Clinicians at Centro Hospitalar do Porto in Portugal reported on the case to highlight risk factors for tumor lysis syndrome (TLS). After 3 cycles of folinic acid, 5-fluorouracil and oxaliplatin (FOLFOX), the patient developed nausea, mild asthenia, tremors, and hyperkalemia that did not respond to standard measures. The differential diagnosis included dehydration, hypotension, exposure to nephrotoxic drugs, and obstructive uropathy, as well as TLS. The patient was diagnosed with acute kidney injury and TLS.
Tumor lysis syndrome is common after the beginning of antineoplastic treatments. As massive amounts of tumor cells are killed, intracellular electrolytes and metabolites flood into the bloodstream. If the metabolites exceed the renal clearance threshold, serious complications ensue, including cardiac arrhythmias or seizures and death. Mortality rates related to TLS in solid tumors can be as high as 35%, the clinicians say. Acute kidney injury during chemotherapy should raise warning flags about TLS, they add, particularly because prompt diagnosis is crucial for short-term outcomes.
The patient was admitted immediately to the intensive care unit with the main aim of preventing severe cardiac events and reversing crystal nephropathy. Adding targeted therapy might have worsened the TLS, so the clinicians opted for high-risk prophylaxis. They advise having rasburicase readily available for treating TLS to degrade urate crystals and reverse nephropathy, reducing the need for renal replacement therapy. However, the clinicians caution that rasburicase and allopurinol (another option) are not free of toxicity.
After a reevaluation computer tomography scan showed that the hepatomegaly was reduced with smaller liver metastases, the clinicians switched the patient to low-risk prophylaxis. The TLS did not recur.
Chemosensitivity, which raises the risk of TLS, is low in colon cancer, the clinicians say. High tumor burden and high proliferation rates seem to be better predictors for TLS.
Source:
Gouveia HS, Lopes SO, Faria AL. BMJ Case Rep. 2018;2018. pii: bcr-2017-223474.
doi: 10.1136/bcr-2017-223474.
