Primary prevention

Prevention relies on early recognition of patients at risk of developing TLS and initiation of appropriate preventive measures.[2]

Patients can be categorized as low, intermediate, or high risk depending on the type of malignancy, treatment sensitivity (of the tumor), disease stage, white blood cell (WBC) count, tumor burden (bulk), lactate dehydrogenase (LDH) level, and pre-existing renal impairment/renal abnormality.[35]

Nephrotoxic agents (e.g., nonsteroidal anti-inflammatory drugs, aminoglycoside antibiotics, and intravenous contrast agents) should be avoided in all patients with hematologic malignancy undergoing chemotherapy. Drugs that increase the levels of uric acid, potassium, and phosphate (e.g., thiazide or potassium-sparing diuretics) should be avoided if possible.

Prophylaxis: low-risk patients

Low-risk patients include those with:[35]

  • Solid tumors, except rare solid tumors that are chemosensitive (e.g., neuroblastoma, germ cell tumors, small cell lung cancer), or others with bulky or advanced disease

  • Chronic myeloid leukemia: chronic phase

  • Chronic lymphocytic leukemia when treated exclusively with alkylating agents

  • Multiple myeloma

  • Hodgkin lymphoma

  • Acute myeloid leukemia with WBC count <25,000/microliter and LDH <2 times the upper limit of normal (ULN)

  • Indolent/low proliferating non-Hodgkin lymphoma (e.g., small lymphocytic lymphoma, follicular lymphoma, marginal B-cell lymphoma, MALT lymphoma, mantle cell lymphoma [non-blastoid], cutaneous T-cell lymphoma, and anaplastic large cell lymphoma [adults])

Patients with low-risk disease who have renal dysfunction/involvement should be categorized as intermediate risk.[35]

Low-risk patients can be observed with regular monitoring of blood biochemistry (including uric acid, phosphate, potassium, calcium, blood urea nitrogen [BUN], creatinine, and LDH) and regular assessment of fluid balance and vital signs.[1]

Allopurinol (a xanthine oxidase inhibitor) may be considered for the management of hyperuricemia in low-risk patients, if required (e.g., if there are signs of metabolic changes, bulky and/or advanced disease, and/or high proliferative disease).[4][35][36] Allopurinol reduces uric acid production by preventing the degradation of purine (from nucleic acids) to uric acid, but it has no effect on uric acid already present.[1][2] It has been shown to reduce the incidence of urate nephropathy related to uric acid crystal precipitation.[37][38]

When allopurinol is used in combination with a purine-based chemotherapeutic agent (e.g., mercaptopurine or azathioprine), dose reduction of the purine-based agent is required to prevent toxicity. Coadministration of allopurinol and capecitabine should be avoided due to the risk of decreased efficacy with capecitabine.

If allopurinol is unsuitable (e.g., due to allergy or intolerance), febuxostat (a nonpurine selective xanthine oxidase inhibitor) can be used in adult patients.[39] The safety and efficacy of febuxostat in children is unclear.

The National Comprehensive Cancer Network (NCCN) recommends starting allopurinol or febuxostat 2 to 3 days prior to initiation of cancer treatment and continuing for 10 to 14 days.[36][40]​​​[41]

Prophylaxis: intermediate-risk patients

Intermediate-risk patients include those with:[35][41]

  • Rare solid tumors that are chemosensitive (e.g., neuroblastoma, germ cell tumors, small cell lung cancer), or others with bulky or advanced-stage disease

  • Early-stage lymphoblastic lymphoma with LDH <2 times ULN

  • Early-stage lymphoblastic lymphoma with LDH <2 times ULN

  • Acute lymphoblastic leukemia with WBC count <100,000/microliter and LDH <2 times ULN

  • Acute myeloid leukemia with WBC count ≥25,000/microliter to <100,000/microliter, or WBC count <25,000/microliter and LDH ≥2 times ULN

  • Chronic lymphocytic leukemia with WBC count ≥50,000/microliter and/or treated with fludarabine or targeted agents (e.g., rituximab, lenalidomide, obinutuzumab, venetoclax)

Patients with intermediate-risk disease who have renal dysfunction/involvement, or uric acid, potassium, and/or phosphate levels above the normal range, should be categorized as high risk.[35]

Intermediate-risk patients should have regular (at least daily) checks of their blood pressure, heart rate, and respiratory rate. Blood biochemistry (including uric acid, phosphate, potassium, calcium, BUN, creatinine, and LDH) should be determined before preventive interventions, and then 1 to 2 times daily for the first 3 days of therapy and once daily thereafter. Guidelines for monitoring and assessment may differ depending on region and center; therefore, referral to local guidance is advised.

