TUMOR LYSIS SYNDROME
	KEY POINTS	NOTES
PATIENT REPORT	24-year-old Presents to emergency department with reports of Muscle cramps Joint pain Lethargy Nausea Recently diagnosed with non-Hodgkin lymphoma Underwent first dose of chemo Admitted to inpatient oncology unit
PATHOPHYSIOLOGY	Oncologic emergency with severe metabolic abnormalities Common during treatment of blood cancers Leukemia and lymphoma Triggered by rapid tumor cell death High tumor burden or fast-growing tumors Cause Tumor cells release contents into bloodstream Hyperkalemia affecting heart and nerves Hyperuricemia leading to kidney injury Hyperphosphatemia binding calcium Leads to hypocalcemia affecting heart and nerves Forms crystals damaging kidney tubules Risk factors Older age Large tumor burden High white blood cell count High LDH levels Bone marrow involvement Preexisting kidney disease Uric acid increasing substances Symptoms Nausea, vomiting and diarrhea Muscle cramps, twitches, and weakness Numbness tingling and confusion Irritability, delirium and seizures Complications Acute kidney injury Arrhythmias Sudden cardiac death
DIAGNOSIS AND TREATMENT	Diagnosis History Physical assessment Laboratory tests ECG Treatment Monitor electrolytes and cardiac function closely Track urine output and kidney function Begin IV isotonic fluids Treatment of electrolyte abnormalities Hemodialysis if levels are severely high Prevention Assess risk before starting chemotherapy Begin aggressive IV hydration early Start allopurinol or rasburicase prophylactically Avoid urinary alkalinization per guidelines
ASSESSMENT	Muscle cramping Joint pain Nausea Lethargy Decreased urine output Bowel sounds present x4 Vital signs Temperature: 98.6°F (37°C) Heart rate: 98 bpm Respirations: 18 breaths/min Blood pressure: 130/80 mmHg Oxygen saturation: 94% on room air Pain 6/10 Laboratory results BUN: 50 mg/dL (17.85 mmol/L) Serum creatinine: 4.9 mg/dL (432.1 μmol/L) Uric acid: 19 mg/dL (1130.1 μmol/L) Potassium: 6.0 mEq/L (6.0 mmol/L) Phosphate: 7.9 mg/dL (2.55 mmol/L) Calcium: 6.1 mg/dL (1.53 mmol/L) ECG Tall, peaked T waves Shortened QT interval ST-segment depression
NURSING DIAGNOSES	Risk for decreased cardiac tissue perfusion related to abnormal electrolyte levels Risk for imbalanced fluid volume related to damage to renal tubules Pain related to effects of imbalanced electrolytes on muscle contraction Nausea related to metabolic derangements Readiness for enhanced knowledge related to prevention and treatment of tumor lysis syndrome
PLANNING	Patient goals Maintain a regular heart rhythm Ensure adequate cardiac perfusion Maintain adequate fluid balance Manage pain to a 3 out of 10 Control nausea effectively Verbalize understanding of treatment plan Verbalize ways to prevent tumor lysis syndrome
IMPLEMENTATION	Initiated continuous ECG monitoring Continued IV fluids at 200 mL per hour Delegated intake/output monitoring to nursing assistant Administered ordered medications Provided patient education Monitor hourly vital signs Serum electrolyte monitoring every 4 hours Patient education Reviewed importance of staying well-hydrated Advised on low-potassium and low-phosphorus diet Avoid high-fat dairy, certain seafood and meats Avoid carbonated drinks, bananas, and potatoes Requested dietician consult Report to HCP Arrhythmias or palpitations Shortness of breath Muscle twitching Changes in mental status Decreased urine output
EVALUATION	Vital signs Blood pressure: 126/78 mmHg Temperature: 98.6°F (37°C) Respirations: 16 breaths per minute Oxygen saturation: 94% room air Heart rate: 85, normal sinus rhythm Pain 2/10 Nausea improved Began tolerating oral fluids Urinary output 150 mL/hour Urine clear and yellow Laboratory results Potassium: 5.3 mEq/L (5.3 mmol/L) Phosphate: 6.6 mg/dL (2.1 mmol/L) Calcium: 7.2 mg/dL (1.8 mmol/L) BUN: 45 mg/dL (16 mmol/L) Creatinine: 4.2 mg/dL (371.2 μmol/L) Uric acid: 14 mg/dL (832.7 μmol/L)

Michael Wheatley is a 24-year-old male client who presents to the emergency department or ED, with muscle cramps in both legs, joint pain in his knees, hips, shoulders and wrists, as well as lethargy and nausea.

He mentions that he was recently diagnosed with non-Hodgkin’s lymphoma, for which he received his first dose of chemotherapy in an outpatient oncology clinic yesterday.

The ED physician orders IV fluids at a rate 200 mL/hour and admits Michael to the inpatient oncology unit for further evaluation and treatment.

