Prophylaxis And Treatment Of Acute Uric Acid Nephropathy And Acute Tumor Lysis Syndrome

Prophylaxis

A. Patients presenting (before chemotherapy) with evidence of large, rapidly proliferating tumor burden and hyperuricemia

1. Correct initial electrolyte and fluid imbalance, and azotemia, if possible; dialysis as indicated for established renal failure or unresponsive electrolyte or metabolic abnormalities

2. Maintain adequate hydration and urine output (>3 L/d). May require 4 to 5 L/24 h of intravenous hypotonic saline or bicarbonate; diuretics as indicated

3. Give Allopurinol* (300 mg/m2) at least 3 days before therapy if possible

4. Alkalinize urine to pH >7.0 (hypotonic NaHCO3 infusion; Diamox if necessary)

5. Postpone chemotherapy (if possible) until uric acid and electrolytes are reasonably normalized

6. Continuous-flow leukapheresis might be indicated for patients with a high circulating blast count (white cell count >100,000/mm3)

B. Patients presenting (before chemotherapy) with normouricemia, but still at risk

1. Allopurinol* 300 mg/m2; at least 2 days before therapy if possible

2. 4 to 5 L/d of intravenous fluid as described above

3. Urinary alkalinization as described above Treatment

C. Patients presenting (usually after chemotherapy) with renal failure

1. Same as for patients with tumor and hyperuricemia if sufficient renal function remains. If dialysis is necessary, continuous hemodialysis or hemofiltration may be preferable if severe hyperuricemia or hyperkalemia is present

2. Discontinue urine alkalinization when uric acid homeostasis is achieved (to avoid Ca3[PO412]precipitation)

3. Treat symptomatic hypocalcemia after correction of hyperphosphatemia

*Allopurinol dosage must be adjusted for level of renal function.

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