Two days before the initiation of cancer treatment, patients at intermediate risk should receive intravenous hydration with isotonic saline to maintain a urinary output of 100 mL/m²/hour (3 mL/kg/hour in children <10 kg body weight). Aggressive hydration improves intravascular volume and enhances renal blood flow.[1][2] A high glomerular filtration rate helps eliminate potassium, uric acid, and phosphate from the bloodstream.

If urine output is not satisfactory despite volume repletion, then loop diuretics may be used.[2] Loop diuretics may, however, cause precipitation of uric acid and calcium phosphate in the tubules and should be avoided in patients with renal obstruction or volume depletion.[42]

Allopurinol or febuxostat (if allopurinol is unsuitable) is recommended for the management of hyperuricemia.[36][41]

Rasburicase (a recombinant form of the urate oxidase enzyme) should be used if hyperuricemia is inadequately managed by allopurinol or febuxostat.[1] Rasburicase transforms uric acid into allantoin. Allantoin is more soluble in urine than uric acid, and more easily eliminated by the kidney.[43] Rasburicase has been shown to reduce the median uric acid concentration from 577 to 60 micromol/L within 4 hours of treatment.[44] One systematic review (of controlled trials for the prevention or management of TLS) concluded that there is insufficient evidence to determine whether rasburicase improves clinical outcomes in adults compared with alternatives.[45]

Rasburicase may be considered for initial management of hyperuricemia in pediatric patients.[1]

Approximately 1% of recipients develop hypersensitivity reactions to rasburicase.

Rasburicase is contraindicated in patients with:

  • Glucose-6-phosphate dehydrogenase deficiency (screening should be performed in all patients before starting treatment)

  • A history of hemolytic anemia or methemoglobinemia.

Alkalinization of urine (to eliminate uric acid) is no longer routinely recommended, although some centers still use this approach.[1] If desired, sodium bicarbonate can be given to raise urinary pH. There is a lack of evidence to support its superiority over volume repletion alone in preventing urate nephropathy, and in the presence of hyperphosphatemia it may induce calcium crystal precipitation and worsen renal function.

Phosphate-binding agents (e.g., aluminum hydroxide) are given to reduce bowel absorption of phosphate, but they are rarely used.[1][2] Aluminum hydroxide may cause constipation, but its use with magnesium hydroxide may reduce colonic adverse effects.

Prophylaxis: high-risk patients

High-risk patients include those with:[35][41]

  • Certain high-grade non-Hodgkin lymphoma (e.g., advanced-stage Burkitt lymphoma or lymphoblastic lymphoma) and bulky high-grade non-Hodgkin lymphoma (e.g., diffuse large B-cell lymphoma)

  • Acute lymphoblastic leukemia with WBC count ≥100,000/microliter, or WBC count <100,000/microliter and LDH ≥2 times ULN

  • Acute myeloid leukemia with WBC count ≥100,000/microliter

  • Chronic lymphocytic leukemia treated with venetoclax if there is a high tumor burden (lymph node ≥10 cm or lymph node ≥5 cm and absolute lymphocyte count [ALC] ≥25,000/microliter) or a medium tumor burden (lymph node 5 cm to <10 cm; or ALC ≥25,000/microliter) in those with creatinine clearance <80 mL/min

High-risk patients should have regular (at least daily) checks of their blood pressure, heart rate, and respiratory rate. Blood biochemistry (including uric acid, phosphate, potassium, calcium, blood urea nitrogen, creatinine, and lactate dehydrogenase) should be determined before preventive interventions, and then monitored frequently thereafter (e.g., 3 to 4 times daily).[28] Guidelines for monitoring and assessment may differ depending on region and center; therefore, referral to local guidance is advised.

Intravenous hydration is the same as that for intermediate-risk patients. Rasburicase is used in preference to allopurinol or febuxostat for the management of hyperuricemia in high-risk patients.[1][36][41]

Secondary prevention

There are limited data on TLS recurrence following the first presentation, but all patients with TLS who have been successfully treated with rasburicase should continue on prophylactic allopurinol for the duration of their cancer treatment.​[36][55]​

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