Spontaneous Tumor Lysis Syndrome: A Case Report and Critical Evaluation of Current Diagnostic Criteria and Optimal Treatment Regimens.
Spontaneous Tumor Lysis Syndrome: A Case Report and Critical Evaluation of Current Diagnostic Criteria and Optimal Treatment Regimens.
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DOI：
10.1177/2324709615603199
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发表时间：
2015-07
影响因子：
1.2
通讯作者：
Kimple ME
中科院分区：
文献类型：
--
作者：
Weeks AC;Kimple ME
肿瘤溶解综合征（TLS）是恶性肿瘤及其治疗的已知并发症。发生率因恶性肿瘤类型而异，但在细胞毒性治疗期间最常见于血液肿瘤。自发性TLS被认为是罕见的。本病例研究涉及一名62岁女性，因多系统器官衰竭入院，随后诊断为侵袭性B细胞淋巴瘤。入院时，实验室检查异常包括肾衰竭、尿酸升高（20.7 mg/dL）和尿分析中3+无定形尿酸盐。尽管积极的水化和利尿剂的使用，少尿性肾衰竭持续存在，需要在化疗前开始血液透析。采用抗高尿酸血症治疗和血液透析解决高尿酸血症。然而，由于预后极差的多系统器官功能障碍综合征，患者最终在终端呼吸机脱机的情况下死亡。尽管我们的患者不符合目前的TLS标准，但由于尿酸肾病（TLS的一种并发症），她需要血液透析。这就提出了一个临床问题，即自发性TLS是否存在足够的诊断标准，以及目前公认的指南的缺乏是否导致其发生率被低估。别嘌呤醇和拉布立酶通常用于预防和治疗TLS。虽然这两种药物都能降低尿酸水平，但别嘌呤醇在机制上阻止了拉布立酶增溶底物的形成。这些药物在我们的患者中一起给药，尽管没有既定的指南推荐联合使用。这就提出了一个临床问题，即联合治疗是否真的有益，或者相反，对患者的结果有害。
Tumor lysis syndrome (TLS) is a known complication of malignancy and its treatment. The incidence varies on malignancy type, but is most common with hematologic neoplasms during cytotoxic treatment. Spontaneous TLS is thought to be rare. This case study is of a 62-year-old female admitted with multisystem organ failure, with subsequent diagnosis of aggressive B cell lymphoma. On admission, laboratory abnormalities included renal failure, elevated uric acid (20.7 mg/dL), and 3+ amorphous urates on urinalysis. Oliguric renal failure persisted despite aggressive hydration and diuretic use, requiring initiation of hemodialysis prior to chemotherapy. Antihyperuricemic therapy and hemodialysis were used to resolve hyperuricemia. However, due to multisystem organ dysfunction syndrome with extremely poor prognosis, the patient ultimately expired in the setting of a terminal ventilator wean. Although our patient did not meet current TLS criteria, she required hemodialysis due to uric acid nephropathy, a complication of TLS. This poses the clinical question of whether adequate diagnostic criteria exist for spontaneous TLS and if the lack of currently accepted guidelines has resulted in the underestimation of its incidence. Allopurinol and rasburicase are commonly used for prevention and treatment of TLS. Although both drugs decrease uric acid levels, allopurinol mechanistically prevents formation of the substrate rasburicase acts to solubilize. These drugs were administered together in our patient, although no established guidelines recommend combined use. This raises the clinical question of whether combined therapy is truly beneficial or, conversely, detrimental to patient outcomes.