Tumor lysis syndromeMANAGEMENT

HEMATOLOGIC AND ONCOLOGIC PRESENTATIONS · 12 SECTIONS

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534 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Acute chest syndrome Acute Hemolytic Transfusion Reaction Aplastic Anemia (Crisis)Autoimmune Hemolytic Anemia Coagulopathy Delayed Hemolytic Transfusion Reaction Disseminated Intravascular Coagulation (DIC)Essential Thrombocythemia Febrile Non-hemolytic Transfusion Reaction Graft Versus Host Disease (Acute)Hemolytic Uremic Syndrome (HUS)Hemophilia A (Bleeding Crisis)Heparin-Induced Thrombocytopenia (HIT)Hyperviscosity syndrome Immune Thrombocytopenic Purpura (ITP)Leukemoid Reaction Myelofibrosis Paroxysmal Nocturnal Hemoglobinuria Polycythemia Vera (Crisis)Pure Red Cell Aplasia Sickle Cell (Acute Chest Syndrome)Sickle Cell (Splenic Sequestration)Sickle cell crisis (vaso-occlusive)Symptomatic anemia Thrombocytopenia (severe)Thrombotic Thrombocytopenic Purpura (TTP)Transfusion-Associated Circulatory Overload (TACO)Transfusion-Related Acute Lung Injury (TRALI)Tumor lysis syndrome Von Willebrand Disease (Bleeding)

