Tumour Lysis Syndrome (TLS)

Tumour lysis syndrome (TLS) results from rapid malignant cell death releasing intracellular contents. Cairo-Bishop lab TLS requires ≥2 of: uric acid >476 μmol/L, K+ >6 mmol/L, phosphate >1.45 mmol/L, Ca²⁺ <1.75 mmol/L. Clinical TLS = lab TLS plus…

BCSH TLS Guideline

The pathway

1 · Risk stratify before chemotherapy

High risk: Burkitt's lymphoma, ALL with WBC >100×10⁹/L, AML with WBC >100×10⁹/L, venetoclax, high-grade lymphoma with bulky disease or raised LDH >2× ULN
Intermediate risk: ALL/AML with moderate WBC, indolent lymphoma with bulky disease
Low risk: solid tumours, CLL (except venetoclax), myeloma

2 · IV hydration

3L/m²/day IV (0.9% NaCl or 0.45% NaCl) — start 24–48h before chemotherapy in high-risk patients
Target urine output >100 ml/hr (>200 ml/hr in established TLS)
Avoid potassium and phosphate in IV fluids
Do NOT alkalinise with bicarbonate — worsens calcium phosphate precipitation

3 · Allopurinol for low/intermediate risk

Allopurinol 300mg OD PO starting 24–48h before chemotherapy
Reduces de novo uric acid synthesis but does not degrade pre-existing uric acid
Reduce dose in renal impairment (CrCl <30: 100mg OD)
Not adequate alone for high-risk patients

4 · Rasburicase for high risk or established TLS

Rasburicase 0.2mg/kg IV — rapidly degrades uric acid to water-soluble allantoin
CONTRAINDICATED in G6PD deficiency → causes haemolytic anaemia — check G6PD status before prescribing
Can repeat daily for up to 5–7 days
Uric acid samples must be kept on ice (rasburicase degrades uric acid ex vivo at room temperature)

5 · Manage electrolyte abnormalities

Hyperkalaemia: calcium gluconate 10% 30ml IV over 10 min for the membrane, then insulin-glucose (10 units Actrapid in 25g glucose). BM at 0, 30, 60, 90 and 120 minutes, then hourly to 6 hours
Add a binder — sodium zirconium cyclosilicate or patiromer. Calcium resonium was dropped from the UKKA 2023 emergency algorithm
Hyperphosphataemia: phosphate binders (sevelamer or aluminium hydroxide), dietary restriction
Hypocalcaemia: treat only if symptomatic (tetany, seizures) — correcting phosphate first prevents calcium phosphate precipitation

6 · Intensive monitoring

Bloods every 6–8 hours: U&E, uric acid, phosphate, calcium, LDH, creatinine
Hourly urine output — catheterise if output uncertain
Continuous ECG monitoring (hyperkalaemia → peaked T waves, widened QRS, sine wave)
Daily weight and fluid balance

7 · Haemodialysis indications

K+ >6.5 mmol/L refractory to medical management
Uric acid >900 μmol/L refractory to rasburicase
Oliguria or anuria with fluid overload
Severe symptomatic hypocalcaemia
Liaise with nephrology and haematology early — do not wait for deterioration

Drugs

Drug	Dose	Route	Notes
Allopurinol	300mg OD	PO	Low/intermediate risk prophylaxis. Start 24–48h before chemotherapy. Reduce to 100mg OD if CrCl <30 ml/min.
Rasburicase	0.2mg/kg OD	IV	High risk or established TLS. CONTRAINDICATED in G6PD deficiency — haemolytic anaemia risk. Keep uric acid sample on ice.
Calcium gluconate 10%	30ml over 10 min	IV	Membrane stabilisation in hyperkalaemia with ECG changes. Does not lower serum K+.
Insulin (Actrapid) + Dextrose 50%	10 units + 50ml	IV	Shifts K+ intracellularly in 20–30 minutes. BM at 0, 30, 60, 90 and 120 minutes, then hourly to 6 hours. If pre-treatment BM <7.0, follow with 10% glucose 50ml/hr for 5 hours (UKKA 2026).
Sodium zirconium cyclosilicate	10g TDS (up to 72h)	Oral	Removes K+ from body. Replaced calcium resonium in the UKKA 2023 emergency algorithm. Onset ~1h. Use alongside rapid-acting agents, never instead of them.

When to escalate

K+ >6.5 mmol/L with ECG changes — urgent haemodialysis discussion with nephrology,Uric acid >900 μmol/L refractory to rasburicase — haemodialysis,Oliguria despite 3L/m²/day hydration — catheterise, review fluid balance, nephrology referral,Symptomatic hypocalcaemia (tetany, seizures) — IV calcium gluconate; correct hyperphosphataemia concurrently,G6PD-deficient patient developing TLS — rasburicase contraindicated; allopurinol + aggressive hydration + early haemodialysis,Clinical TLS (AKI, arrhythmia, or seizure) — HDU/ITU, continuous cardiac monitoring, emergency nephrology

Reference: BCSH Guidelines for the Management of Tumour Lysis Syndrome 2015

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