Tumor lysis syndrome, or TLS, is an oncologic emergency that’s characterized by severe metabolic and electrolyte abnormalities. This most often occurs as a complication during treatment of hematological malignancies, like leukemia and lymphoma, with chemotherapeutic medications that rapidly kill large numbers of tumor cells.

Rarely, TLS can also occur spontaneously with tumors that have a high proliferative rate or a large tumor burden, prior to any treatment. Regardless, the end result is a massive release of intracellular contents during lysis, of tumor cells into the bloodstream.

This results in hyperkalemia, which can interfere with electrical activity in the heart, brain, and nerves. In addition, there’s hyperuricemia, and the excess uric acid can form crystals that deposit in the tiny kidney tubules, resulting in acute kidney injury.

Finally, there’s hyperphosphatemia, and the excess phosphate can bind to the calcium in the blood, forming a complex, leading to hypocalcemia, which can also interfere with electrical activity in the heart, brain, and nerves.

Moreover, these phosphate-calcium complexes can also form crystals that deposit in the kidney tubules, contributing to the development of acute kidney injury.

Now, there are some factors that may put the client at risk of TLS, such as older age, and having a large tumor burden, which can be evidenced by the presence of a very high white blood cell count, and high lactate dehydrogenase or LDH, as well as bone marrow involvement by the malignancy.

Other risk factors include having an underlying renal disease that reduces urinary output, thus promoting the precipitation of uric acid or phosphate-calcium crystals in the renal tubules.

Finally, the risk of TLS is also higher with the use of substances that increase the uric acid levels in blood, such as alcohol and medications like thiazide diuretics or levodopa.

Now, symptoms of TLS include nausea, vomiting, and diarrhea, as well as muscle cramps or twitches, often associated with weakness, numbness, and tingling.

In addition, clients may experience confusion, irritability, delirium, and seizures. An important complication of TLS is acute kidney injury, which typically presents with oliguria, or a decreased urine output.

Finally, clients may experience arrhythmias, which can lead to palpitations and syncope. If not treated, TLS can cause sudden cardiac death.Now, diagnosis of TLS begins with history and clinical findings.

Upon lab tests, a complete metabolic panel will be reflective of electrolyte imbalance, typically showing hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia.

In addition, LDH is typically increased. Other diagnostic tests include kidney function tests, which typically show increased serum creatinine and blood urea nitrogen, or BUN; as well as a urinalysis, which usually reveals the presence of uric acid crystals in urine.

Finally, an electrocardiography, or ECG, can be done to assess for cardiac complications. Treatment of TLS also involves close monitoring of electrolyte levels, urine output, and cardiac function.

Treatment starts with intravenous isotonic fluids to help correct the electrolytes abnormalities. In addition, hyperkalemia can be managed with IV insulin and dextrose, which helps move some of the excess potassium to the inside of the cells and decreases its level in the blood, or with polystyrene sulfonate or kayexalate if the potassium levels are lower than 6.5 mEq/L and cardiac symptoms are absent.

Hyperphosphatemia can be treated with IV fluids, phosphate-binding agents such as aluminum hydroxide and dietary restriction of phosphate; whereas hypocalcemia usually resolves with the management of hyperphosphatemia.

Hyperuricemia can be managed with medications like allopurinol, which decreases the production of uric acid, or with rasburicase, which breaks down uric acid to be easily excreted by the kidneys.

If the level of potassium, phosphate or uric acid is too high, urgent hemodialysis might be needed. Finally, TLS can be prevented by taking certain measures before starting chemotherapy, such as aggressive intravenous hydration as well as medications to prevent hyperuricemia like allopurinol or rasburicase.

Let’s get back to assess our client Michael. When you ask him how he’s feeling he states he has been having intense muscle cramping and joint pain since the previous night, and he’s been nauseous and lethargic.

When asked about his recent voiding pattern, if there is any blood present in his urine , and how often he has been drinking fluids in the last 24 hours, he says that he has been needing to use the bathroom less than usual, only about twice daily, because he has not been able to tolerate eating or drinking due to feeling nauseated.

Key Takeaways

Tumor lysis syndrome (TLS) is a potentially life-threatening complication that can occur in cancer patients during or shortly after cancer treatment, especially in leukemia and lymphoma. TLS occurs as a result of the killing of large numbers of tumor cells by chemotherapeutic medications. This releases large amounts of intracellular contents, such as nucleic acids and potassium, into the bloodstream after cancer cells are destroyed by chemotherapy or radiation therapy. The resulting metabolic imbalances can cause electrolyte abnormalities, acute kidney injury, and other serious complications. Treatment of TLS typically involves aggressive fluid and electrolyte management and may require dialysis in severe cases.

Tumor lysis syndrome (TLS): Nursing Process (ADPIE)

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