HYPERURICEMIA &TUMOR LYSISSYNDROME

Babak Tamizi Far MD.Assistant professor of internal medicineAl-zahra hospital, Isfahan university ofmedical sciences

Key Features

Complication of rapidlyproliferating malignancies as wellas treatment-associated tumorlysis of hematologic malignancies

May be worsened by thiazidediuretic use

Complication of rapidlyproliferating malignancies as wellas treatment-associated tumorlysis of hematologic malignancies

May be worsened by thiazidediuretic use

Key Features

Rapid increase in serum uric acidcan result in acute uratenephropathy caused by uric acidcrystallization

To prevent urate nephropathy,serum uric acid must be reducedbefore chemotherapy

Rapid increase in serum uric acidcan result in acute uratenephropathy caused by uric acidcrystallization

To prevent urate nephropathy,serum uric acid must be reducedbefore chemotherapy

Clinical Implications--hyperuricemia– Gout (the amount of increase is not directly

related to the severity of the disease)– Renal diseases and renal failure, prerenal

azotemia– Alcoholism (ethanol consumption)– Down syndrome– Lead poisoning– Leukemia, multiple myeloma, lymphoma– Lesch-Nyhan syndrome (hereditary gout)– Starvation, weight-loss diets

– Gout (the amount of increase is not directlyrelated to the severity of the disease)

– Renal diseases and renal failure, prerenalazotemia

– Alcoholism (ethanol consumption)– Down syndrome– Lead poisoning– Leukemia, multiple myeloma, lymphoma– Lesch-Nyhan syndrome (hereditary gout)– Starvation, weight-loss diets

Clinical Implications--hyperuricemia–Metabolic acidosis, diabetic

ketoacidosis– Toxemia of pregnancy (serial

determination to follow therapy)– Liver disease– Hyperlipidemia, obesity– Hypoparathyroidism, hypothyroidism– Hemolytic anemia, sickle cell anemia

–Metabolic acidosis, diabeticketoacidosis

– Toxemia of pregnancy (serialdetermination to follow therapy)

– Liver disease– Hyperlipidemia, obesity– Hypoparathyroidism, hypothyroidism– Hemolytic anemia, sickle cell anemia

Clinical Implications--hyperuricemia–Following excessive cell destruction, asin chemotherapy and radiation treatment(acute elevation sometimes followstreatment)–Psoriasis–Glycogen storage disease (G6PDdeficiency)

–Following excessive cell destruction, asin chemotherapy and radiation treatment(acute elevation sometimes followstreatment)–Psoriasis–Glycogen storage disease (G6PDdeficiency)

Decreased levels of uric acid :

– Fanconi's syndrome–Wilson's disease– SIADH– Some malignancies (eg, Hodgkin's

disease, multiple myeloma)– Xanthinuria (deficiency of xanthine

oxidase)

– Fanconi's syndrome–Wilson's disease– SIADH– Some malignancies (eg, Hodgkin's

disease, multiple myeloma)– Xanthinuria (deficiency of xanthine

oxidase)

Clinical Findings

Acute kidney injuryHyperuremiaHyperphosphatemia (associated

symptoms include nausea,vomiting, seizures)

Hyperkalemia (can causearrhythmias and sudden death)

Acute kidney injuryHyperuremiaHyperphosphatemia (associated

symptoms include nausea,vomiting, seizures)

Hyperkalemia (can causearrhythmias and sudden death)

Diagnosis

Laboratory values should bemonitored following initiation ofchemotherapy

Elevated potassium or phosphoruslevels need to be promptlymanaged

Laboratory values should bemonitored following initiation ofchemotherapy

Elevated potassium or phosphoruslevels need to be promptlymanaged

Treatment

Prevention is most important The American Society of Clinical

Oncology guidelines recommendaggressive hydration before,during, and after chemotherapy tohelp keep urine flowing andfacilitate excretion of uric acid andphosphorus

Prevention is most important The American Society of Clinical

Oncology guidelines recommendaggressive hydration before,during, and after chemotherapy tohelp keep urine flowing andfacilitate excretion of uric acid andphosphorus

Allopurinol

Blocks the enzyme xanthineoxidase and therefore theformation of uric acid from purinebreakdown–

100 mg/m2 every 8 hours orally(maximum 800 mg/day) with doseadjustments for kidney diseaseshould be given before startingchemotherapy

Blocks the enzyme xanthineoxidase and therefore theformation of uric acid from purinebreakdown–

100 mg/m2 every 8 hours orally(maximum 800 mg/day) with doseadjustments for kidney diseaseshould be given before startingchemotherapy

Rasburicase

Indicated for patients at high riskfor developing tumor lysissyndrome or in whomhyperuricemia develops despitetreatment with allopurinol–

Indicated for patients at high riskfor developing tumor lysissyndrome or in whomhyperuricemia develops despitetreatment with allopurinol–

Rasburicase

Dosage: 0.1–0.2 mg/kg/dayintravenously for 1–7 days– Cannotbe given to patients with knownglucose 6-phosphatedehydrogenase (G6PD) deficiencynor can it be given to pregnant orlactating women

Dosage: 0.1–0.2 mg/kg/dayintravenously for 1–7 days– Cannotbe given to patients with knownglucose 6-phosphatedehydrogenase (G6PD) deficiencynor can it be given to pregnant orlactating women

Systemic bicarbonate infusions areno longer recommended