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp46

Immediate priorities

›Stabilization priorities

›Airway protection triggers

›Depressed mental status from severe electrolyte abnormality

›Refractory seizures

›Cardiac monitoring

›Continuous telemetry for dysrhythmia risk

›Defibrillator pads for wide-complex rhythm or severe hyperkalemia

›Vascular access

›2 large-bore IVs

›Central access if poor peripheral access or anticipated dialysis

›Bedside escalation triggers

›Ventricular dysrhythmia

›Potassium 6.0 mmol/l or ECG changes

›Symptomatic hypocalcemia

›Rising creatinine or oliguria

›Lactate rising with shock physiology

Early TLS recognition

›Pattern recognition

›Recent cytotoxic therapy

›Chemotherapy initiation within 12-72 hours

›Corticosteroid initiation in high-grade lymphoma or ALL

›High tumor burden context

›Bulky lymphadenopathy or massive splenomegaly

›Very high LDH

›Classic lab cluster

›Hyperkalemia

›Hyperphosphatemia

›Hyperuricemia

›Hypocalcemia

›Acute kidney injury

Monitoring and targets

›Monitoring cadence

›Electrolytes frequency

›Every 4-6 hours for active TLS or high risk on therapy

›Every 8-12 hours for intermediate risk prophylaxis

›Urine output tracking

›Hourly urine output with strict input output

›Foley catheter if critically ill or unreliable measurements

›ECG surveillance

›Repeat ECG with potassium rise

›Repeat ECG with symptomatic hypocalcemia

›Hemodynamic and renal targets

›Perfusion targets

›MAP 65 mmHg or baseline for chronic hypertension

›Lactate trend down

›Renal protection targets

›Urine output 1-2 ml/kg/hour if feasible

›Avoid nephrotoxins

02History/hx50

Key context

›Oncologic timeline

›Malignancy type

›High-grade lymphoma

›Acute lymphoblastic leukemia

›Acute myeloid leukemia

›Germ cell tumor

›Small cell carcinoma

›Therapy exposure

›Chemotherapy start date and agents

›Steroids initiation and dose

›Targeted therapy

›Radiation

›Tumor burden indicators

›Bulky disease

›High baseline LDH

›High WBC count in leukemia

Symptoms and complications

›Symptom cluster

›Cardiac symptoms

›Palpitations

›Syncope

›Chest pain

›Neuromuscular symptoms

›Weakness

›Paresthesias

›Muscle cramps

›Tetany

›Neurologic symptoms

›Seizure

›Confusion

›Renal symptoms

›Oliguria

›Flank pain

›Dark urine

›GI symptoms

›Nausea

›Vomiting

›Diarrhea

Risk modifiers

›Baseline risks

›Chronic kidney disease

›Reduced reserve for phosphate and uric acid clearance

›Dehydration

›Poor oral intake

›Vomiting or diarrhea

›Concomitant nephrotoxins

›NSAIDs

›ACE inhibitor or ARB

›IV contrast exposure

›G6PD deficiency risk

›Prior hemolysis history

›High-risk ancestry context when status unknown

03Physical Exam/exam42

High-risk findings

›Instability markers

›Vital sign abnormalities

›Hypotension

›Tachycardia

›Fever

›Volume status

›Dry mucous membranes

›Poor skin turgor

›Orthostasis

›Peripheral edema and crackles suggesting overload

›Renal perfusion clues

›Oliguria

›Bladder distension

Electrolyte effect findings

›Neuromuscular signs

›Hypocalcemia signs

›Perioral numbness

›Carpopedal spasm

›Chvostek sign

›Trousseau sign

›Hyperkalemia effect

›Muscle weakness

›Flaccid paralysis

›Cardiac exam

›Dysrhythmia signs

›Irregular pulse

›Poor perfusion

›Heart failure signs

›Elevated JVP

›S3

›Pulmonary rales

Malignancy burden clues

›Tumor burden exam

›Lymphadenopathy distribution

›Cervical

›Axillary

›Inguinal

›Hepatosplenomegaly

›Splenomegaly

›Hepatomegaly

›Airway or SVC compromise clues

›Facial swelling

›Stridor

›Venous distension

04Differential Diagnosis/ddx26

Life threats that mimic TLS physiology

›Hyperkalemia syndromes

›Acute kidney injury from other cause ICD-10 N17.9

›Sepsis-associated AKI

›Rhabdomyolysis-associated AKI

›Obstructive uropathy

›Adrenal insufficiency ICD-10 E27.2

›Hyperkalemia with hypotension

›Metabolic emergencies

›Diabetic ketoacidosis ICD-10 E10.10 or E11.10

›High anion gap acidosis

›Lactic acidosis from shock ICD-10 E87.2

›Lactate elevation predominant

›Treatment-related syndromes

›Sepsis after chemotherapy ICD-10 A41.9

›Fever and hypotension with organ dysfunction

›Hemolysis ICD-10 D59.9

›Anemia with jaundice and elevated LDH

›Calcium phosphate precipitation syndromes

