Tumor Lysis SyndromeTumor Lysis Syndrome

Carol S. Viele RN, MSCarol S. Viele RN, MSClinical Nurse SpecialistClinical Nurse SpecialistHematology-Oncology-Bone Marrow Hematology-Oncology-Bone Marrow TransplantTransplant

DefinitionDefinition

Potentially fatal metabolic complication Potentially fatal metabolic complication that occurs in some patients with that occurs in some patients with cancercancer

Can result in potentially life threatening Can result in potentially life threatening metabolic and electrolyte metabolic and electrolyte abnormalitiesabnormalities

PathophysiologyPathophysiology

Involves a complex series of events Involves a complex series of events related to the liberation of intracellular related to the liberation of intracellular contents from tumor cells and inability contents from tumor cells and inability of the kidneys to excrete and maintain of the kidneys to excrete and maintain normal serum compositionnormal serum composition

ManifestationsManifestations

Usually occurs within 24-48 hours after Usually occurs within 24-48 hours after initiation of chemotherapy and may initiation of chemotherapy and may persist for 5-7 days post therapypersist for 5-7 days post therapy

May occur as early as 6 hours post May occur as early as 6 hours post chemotherapy administrationchemotherapy administration

Tumor TypesTumor Types

Non-Hodgkins lymphomaNon-Hodgkins lymphoma– Burkitt’sBurkitt’s– High grade T-cellHigh grade T-cell

Acute Leukemia’sAcute Leukemia’s– Acute Promyelocytic leukemiaAcute Promyelocytic leukemia– Acute lymphoblastic leukemiaAcute lymphoblastic leukemia

Chronic Lymphoblastic leukemiaChronic Lymphoblastic leukemia Solid tumorsSolid tumors

– Small cell lung cancerSmall cell lung cancer– Breast cancerBreast cancer

SymptomsSymptoms

Cardiac:Cardiac:– Presence of S3Presence of S3– BradycardiaBradycardia– Heart BlockHeart Block– Cardiac ArrestCardiac Arrest

SymptomsSymptoms

Neuromuscular:Neuromuscular:– WeaknessWeakness– LethargyLethargy– CrampingCramping– TetanyTetany– Chvostek’s signChvostek’s sign– Trousseau’s signTrousseau’s sign– ConvulsionsConvulsions

SymptomsSymptoms

Renal:Renal:– OliguriaOliguria– Renal InsufficiencyRenal Insufficiency– Flank painFlank pain– Weight gainWeight gain– EdemaEdema– Renal failureRenal failure

SymptomsSymptoms

Gastrointestinal:Gastrointestinal:– NauseaNausea– VomitingVomiting– DiarrheaDiarrhea– ConstipationConstipation

HyperuricemiaHyperuricemia

Results from tumor cell destructionResults from tumor cell destruction Most common signs and symptoms:Most common signs and symptoms:

– Nausea and vomitingNausea and vomiting– AzotemiaAzotemia– OliguriaOliguria– AnuriaAnuria– Decreased urine pHDecreased urine pH– Uric acid crystals found in urinalysisUric acid crystals found in urinalysis

HyperkalemiaHyperkalemia Results from rapid destruction of cellsResults from rapid destruction of cells Most common signs and symptomsMost common signs and symptoms

– EKG changesEKG changes Peaked t wavesPeaked t waves Flat p wavesFlat p waves Wide QRS complexesWide QRS complexes BradycardiaBradycardia Ventricular tachycardiaVentricular tachycardia Ventricular fibrillationVentricular fibrillation AsystoleAsystole Pulseless electrical activityPulseless electrical activity

HyperkalemiaHyperkalemia

Results from rapid destruction of cellsResults from rapid destruction of cells Most common signs and symptomsMost common signs and symptoms

– WeaknessWeakness– Twitching Twitching – Increased bowel soundsIncreased bowel sounds– NauseaNausea– DiarrheaDiarrhea

