Patient at Risk for Tumor Lysis Syndrome
Initiating cytotoxic therapy for malignancy with high tumor burden
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Hematology & OncologyEmergency
Tumor Lysis Syndrome (TLS) Prevention & Management
Tumor Lysis Syndrome (TLS) Prevention & Management: Patient at Risk for Tumor Lysis Syndrome → Assess TLS Risk Category → HIGH RISK: Rasburicase + Aggre...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Decision Assess TLS Risk Category
Based on tumor type, burden, and treatment
- HIGH RISK: Burkitt lymphoma, ALL with WBC >100k, AML with WBC >100k, bulky NHL with elevated LDH
- INTERMEDIATE: ALL with WBC 50-100k, AML with WBC 25-100k, DLBCL, CLL treated with venetoclax
- LOW RISK: Solid tumors, indolent lymphomas, CLL with WBC <50k
03Action HIGH RISK: Rasburicase + Aggressive Hydration
Intensive prophylaxis required
- Rasburicase 0.2 mg/kg IV single dose (max 7.5mg)
- May repeat if uric acid remains elevated
- IV fluids 2.5-3 L/m²/day (avoid K+, phosphate)
- Monitor labs Q6h during treatment initiation
- Hold allopurinol (interferes with uric acid monitoring)
04Warning ⚠️ G6PD Deficiency
Rasburicase CONTRAINDICATED - causes severe hemolysis
- Screen all patients before rasburicase
- Use allopurinol or febuxostat instead
- Higher risk in African, Mediterranean, Asian descent
05Action Laboratory Monitoring
Check electrolytes and renal function frequently
- Potassium, Phosphorus, Calcium, Uric acid, Creatinine, LDH
- High risk: Q4-6h for first 24-48h
- Intermediate: Q8-12h
- ECG monitoring for hyperkalemia
06Decision Laboratory TLS Present?
Cairo-Bishop Criteria (≥2 abnormalities)
- Uric acid ≥8 mg/dL or 25% increase
- Potassium ≥6 mEq/L or 25% increase
- Phosphorus >4.5 mg/dL (adult) or 25% increase
- Calcium ≤7 mg/dL or 25% decrease
07Decision Clinical TLS Present?
Lab TLS + End-organ dysfunction
- AKI: Creatinine ≥1.5x ULN
- Cardiac arrhythmia or sudden death
- Seizures
- Death attributable to TLS
08Action Treat Hyperkalemia
Life-threatening - treat immediately
- K+ >6 or ECG changes: Calcium gluconate 1-2g IV
- Insulin 10U regular + D50 50mL IV
- Albuterol nebulized 10-20mg
- Kayexalate 30-60g PO/PR (delayed effect)
- Dialysis if refractory
09Decision Renal Replacement Therapy Needed?
Indications for urgent dialysis
- Refractory hyperkalemia despite medical therapy
- Severe hyperphosphatemia (>10 mg/dL)
- Volume overload unresponsive to diuretics
- Symptomatic uremia
- Oliguria/anuria with rising creatinine
10Action Initiate Renal Replacement Therapy
CRRT preferred for hemodynamic instability
- CRRT (CVVHD/CVVHDF) for unstable patients
- Intermittent HD if hemodynamically stable
- High-flux dialyzer for uric acid clearance
- May need extended or daily treatments initially
11Action Continue Aggressive Monitoring & Hydration
Maintain until TLS resolves
- Continue IV fluids to maintain UOP >100 mL/m²/hr
- Labs Q6-8h until stable
- May resume/continue chemotherapy when stable
- Typically resolves within 5-7 days
12Outcome TLS Resolved - Continue Cancer Treatment
Electrolytes normalized, renal function stable
- Path rejoins step 11Shared downstream outcome
13Action Treat Hyperphosphatemia
Reduces calcium and causes precipitation
- Phosphate binders: Sevelamer 800mg TID with meals
- Aluminum hydroxide (short-term only)
- Restrict dietary phosphorus
- Dialysis for severe/refractory cases
- Path rejoins step 09Shared downstream outcome
14Action Treat Hypocalcemia
Only if symptomatic (tetany, seizures, QTc prolongation)
- SYMPTOMATIC: Calcium gluconate 1-2g IV slowly
- ASYMPTOMATIC: Monitor only - avoid calcium unless symptomatic
- Calcium infusion can worsen calcium-phosphate precipitation
- Correct phosphorus first
- Path rejoins step 09Shared downstream outcome
- Path rejoins step 11Shared downstream outcome
15Action INTERMEDIATE RISK: Allopurinol + Hydration
Standard prophylaxis
- Allopurinol 300mg PO BID (start 2-3 days before chemo)
- IV fluids 2-2.5 L/m²/day
- Monitor labs Q8-12h initially
- Escalate to rasburicase if uric acid rises >8 mg/dL
- Consider rasburicase if baseline uric acid elevated
- Path rejoins step 05Shared downstream outcome
16Action LOW RISK: Hydration + Monitoring
Minimal prophylaxis
- Oral hydration 2L/day or IV 2L/m²/day
- Monitor labs daily
- Consider allopurinol if any risk factors present
- Escalate if uric acid rises
- Path rejoins step 05Shared downstream outcome
Guideline Source
ASCO TLS Guidelines + 2023 US Expert Consensus
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Pediatric dosing may differ - consult pediatric oncology
- Rasburicase contraindicated in G6PD deficiency
- Renal replacement therapy thresholds may vary by institution
- Does not address specific chemotherapy regimen modifications
Contraindicated Populations
G6PD_deficiency_for_rasburicase
Applicable Regions
USEU
EU: Rasburicase (Fasturtec) approved
US: Rasburicase (Elitek) approved; febuxostat as alternative
Version 1Next review: 2028-01-01
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Frequently Asked Questions
What is the Tumor Lysis Syndrome (TLS) Prevention & Management?
The Tumor Lysis Syndrome (TLS) Prevention & Management is a emergency clinical algorithm for Hematology & Oncology. It provides a structured decision tree to guide clinical decision-making, based on ASCO TLS Guidelines + 2023 US Expert Consensus.
What guideline is the Tumor Lysis Syndrome (TLS) Prevention & Management based on?
This algorithm is based on ASCO TLS Guidelines + 2023 US Expert Consensus (DOI: 10.1016/j.ctrv.2023.102603).
What are the limitations of the Tumor Lysis Syndrome (TLS) Prevention & Management?
Known limitations include: Pediatric dosing may differ - consult pediatric oncology; Rasburicase contraindicated in G6PD deficiency; Renal replacement therapy thresholds may vary by institution; Does not address specific chemotherapy regimen modifications. Individual patient factors may require deviation from these recommendations.
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