›Acute phosphate nephropathy

›Recent phosphate load or bowel prep context

TLS variants

›Spontaneous TLS

›TLS before therapy initiation

›Rapidly proliferative malignancy with very high tumor burden

›Treatment-associated TLS

›TLS within days of cytotoxic or steroid therapy

›TLS after targeted therapy initiation in sensitive tumors

05Laboratory Tests/lt50

Core TLS panel

›Core chemistries

›Electrolytes and renal function

›Potassium

›Hyperkalemia severity stratification

›ECG correlation with potassium level

›Phosphate

›Hyperphosphatemia for calcium phosphate precipitation risk

›Calcium

›Ionized calcium when symptomatic or albumin abnormal

›Creatinine

›Trend for evolving AKI

›Bicarbonate

›Metabolic acidosis assessment

›Uric acid

›Hyperuricemia supporting TLS biology

›Rapid fall after rasburicase as response marker

›LDH

›High LDH as tumor turnover marker

›Baseline risk stratification input

Expanded labs for complications

›Hematology and hemolysis

›Complete blood count

›Leukocytosis in leukemia

›Anemia and thrombocytopenia baseline

›Peripheral smear when leukemia suspected

›Blasts

›Haptoglobin and bilirubin when hemolysis concern

›Rasburicase hemolysis differential in G6PD deficiency

›Acid-base and perfusion

›Venous or arterial blood gas

›Potassium confirmation in critical values

›pH and bicarbonate for acidosis severity

›Lactate

›Shock physiology assessment

›Renal and urinary

›Urinalysis

›Crystals

›Hematuria

›Specific gravity for dehydration

›Urine output and urine sodium when AKI etiology unclear

›Pre-renal pattern versus intrinsic

Lab pitfalls

›Interpretation caveats

›Pseudohyperkalemia

›Hemolyzed sample

›Marked leukocytosis or thrombocytosis

›Total calcium limitation

›Albumin effect on total calcium

›Ionized calcium preferred for symptoms

›Uric acid after rasburicase

›Sample handling requirement

›Keep sample cold and process rapidly to avoid falsely low results

06Diagnostic Tests/dt58

Scoring Systems

›TLS definitions and grading

›Cairo-Bishop laboratory TLS criteria

›Uric acid rise 25 percent or above threshold

›Potassium rise 25 percent or above threshold

›Phosphate rise 25 percent or above threshold

›Calcium fall 25 percent or below threshold

›Cairo-Bishop clinical TLS features

›Creatinine rise compatible with AKI

›Seizure

›Dysrhythmia

›Sudden death

›Howard modification practical criteria

›Absolute lab thresholds without 25 percent change requirement

›Timing window around therapy initiation

›Risk stratification concepts

›High risk

›Burkitt lymphoma

›High-grade lymphoma with bulky disease

›ALL with high WBC

›Very high LDH

›Baseline renal dysfunction

›Intermediate risk

›Chemo-sensitive malignancy without bulky disease

›Moderate LDH elevation

›Low risk

›Indolent malignancy

›Small tumor burden

MRI

›MRI roles in TLS context

›Alternative staging imaging

›Contrast avoidance in AKI

›Non-contrast protocols when appropriate

›Neurologic complication evaluation

›Seizure workup when focal deficit or concern for CNS disease

›MRI limitations

›Limited utility for acute metabolic derangement diagnosis

›Delays in unstable patient

›CT roles in TLS context

›Tumor burden assessment

›Bulky nodal disease

›Organ infiltration

›Obstructive uropathy evaluation

›Hydronephrosis when ultrasound nondiagnostic

›Complication evaluation

›Bowel ischemia or perforation when severe abdominal pain

›CT contrast considerations

›Contrast nephropathy risk in AKI

›Non-contrast alternatives when feasible

›Hydration optimization when contrast unavoidable

Ultrasound

›POCUS and formal ultrasound

›Renal ultrasound

›Hydronephrosis for obstruction

›Bladder volume for retention

›Volume status ultrasound

›IVC assessment adjunct

›Lung B-lines for overload during aggressive fluids

›Cardiac POCUS

›Hyperkalemia dysrhythmia context supportive evaluation

›Global function when shock develops

07Disposition/dispo38

Level of care

›ICU indications

›Clinical TLS

›Dysrhythmia

›Seizure

›Shock

›Severe electrolyte derangements

›Potassium 6.0 mmol/l or ECG changes

›Symptomatic hypocalcemia

›Rapidly rising phosphate with AKI

›Renal failure escalation

›Oliguria or anuria

›Rising creatinine despite resuscitation

›Dialysis anticipated within 24 hours

