Clinical Oncology 1, 2
First, eliminate phosphate from intravenous solutions and maintain adequate hydration to manage hyperphosphatemia in TLS patients, as suggested by the European Hematology Association 2

Administer phosphate binders, such as aluminum hydroxide: 50-150 mg/kg/day divided into 4 doses (orally or via nasogastric tube), for the management of hyperphosphatemia in TLS patients, according to the American Society of Clinical Oncology 1, 2
Limit aluminum hydroxide use to 1-2 days to avoid cumulative aluminum toxicity in patients with TLS, as recommended by the American Society of Clinical Oncology 1
Lanthanum carbonate is an alternative non-calcium, non-aluminum phosphate binder for managing hyperphosphatemia in TLS patients, as suggested by the National Kidney Foundation 1, 3
Calcium carbonate should only be used if calcium levels are low; it is contraindicated in hypercalcemia, as per the American College of Clinical Pharmacy 1, 2, 4

For severe hyperphosphatemia unresponsive to phosphate binders, hemodialysis is the most effective method for phosphate clearance, as recommended by the American Society of Nephrology 1, 2
Alternatives to hemodialysis include peritoneal dialysis or continuous venovenous hemofiltration for severe hyperphosphatemia in TLS patients, according to the European Renal Association 1
Early start of renal replacement therapy is advised to remove phosphate and improve associated electrolyte abnormalities in patients with severe hyperphosphatemia, as suggested by the International Society of Nephrology 2

Calcium-containing phosphate binders should be avoided in patients with hypercalcemia, as per the Endocrine Society 1, 2, 4
Aluminum hydroxide should be limited to short-term use (1-2 days) due to the risk of aluminum toxicity, as recommended by the American Academy of Pediatrics 1
Phosphate clearance is better with hemodialysis compared to continuous venovenous hemofiltration or peritoneal dialysis when needed, according to the American Society of Nephrology 1