TUMOR LYSIS SYNDROME EXAM TEST

TUMOR LYSIS SYNDROME EXAM TEST Tumor Lysis Syndrome - CORRECT ANSWER-- Rapid release of intracellular contents of tumor cells into bloodstream (can be spontaneous or in response to chemo or RDT) - Metabolic disturbances (lead to clinical toxic effects) - common with hematologic malignancy (leukemias, lymphomas, solid tumors with high growth fraction like SCLC and Germ cell neoplasms) Metabolic changes - CORRECT ANSWER-- increase in uric acid (hyperuricemia > 8 mg/dL) - increase in K (hyperkalemia > 6 mmol/L) - increase in phosphate (hyperphosphatemia > 4.5 mg/dL) - decrease Ca (hypocalcemia < 7 mg/dL **corrected**) Clinical effects - CORRECT ANSWER-- acute renal failure - cardiac arryhthmias - seizures - death (multi-organ failure) - flank pain (nephrolithiasis) - muscle weakness/tetany - N/V - lethargy Risk Factors - CORRECT ANSWER-- high tumor burden - elevated baseline SCr (including dehydration) - elevated baseline uric acid - increase LDH Diagnosis - CORRECT ANSWER-- complete metabolic panel - LDH - serum uric acid - urinalysis - EKG Tumor lysis syndrome "pathway" - CORRECT ANSWER-1. Risk assessment 2. Prophylaxis 3. Treatment Preferable to provide PROPHYLAXIS - CORRECT ANSWER-- anticipate at risk patients - vigorous hydration - urinary alkalization with sodium bicarb - allopurinol Allopurinol - CORRECT ANSWER-- xanthine oxidase inhibitor (prevents formation of uric acid) - may take 2-3 days to decrease serum and urinary uric acid - 100 mg/m2 PO Q8 - 50% dose reduction in AKI Treatment in symptomatic patients - CORRECT ANSWER-- same measures as prophylaxis (- allopurinol) - Rasburicase (Elitek) instead of allopurinol Rasburicase (Elitek) - CORRECT ANSWER-- recombinant urate-oxidase - catalyzes uric acid into allantoin (more soluble and inactive metabolite) - **works immediately** - 0.2 mg/kg QD for up to 5 days - CI in G6PD deficiency negligible risk - CORRECT ANSWER-- no prophylaxis - no monitoring low risk - CORRECT ANSWER-- IV fluids - Allopurinol 300 mg BID - Daily labs Intermediate risk - CORRECT ANSWER-- IV fluids - allopurinol or rasburicase - inpatient monitoring - lab tests every 8-12 hours High risk - CORRECT ANSWER-- IV fluids -rasburicase - cardiac monitoring - lab tests every 6-8 hours Clinical TLS - CORRECT ANSWER-- IV fluids - Rasburicase - cardiac monitoring - ICU - lab tests every 4-6 hours TLS - Additional things to treat - CORRECT ANSWER-- Treatment of hyperkalemia - caution with Ca replacement (need to look at corrected CA) - Dialysis may be required (removal of K and phos) Management of Electrolytes - CORRECT ANSWER-1. Hyperphosphatemia 2. Hypocalcemia 3. Hyperkalemia Hyperphosphatemia - CORRECT ANSWER-- restrict phosphorus intake - administer phosphate binder (**sevelamer, lanthanum carbonate, calcium acetate) - consider dialysis in severe cases Hypocalcemia - CORRECT ANSWER-- no therapy unless symptomatic - Ca gluconate Ig IV (infuse slowly) Hyperkalemia - CORRECT ANSWER-- restrict potassium intake - Na polystyrene sulfonate asymptomatic/moderate - Sympotmatic or severe increase IV insulin 10 U and D10W 500 ml Albuterol 10-20 nebulization