eMedicine Specialties > Oncology > Special Topics in Oncology

Tumor Lysis Syndrome: Differential Diagnoses & Workup

Author: Koyamangalath Krishnan, MD, FRCP, FACP, Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine and Chief of Hematology-Oncology, Program Director, Hematology-Oncology Fellowship, James H Quillen College of Medicine at East Tennessee State University
Coauthor(s): Ahmad Hammad, MD, Clinical Assistant Professor, Department of Internal Medicine, Division of Hematology/Oncology, East Tennessee State University, James H Quillen Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Mar 11, 2009

Differential Diagnoses

Acute Renal Failure

Other Problems to Be Considered

Patients with cancer are at increased risk of renal failure from etiologies other than tumor lysis syndrome.18 Prerenal causes include volume depletion from anorexia, vomiting, diarrhea, and bleeding. Pelvic or retroperitoneal masses can lead to kidney failure from postrenal urinary tract obstruction. Renal parenchymal diseases include tumor infiltration, myeloma kidney, drug nephrotoxicity from chemotherapeutic agents or antibiotics, radiocontrast nephropathy, vasculitis, and cryoglobulinemic glomerulonephritis. The combination of volume depletion, hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia strongly support the diagnosis of tumor lysis syndrome over other causes.

Workup

Laboratory Studies

  • Blood chemistry
    • Most patients have laboratory derangements in potassium, phosphate, calcium, and uric acid, and abnormal renal functions, occurring 1-3 days following chemotherapy initiation.
    • Hyperkalemia is often the first life-threatening abnormality.
    • High-risk patients should have laboratory monitoring (BUN, creatinine, phosphate, uric acid, LDH, and calcium) prior to therapy and for 48-72 hours after treatment induction. Follow measurements at least twice daily or more often if evidence of tumor lysis syndrome develops.
  • Urine pH
    • If hyperuricemia develops, urine alkalinization prevents renal precipitation of uric acid.
    • If alkaline diuresis is employed, regular determinations of urine pH should guide the extent of therapy.

Other Tests

  • Because increased urine flow rates help to inhibit crystal deposition in renal tubules, close monitoring of urine output is necessary to assess adequacy of hydration. Monitoring urine output for signs of oliguric renal failure is also necessary.
  • Frequent cardiac assessment (ECG or continuous cardiac monitoring) is necessary to monitor electrocardiographic changes, which may herald a lethal arrhythmia caused by potassium and calcium disturbances.

Histologic Findings

Pathologic studies demonstrate deposits of uric acid within the distal renal tubule lumina, causing intrarenal hydronephrosis. Uric acid crystals can also be seen within tubular epithelial cells and the medullary microcirculation. Uric acid precipitates may also occur in the renal pelvis and ureters, leading to hydronephrosis and acute renal failure from extrarenal sources.

More on Tumor Lysis Syndrome

Overview: Tumor Lysis Syndrome
Differential Diagnoses & Workup: Tumor Lysis Syndrome
Treatment & Medication: Tumor Lysis Syndrome
Follow-up: Tumor Lysis Syndrome
References
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References

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Further Reading

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Keywords

tumor lysis syndrome, TLS, acute tumor lysis syndrome, ATLS, hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, acute renal failure, ARF, malignancy-associated hyperuricemia, acute leukemia, non-Hodgkin lymphoma, Burkitt lymphoma, Burkitt's lymphoma, malignancy, anticancer treatment, cancer treatment, acute hyperphosphatemia, cardiac arrhythmia, metabolic acidosis, rapid tumor cell turnover, metabolic derangements, rapid cell lysis

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Contributor Information and Disclosures

Author

Koyamangalath Krishnan, MD, FRCP, FACP, Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine and Chief of Hematology-Oncology, Program Director, Hematology-Oncology Fellowship, James H Quillen College of Medicine at East Tennessee State University
Koyamangalath Krishnan, MD, FRCP, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society of Hematology, and Royal College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Ahmad Hammad, MD, Clinical Assistant Professor, Department of Internal Medicine, Division of Hematology/Oncology, East Tennessee State University, James H Quillen Veterans Affairs Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Philip Schulman, MD, Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center; Clinical Professor, Department of Medicine, New York University School of Medicine
Philip Schulman, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, and Medical Society of the State of New York
Disclosure: celgene Honoraria Speaking and teaching; Amgen Honoraria Speaking and teaching; genetech/idec Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting

 
 
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