HyperphosphatemiaHyperphosphatemia

Most common signs and symptomsMost common signs and symptoms– HypocalcemiaHypocalcemia– Renal failureRenal failure

AzotemiaAzotemia OloguriaOloguria AnuriaAnuria

– HypertensionHypertension– EdemaEdema

HypocalcemiaHypocalcemia

Results from hyperphosphatemia and Results from hyperphosphatemia and the inverse relationship between the inverse relationship between calcium and phosphorouscalcium and phosphorous

Most common signs and symptomsMost common signs and symptoms– EKG changesEKG changes

Prolonged QTProlonged QT Inverted T wavesInverted T waves Ventricular dysrhythmiasVentricular dysrhythmias Heart blockHeart block Cardiac arrestCardiac arrest

HypocalcemiaHypocalcemia

Neuromuscular signs and symptomsNeuromuscular signs and symptoms– Tetany Tetany – Twitching Twitching – ParesthesiasParesthesias– SeizuresSeizures

GI SymptomsGI Symptoms– DiarrheaDiarrhea

Diagnostic TestsDiagnostic Tests

ChvostekChvostek– Tapping the cheek below the temple Tapping the cheek below the temple

where the facial nerve emergeswhere the facial nerve emerges

Diagnostic TestsDiagnostic Tests

Trousseau SignTrousseau Sign– Occluding the arterial blood flow in the Occluding the arterial blood flow in the

arm with the blood pressure cuff for one arm with the blood pressure cuff for one to five minutes, if the thumb adducts and to five minutes, if the thumb adducts and the phalangeal joints extend the test is the phalangeal joints extend the test is positivepositive

PreventionPrevention

Identify patients at riskIdentify patients at risk Monitor for all electrolyte abnormalitiesMonitor for all electrolyte abnormalities Administer allopurinol, Administer allopurinol,

– Decrease uric acid levels by interfering with purine Decrease uric acid levels by interfering with purine metabolism through the inhibition of the enzyme xanthine metabolism through the inhibition of the enzyme xanthine oxidase that is essential for the conversion of nucleic acids oxidase that is essential for the conversion of nucleic acids to uric acidto uric acid

Alkalinization of the urineAlkalinization of the urine– Prevent as much as possible renal damagePrevent as much as possible renal damage

Sodium bicarbonate solutionSodium bicarbonate solution– Decreases the risk of renal obstruction, however urinary Decreases the risk of renal obstruction, however urinary

alkalinization should be used cautiously because of risk of alkalinization should be used cautiously because of risk of precipitation in the kidneys of calcium-phosphorous binding precipitation in the kidneys of calcium-phosphorous binding and the risk of hypocalcemic induced neuromuscular and the risk of hypocalcemic induced neuromuscular irritabilityirritability

PreventionPrevention

Rasburicase- recombinant urate oxidase- Rasburicase- recombinant urate oxidase- – Reduces the uric acid poolReduces the uric acid pool– Reduces existing uric acidReduces existing uric acid– Prevents the accumulation of xanthines and Prevents the accumulation of xanthines and

hypoxanthinehypoxanthine– Does not require alkalinizationDoes not require alkalinization– Facilitates phosphorous excretionFacilitates phosphorous excretion– Dosing:Dosing:– IV over 30 minutesIV over 30 minutes– 0.2 mg/kg IV QD or BID0.2 mg/kg IV QD or BID

ManagementManagement

HydrationHydration– 3 Liters daily3 Liters daily– Aggressive hydration starting 1-2 days Aggressive hydration starting 1-2 days

prior to chemotherapy and continuing for prior to chemotherapy and continuing for a few days post chemotherapya few days post chemotherapy

ManagementManagement

Diuretics:Diuretics:– FurosemideFurosemide

Renal dose Dopamine- 2-4 mcg/kgRenal dose Dopamine- 2-4 mcg/kg Prevents:Prevents:

– Fluid overloadFluid overload– Electrolyte imbalanceElectrolyte imbalance– Complications of uric acid buildupComplications of uric acid buildup

