Treatment of Tumor Lysis Syndrome

Core Treatment Strategy

The American Society of Hematology recommends aggressive intravenous hydration through central venous access plus rasburicase immediately to prevent life-threatening complications including acute renal failure, cardiac arrhythmias, seizures, and death in patients with clinical tumor lysis syndrome (TLS) 1, 2, 3
The European Hematology Association suggests starting IV hydration at least 48 hours before chemotherapy when possible, though rasburicase allows earlier chemotherapy initiation if needed 1, 2, 3
The National Comprehensive Cancer Network recommends maintaining urine output at minimum 100 mL/hour (or 3 mL/kg/hour in children <10 kg) 1, 2, 3
The American College of Physicians advises using loop diuretics (furosemide) or mannitol to achieve target urine output if needed, except in patients with obstructive uropathy or hypovolemia 1, 2, 3, 4

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend aggressive IV hydration plus loop diuretics (furosemide 40-80 mg IV) for mild hyperkalemia (<6 mmol/L) 1, 2, 4
The American Heart Association suggests calcium gluconate 50-100 mg/kg IV over 2-5 minutes to stabilize myocardial membrane in severe hyperkalemia (≥6 mmol/L or any ECG changes) 1, 2, 4
The European Society of Cardiology recommends rapid insulin 0.1 units/kg IV plus 25% dextrose 2 mL/kg (onset 15-30 minutes, duration 4-6 hours) for severe hyperkalemia 1, 2, 4

The American Society of Nephrology recommends initiating hemodialysis urgently when oliguria or anuria develops despite aggressive hydration 1, 5
The National Kidney Foundation suggests initiating hemodialysis urgently when severe, refractory hyperkalemia (≥6 mmol/L unresponsive to medical management) occurs 1, 5, 4

The College of American Pathologists recommends rechecking potassium every 2-4 hours after initial treatment 4
The American Society of Clinical Oncology advises obtaining comprehensive metabolic panel, LDH, and CBC immediately when TLS is suspected 6

The American Society of Hematology recommends the same aggressive treatment as clinical TLS in all adults with laboratory TLS 1, 2, 3
The European Hematology Association suggests the same aggressive treatment as clinical TLS in children at high risk for TLS 1, 2, 3

The American Society of Hematology recommends administering rasburicase to patients with clinical tumor lysis syndrome (TLS), which includes decreased urinary output as a manifestation of acute kidney injury, to rapidly reduce uric acid levels and prevent complete renal shutdown and fatal hyperkalemia 7, 8, 9

Rasburicase should be administered at a dose of 0.2 mg/kg IV over 30 minutes immediately, and continued for 3-5 days as needed, with the first dose given at least 4 hours before chemotherapy when possible 7, 8
The European Society for Medical Oncology recommends not giving allopurinol concurrently with rasburicase, as this causes xanthine accumulation and removes substrate for rasburicase 7

The National Comprehensive Cancer Network recommends using loop diuretics only if the patient is adequately hydrated, has no obstructive uropathy, and is not hypovolemic, to maintain urine output in TLS patients 7, 8, 10
Loop diuretics should not be used in patients with anuria or established oliguria despite adequate hydration, as these patients require urgent hemodialysis 7, 8, 10

For hyperkalemia, the American Heart Association recommends administering calcium gluconate 50-100 mg/kg IV over 2-5 minutes to stabilize cardiac membrane, followed by insulin 0.1 units/kg IV plus 25% dextrose 2 mL/kg IV 8, 9
For hyperphosphatemia, the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend using aluminum hydroxide 50-100 mg/kg/day divided in 4 doses for mild cases (<1.62 mmol/L) 8

The International Society of Nephrology recommends rechecking potassium every 2-4 hours after initial treatment, monitoring uric acid, electrolytes, phosphate, calcium every 6 hours for the first 24 hours, and measuring hourly urine output 8, 10
Continuous ECG monitoring is also recommended to detect hyperkalemia-induced arrhythmias 8