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Key Features

  • Complication of treatment-associated tumor lysis of hematologic as well as rapidly proliferating malignancies

  • May be worsened by thiazide diuretic use

  • Rapid increase in serum uric acid can cause acute urate nephropathy from uric acid crystallization

  • To prevent urate nephropathy, serum uric acid must be reduced before chemotherapy

Clinical Findings

  • Acute kidney injury

  • Hyperuricemia

  • Hyperphosphatemia (associated symptoms include nausea, vomiting, seizures)

  • Hyperkalemia (can cause arrhythmias and sudden death)

Diagnosis

  • Laboratory tests (serum uric acid, phosphorus, calcium, electrolytes [particularly, potassium and sodium], creatinine) should be monitored following initiation of chemotherapy

Treatment

  • Prevention of hyperuricemia, hyperphosphatemia and hyperkalemia are most important, though bicarbonate infusions are no longer recommended

    • The American Society of Clinical Oncology guidelines recommend aggressive hydration before, during, and after chemotherapy to help keep urine flowing and facilitate excretion of uric acid and phosphorus

  • Treatment for hyperuricemia

    • Allopurinol

      • Blocks the enzyme xanthine oxidase and therefore the formation of uric acid from purine breakdown

      • 100 mg/m2 every 8 hours orally (maximum 800 mg/day) with dose adjustments for impaired kidney function should be given before starting chemotherapy

    • Rasburicase

      • Indicated for patients at high risk for developing tumor lysis syndrome or in whom hyperuricemia develops despite treatment with allopurinol

      • Dosage: 0.1–0.2 mg/kg/day intravenously for 1–7 days

      • Cannot be given to patients with known glucose 6-phosphate dehydrogenase (G6PD) deficiency nor can it be given to pregnant or lactating women

  • Elevated potassium or phosphorus levels need to be promptly treated (see Hyperkalemia and Hyperphosphatemia)

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