ManagementManagement

HyperkalemiaHyperkalemia– Kayexalate with sorbitolKayexalate with sorbitol

POPO RectalRectal

– Calcium GluconateCalcium Gluconate– Sodium bicarbonateSodium bicarbonate– Hypertonic dextrose and regular insulinHypertonic dextrose and regular insulin– Albuterol (Ventolin) or another beta Albuterol (Ventolin) or another beta

stimulantstimulant

ManagementManagement

Dialysis: Hemodialysis/CVVH/CRRT( Requires Dialysis: Hemodialysis/CVVH/CRRT( Requires ICU Care)ICU Care)– Used for patients unresponsive to preventive Used for patients unresponsive to preventive

measures and electrolyte correctionsmeasures and electrolyte corrections

– Used to remove uric acidUsed to remove uric acid

– Used in patients with:Used in patients with: Serum potassium >6 mEq/LSerum potassium >6 mEq/L Uric acid >10 mg/dlUric acid >10 mg/dl Phosphorous > 10 mg/dlPhosphorous > 10 mg/dl Symptomatic hypocalcemiaSymptomatic hypocalcemia Presence of volume overloadPresence of volume overload

Medication ManagementMedication Management

Avoid nephrotoxic medicationsAvoid nephrotoxic medications Avoid agents which block tubular Avoid agents which block tubular

reabsorption of uric acidreabsorption of uric acid– AspirinAspirin– ProbencidProbencid– Thiazide diureticsThiazide diuretics– Radiographic contrast containing iodineRadiographic contrast containing iodine

Nursing InterventionsNursing Interventions

Symptom managementSymptom management Maintenance of fluid statusMaintenance of fluid status Review of systemsReview of systems

– Cardiac via EKGCardiac via EKG– NeurologicNeurologic– NeuromuscularNeuromuscular– GastrointestinalGastrointestinal– RenalRenal

Nursing InterventionsNursing Interventions

MonitorMonitor weights at least dailyweights at least daily Daily EKG’sDaily EKG’s Monitor for altered level of Monitor for altered level of

consciousnessconsciousness Strict I&OStrict I&O Check pH of urine with each void, goal Check pH of urine with each void, goal

is to keep pH >7.0is to keep pH >7.0 Monitor for signs and symptoms of Monitor for signs and symptoms of

nausea and vomiting, administer nausea and vomiting, administer antiemetics as orderedantiemetics as ordered

ReferencesReferences

Jeha,S., Pui, C. ‘Recombinant Urate Jeha,S., Pui, C. ‘Recombinant Urate Oxidase (Rasburicase) in the Oxidase (Rasburicase) in the Prophylaxis and Treatment of Tumor Prophylaxis and Treatment of Tumor Lysis Syndrome, Ronco,R. Lysis Syndrome, Ronco,R. Rodeghiero, F. (eds) Rodeghiero, F. (eds) Hyperuricemic Hyperuricemic Syndrome: Pathophysiology and Syndrome: Pathophysiology and Therapy, Contrib NephrolTherapy, Contrib Nephrol, , Basel,Karger,2005,Vol 147,pp69-79Basel,Karger,2005,Vol 147,pp69-79

ReferencesReferences

Reid-Finlay,M. Kaplow, R. ‘Leukemia Reid-Finlay,M. Kaplow, R. ‘Leukemia and Bone Marrow Transplantation’, and Bone Marrow Transplantation’, Schell,H., Puntillo, K., Schell,H., Puntillo, K., Critical Care Critical Care Nursing Secrets, Nursing Secrets, Hanley and Belfus, Hanley and Belfus, Inc, Philadelphia 2001,p. 209-215Inc, Philadelphia 2001,p. 209-215

Zobec,A., ‘Tumor Lysis Syndrome’, Zobec,A., ‘Tumor Lysis Syndrome’, Oncology Nursing Secrets, Oncology Nursing Secrets, Hanley and Hanley and Belfus, 2008, p. 557-560Belfus, 2008, p. 557-560