›Inpatient monitored bed indications

›Laboratory TLS without end-organ complications

›Intermediate risk receiving cytotoxic therapy

›Need for q4-6h labs and IV prophylaxis

Consultation and transfer

›Specialty involvement

›Oncology

›Risk category confirmation

›Antineoplastic therapy adjustments

›Nephrology

›Dialysis planning triggers

›Continuous renal replacement therapy candidacy

›Critical care

›Hemodynamic instability

›Need for invasive monitoring

›Transfer criteria

›Dialysis capability unavailable locally

›Pediatric oncology center requirement

›Continuous renal replacement therapy requirement

Discharge considerations

›Outpatient only scenarios

›Low TLS risk

›No lab TLS

›Reliable follow-up within 24-48 hours

›Oral hydration tolerated

›Clear return precautions and lab plan

›Same-day or next-day labs arranged

08Treatment/t118

Fluids and renal protection

›IV hydration strategy

›Isotonic crystalloid

›2-3 l/m2/day typical prophylaxis range

›Individualize for heart failure or CKD

›Urine output targets

›1-2 ml/kg/hour if feasible

›Adjust goal to avoid pulmonary edema

›Diuretics role

›If volume replete and oliguria

›Loop diuretic trial with close monitoring

›Avoid harmful adjuncts

›Urine alkalinization avoidance

›Increased calcium phosphate precipitation risk

›Most guidelines discourage routine alkalinization

Uric acid lowering

›Xanthine oxidase inhibition

›Allopurinol

›Prophylaxis in intermediate risk

›Typical adult dose 300 mg daily

›Dose reduction in renal impairment

›Limitations

›Prevents new uric acid formation

›Does not remove existing uric acid

›Xanthine accumulation risk

›Uric acid oxidation

›Rasburicase

›Indications

›High TLS risk prophylaxis

›Established TLS with hyperuricemia

›AKI with hyperuricemia

›Adult dosing strategies

›Fixed dose 3 mg IV once option

›Weight-based 0.2 mg/kg IV once daily option

›Repeat dosing based on uric acid rebound and risk

›Contraindications and cautions

›G6PD deficiency

›Hemolysis risk

›Methemoglobinemia risk

›Pregnancy risk-benefit individualized

›Lab handling after administration

›Uric acid sample on ice

›Rapid processing to avoid falsely low result

Hyperkalemia management

›Cardiac membrane stabilization

›Calcium gluconate IV

›Indications

›ECG changes

›Potassium 6.5 mmol/l or higher

›Typical adult dose

›10 ml of 10 percent solution IV over 5-10 minutes

›Repeat dosing

›If ECG changes persist

›Potassium shifting therapies

›Insulin with dextrose

›Regular insulin 10 units IV

›Dextrose 25 g IV if glucose below 13.9 mmol/l

›Glucose checks

›At 30 minutes

›Hourly for 3-4 hours

›Nebulized beta agonist

›Albuterol 10-20 mg nebulized

›Reduced effect in some patients

›Potassium removal

›Dialysis

›Refractory hyperkalemia

›Severe AKI with oliguria

›Potassium binders

›Adjunct only

›Not for unstable ECG-threatening hyperkalemia

Hyperphosphatemia and hypocalcemia

›Phosphate control

›Dietary phosphate restriction

›Stop phosphate-containing infusions

›Phosphate binders

›Sevelamer oral

›Typical adult starting 800-1600 mg with meals

›Titration based on phosphate trend

›Calcium-based binders

›Avoid if hypercalcemia risk

›Caution with calcium phosphate precipitation

›Dialysis

›Severe hyperphosphatemia with AKI

›Symptomatic hypocalcemia from phosphate load

›Calcium strategy

›Asymptomatic hypocalcemia

›Avoid routine calcium replacement

›Calcium phosphate precipitation risk

›Symptomatic hypocalcemia

›Calcium gluconate IV

›Tetany

›Seizure

›Prolonged QT with symptoms

›Treat concurrent hyperphosphatemia aggressively

AKI and renal replacement therapy

›AKI management

›Perfusion optimization

›Maintain MAP goals

›Treat sepsis if present

›Nephrotoxin avoidance

›NSAIDs avoidance

›Adjust renally cleared meds

›Dialysis triggers

›Refractory hyperkalemia

›Refractory hyperphosphatemia

›Severe metabolic acidosis

›Volume overload with respiratory compromise

›Uremic complications

›Modality considerations

›Intermittent hemodialysis

›Rapid potassium clearance

›Continuous renal replacement therapy

›Hemodynamic instability

›Ongoing high solute load

Evidence and guideline framing

›Guideline consensus themes

›Aggressive IV hydration as foundational therapy

›Broad guideline agreement

