Acute lymphoblastic leukaemia – tumour lysis syndrome

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Treating leukaemia produces its own complications. The most common time to have complications is during induction. For any new presentations of tumours, or for patients at the start of treatment, be aware of tumour lysis and how it can present.

View all our Acute Lymphoblastic Leukaemia Week posts

Tumour lysis syndrome is most commonly seen at the start of treatment as this is when there is the highest tumour load.

What is tumour lysis syndrome (TLS)?

TLS results from cell death and the subsequent release of chemicals from these cells.

It can be triggered by steroids, chemotherapy, fever, or dehydration.

What are the chemical abnormalities in TLS?

When cells die, they release their intracellular potassium and phosphate. Calcium then binds to the phosphate in the tissues. Urate is also deposited in the kidneys. The usual order of detected abnormalities is:

  1. High potassium
  2. High phosphate
  3. Low calcium – this can also be associated with kidney calcification
  4. High urea and creatinine  – this is due to renal failure and if this happens then the renal team need to be involved and the patient will likely require dialysis.

How do we treat TLS?

Treatment is through three main ways:

  • Hydration
  • Allopurinol – aiming to reduce the urate
  • Rasburicase – a medication that converts uric acid to allantoin which is water soluble and excreted in the urine.

Also, beware that if the patient has a high potassium, they are at risk of cardiac arrest so may also need standard hyperkalaemia management.

What are the other potential complications of ALL?

Anaemia – often the presenting complaint and result of treatment. Most patients require platelet & red cell transfusions.

Febrile neutropenia – most patients will have an episode of febrile neutropenia during induction. This can be due to life-threatening sepsis. Find your hospital guideline and if you suspect febrile neutropenia, talk to your consultant early.

Hyperviscosity syndrome – can be a presenting complaint, associated with WCC >100×109/L 

About the authors

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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