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Management of electrolyte abnormalities in tumor lysis syndrome

Management of electrolyte abnormalities in tumor lysis syndrome
Abnormality Management recommendation
Hyperphosphatemia
Moderate, ≥2.1 mmol/L (6.5 mg/dL) Restrict phosphate intake (avoid IV and oral phosphate; limit dietary sources)
Phosphate binders:
Calcium acetate* Adult: 2 to 3 tabs (1334 to 2668 mg) with each meal; or
Calcium carbonate* Adult: 1 to 2 grams with each meal; Pediatric: 30 to 40 mg/kg with each meal; or
Sevelamer Adult: 800 to 1600 mg with each meal; Pediatric: 40 to 54 mg/kg with each meal; or
Lanthanum carbonate Adult: 500 to 1000 mg with each mealΔ; or
Aluminum hydroxide Adult: 300 to 600 mg with each meal; Pediatric: 12.5 to 37.5 mg/kg four times daily with meals; (avoid use in patients with renal insufficiency)
Severe Dialysis, CAVH, CVVH, CAVHD, or CVVHD
 
Hypocalcemia, total serum calcium ≤1.75 mmol/L (7 mg/dL) or ionized calcium ≤0.8 mmol/L (3.2 mg/dL)
Asymptomatic No therapy
Symptomatic Calcium gluconate administered slowly with ECG monitoring; patients with acute hypocalcemia and hyperphosphatemia should not be treated with calcium until the hyperphosphatemia is corrected (unless they have tetany or a cardiac arrhythmia from hypocalcemia)
Calcium gluconate Adult: 1 gram (10 mL of 10 percent solution); Pediatric: 50 to 100 mg/kg. Slow IV infusion (maximum 50 to 100 mg per minute) in large vein. May be repeated after 5 to 10 minutes if symptoms or ECG changes persist.
 
Hyperkalemia§
Moderate and asymptomatic, ≥6.0 mmol/L Avoid IV and oral potassium
ECG and cardiac rhythm monitoring
Sodium polystyrene sulfonate¥ Adult: 15 to 30 grams orally; Pediatric: 1 gram/kg orally. Onset 1 to 2 hours. Repeat every 4 to 6 hours up to four times daily as needed based on repeat serum K+ level.
Severe (>7.0 mmol/L) and/or symptomatic Same as above, plus:
To stabilize cardiac membranes:
For patients with ECG changes (widening of the QRS complex or loss of p-waves but not peaked t-waves alone), give calcium gluconate by slow IV infusion to prevent life-threatening arrhythmias:
Calcium gluconate Adult: 1 gram (10 mL of 10 percent solution); Pediatric: 50 to 100 mg/kg. Slow IV infusion (maximum 50 to 100 mg per minute) in large vein. May be repeated after 5 to 10 minutes if ECG changes persist.
To temporarily shift potassium into cells:
Give IV insulin and dextrose:
IV insulin and dextrose Adult: regular insulin (10 units) IV plus 100 mL of a 50 percent dextrose solution (D50) IV; Pediatric: regular insulin (0.1 unit/kg) IV, plus 25 percent dextrose solution (D25) 0.5 gram/kg (2 mL/kg of D25) IV over thirty minutes. May be repeated after thirty to sixty minutes. Monitor fingerstick glucose closely.
Sodium bicarbonate can be given to induce influx of potassium into cells if patient is acidemic. Sodium bicarbonate and calcium solutions should not be administered through the same line due to incompatibility.
Sodium bicarbonate Adult: 45 to 50 mEq; Pediatric: 1 to 2 mEq/kg. Slow IV infusion over five to ten minutes.
Beta 2 agonist inhalation: Albuterol per nebulisation or metered dose inhaler
Albuterol Adult: 10 to 20 mg in 4 mL saline nebuilzed over 20 minutes or 10 to 20 puffs per metered dose inhaler over 10 to 20 minutes; Pediatric: 0.1 to 0.3 mg/kg per nebulisation.
Dialysis
 
Uremia (renal dysfunction)
  Fluid and electrolyte management
Uric acid and phosphate management
Adjust renally excreted drug doses
Dialysis (hemo- or peritoneal)
Hemofiltration (CAVH, CVVH, CAVHD, or CVVHD)
Pediatric dose should not exceed usual adult dose.
IV: intravenous; CAVH: continuous arterial-venous hemofiltration; CVVH: continuous veno-venous hemofiltration; CAVHD: continuous arterial-venous hemodialysis; CVVHD: continuous veno-venous hemodialysis; ECG: electrocardiogram.
* Calcium-containing binders are generally preferred in presence of hypocalcemia; avoid if hypercalcemic.
¶ Preferred binder in presence of hypercalcemia.
Δ A pediatric dose of lathanum carbonate 7 mg/kg with each meal has been suggested based on limited experience. US FDA product information states pediatric use is not recommended.
◊ 10% calcium gluconate (90 mg elemental calcium/10 mL) or 10% calcium chloride (270 mg elemental calcium/10 mL) can be used. Calcium gluconate is usually preferred because it is less likely to cause tissue necrosis if extravasated. For additional information refer to UpToDate topic on"Treatment of hypocalcemia".
§ For additional information, refer to UpToDate topic on "Treatment and prevention of hyperkalemia in adults".
¥ Patients receiving sodium polystyrene sulfonate should be monitored for the development of hypocalcemia and hypomagnesemia.
Data from: Coiffier B, Altman A, Pui CH, et al. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol 2008; 26:2767.
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