腫瘤溶解症候群

Buzzwords → Dx

Diagnostic Criteria (Cairo-Bishop)

Laboratory TLS (≥2 within 3 d before / 7 d after chemo):

• Uric acid ≥8 mg/dL (or 25 % increase)
• K ≥6.0 mEq/L (or 25 % increase)
• Phosphate ≥4.5 mg/dL adults / ≥6.5 children (or 25 % increase)
• Calcium ≤7.0 mg/dL (or 25 % decrease)

Clinical TLS = laboratory TLS + ≥1 of:

• Cr ≥1.5× ULN
• Cardiac arrhythmia / sudden death
• Seizure

Risk Stratification (high-risk → use rasburicase + IVF + admission for monitoring)

• High-risk: Burkitt, ALL with WBC >100K or LDH ≥2× ULN, AML with WBC >50K, DLBCL with bulky disease + LDH ≥2× ULN, T-ALL, venetoclax in CLL with bulky / lymphocytosis.
• Intermediate-risk: AML with WBC 25–50K, ALL with WBC 50–100K, intermediate-grade B-NHL.
• Low-risk: indolent NHL, CLL chronic phase without progressive lymphadenopathy.

Workup

• Pre-chemo labs: UA, K, Ph, Ca, Cr, LDH, bicarbonate.
• G6PD activity (before rasburicase).
• Hydration assessment — IVF goal 2–3 L/m²/day or 100 mL/kg/d.
• Cardiac monitoring (telemetry) for high-risk during induction.
• Frequency of labs: q4–8h for high-risk during peak risk window (typically first 24–72 h of chemo).

Treatment Algorithm

flowchart TD
  A[High-risk for TLS] --> B[Aggressive IV fluids<br>2-3 L/m²/d goal UO 100 mL/h]
  B --> C{Risk level}
  C -- low --> D[+ allopurinol 100-300 mg/d]
  C -- intermediate --> E[+ allopurinol; consider rasburicase if rising UA]
  C -- high --> F[+ rasburicase 0.2 mg/kg ×1 (or 1.5-7.5 mg fixed)<br>BUT FIRST: check G6PD]
  F --> G{G6PD deficient?}
  G -- yes --> H[Use allopurinol + aggressive IVF<br>NO rasburicase — severe hemolysis risk]
  G -- normal --> I[Rasburicase + allopurinol can be combined or sequenced]
  D --> J[Monitor labs q4-8h<br>K, Ph, Ca, UA, Cr]
  E --> J
  H --> J
  I --> J
  J -- TLS develops --> K[Treat hyperK: insulin/glucose, kayexalate, calcium gluconate, dialysis if refractory<br>treat hypoCa: replace ONLY if symptomatic (deposits with high PO₄)<br>treat hyperPO₄: phosphate binders<br>dialysis if multi-electrolyte refractory or AKI]

Pearls / Pitfalls

• Burkitt lymphoma frequently has SPONTANEOUS TLS at presentation — pre-phase rasburicase + IVF before any chemo.
• G6PD deficiency + rasburicase → severe hemolysis + methemoglobinemia. Always screen before rasburicase, especially African, Mediterranean, and Southeast Asian patients.
• Sample handling for uric acid after rasburicase: sample must be kept on ice + processed within 4 h (rasburicase continues to degrade UA in tube → falsely low values).
• Don't replete calcium aggressively in TLS unless symptomatic (tetany, arrhythmia) — calcium phosphate precipitation worsens AKI.
• Venetoclax ramp-up TLS risk in CLL with bulky lymphadenopathy or high lymphocyte count — daily lab monitoring during dose escalation; admit for first dose if high-risk.
• Acetazolamide / urinary alkalinization is NO LONGER recommended (calcium phosphate precipitation in alkaline urine).
• Hemodialysis indications: refractory hyperkalemia, AKI requiring renal replacement, severe hyperphosphatemia.
• Continuous renal replacement therapy (CRRT) preferred over intermittent HD in unstable pts.
• PO₄ × Ca product >70 → high risk for soft tissue / renal calcium phosphate deposition.
• Allopurinol-rasburicase interaction: minor; can use sequentially or together; allopurinol 24 h before chemo allows accumulation of xanthine + hypoxanthine but rasburicase clears uric acid.
• TLS prophylaxis in MM with venetoclax has been studied; less than CLL but still relevant in t(11;14) MM treatment.

Cross-references

• Burkitt — spontaneous TLS
• AML — induction TLS risk
• CLL — venetoclax TLS
• G6PD screening before rasburicase
• Lab Values — UA, K, Ph, Ca

相關題目

• Q-049 — Burkitt — pre-induction TLS prophylaxis
• Q-116 — G6PD — rasburicase contraindication
• Q-175 — TLS — Cairo-Bishop laboratory criteria
• Q-176 — TLS — venetoclax ramp-up in CLL
• Q-177 — TLS — calcium replacement decision

Sources