›Rasburicase preferred for high risk or established TLS

›Class I style recommendation in multiple oncology guidelines

›Allopurinol appropriate for prophylaxis in intermediate risk

›Class I style recommendation in multiple oncology guidelines

›Routine urine alkalinization discouraged

›Guideline consensus due to precipitation risk

09Special Populations/sp31

Pregnancy

›Pregnancy considerations

›Maternal priorities

›Maternal stabilization first

›Continuous fetal monitoring when viable gestational age and feasible

›Medication considerations

›Allopurinol risk-benefit individualized

›Rasburicase risk-benefit individualized

›Limited pregnancy data

›Avoid if G6PD deficiency

›Fluid management

›Lower threshold for pulmonary edema monitoring

›Ultrasound guidance for overload

Geriatric

›Geriatric considerations

›Fluid sensitivity

›Heart failure prevalence

›Lower starting rate with frequent reassessment

›Renal reserve limitation

›Earlier nephrology involvement

›Lower threshold for dialysis planning

›Polypharmacy

›ACE inhibitor or ARB contribution to hyperkalemia

›NSAID contribution to AKI

Pediatrics

›Pediatric considerations

›Risk profile

›ALL and high-grade lymphoma common TLS contexts

›Weight-based dosing

›Rasburicase 0.2 mg/kg IV once daily option

›Fluids in ml/m2/day or ml/kg/hour per institutional protocol

›Dialysis planning

›Early transfer to pediatric dialysis capable center if needed

›Continuous renal replacement therapy availability variability

10Background/b40

Epidemiology

›TLS epidemiology

›Highest incidence settings

›Burkitt lymphoma

›High-grade non-Hodgkin lymphoma

›Acute leukemias

›Timing

›Most common within 12-72 hours after therapy initiation

›Possible up to 7 days after therapy

›Spontaneous TLS

›Occurs before therapy in very high tumor burden malignancy

›Often with marked hyperuricemia and AKI

Pathophysiology

›Core mechanism

›Rapid cell lysis

›Release of intracellular potassium

›Release of intracellular phosphate

›Release of nucleic acids leading to uric acid

›Kidney injury pathways

›Uric acid crystal nephropathy

›Calcium phosphate precipitation in renal tubules

›Reduced renal perfusion from dehydration

›System effects

›Hyperkalemia causing dysrhythmia

›Hypocalcemia causing neuromuscular irritability and seizures

›Acidosis worsening potassium shift and renal injury

Therapeutic Considerations

›Treatment rationale links

›Hydration

›Increases renal perfusion

›Increases solute delivery and excretion

›Allopurinol

›Reduces new uric acid formation

›Best as prophylaxis rather than rescue

›Rasburicase

›Converts uric acid to allantoin

›Rapid uric acid reduction

›Hyperkalemia pathway

›Calcium for membrane stabilization

›Insulin and beta agonist for intracellular shift

›Dialysis for definitive removal

›Calcium replacement restraint

›Avoid worsening calcium phosphate precipitation unless symptomatic

11Patient Discharge Instructions/pdi18

copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Tumor lysis risk causes dangerous electrolyte changes and kidney strain

›Home plan

›Oral hydration goal individualized

›Medication adherence for prophylaxis plan

›Lab follow-up

›Bloodwork within 24-48 hours or as oncology directs

›Return to ED now

›Chest pain

›Palpitations

›Fainting

›New weakness

›Severe muscle cramps or spasms

›Seizure

›Confusion

›Minimal urine output over 8-12 hours

›Persistent vomiting preventing hydration

12References/r17

Clinical guidelines and consensus

›Guideline sources

›ASCO clinical guidance on TLS prevention and management

›Risk stratification

›Hydration and urate-lowering strategy

›NCCN supportive care guidance covering TLS

›Prophylaxis pathways by risk

›Rasburicase use in high risk

›British Committee for Standards in Haematology TLS guidance

›Diagnostic definitions

›Management escalation and dialysis triggers

Definitions and seminal frameworks

›Foundational criteria sources

›Cairo-Bishop TLS definition framework

›Laboratory TLS criteria

›Clinical TLS criteria

›Howard TLS definition modification

›Absolute thresholds emphasis

›Practical timing alignment with therapy

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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