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For further information, see CMDT Part 39-28: Hyperuricemia & Tumor Lysis Syndrome

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

    • 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

    • Bicarbonate infusions are no longer recommended

  • Treatment for hyperuricemia

    • Allopurinol

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

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

    • Rasburicase

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

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

      • May be considered for patients with baseline elevated uric acid who are being treated with venetoclax (Bcl-2 inhibitor) for chronic lymphocytic leukemia who have large lymph nodes [≥ 10 cm] or nodes ≥ 5 cm accompanied by white blood cell counts > 25,000/mcL [25 × 109/L]

      • 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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