Day 2 after first chemo for Burkitt lymphoma — K⁺ 6.4, phosphate 2.8, creatinine doubling. Cell death is flooding the blood: fluids, rasburicase, treat the potassium.
ABCDE
Cardiac monitor; aggressive IV fluids (no K⁺); rasburicase if high-risk (check G6PD first); treat hyperkalaemia immediately; avoid anything nephrotoxic.
Recognise (Cairo-Bishop): ↑uric acid, ↑K⁺, ↑phosphate, ↓Ca²⁺ ± AKI within 12–72 h of chemo (or spontaneously in high-turnover tumours — Burkitt, ALL, high WBC)
Volume first: isotonic saline 3 L/m²/day (≈200–250 mL/h) targeting urine output 100 mL/h — NO potassium in fluids, no routine alkalinisation
Hyperkalaemia NOW: calcium gluconate 10% 10–30 mL IV (cardiac protection) → insulin 10 units + 25 g dextrose → salbutamol nebs; dialysis if refractory
Uric acid: high-risk/established → rasburicase 0.15–0.2 mg/kg IV (check G6PD — deficiency = haemolysis); intermediate → allopurinol 300 mg
After rasburicase: do NOT send serial uric acid (ex-vivo degradation gives false lows); treat hyperphosphataemia with binders; calcium ONLY if symptomatic (tetany/QT — risk of Ca-phosphate precipitation)
Dialysis triggers: refractory hyperkalaemia, hyperphosphataemia with symptomatic hypocalcaemia, oliguria/overload, severe metabolic acidosis — call renal early
Order set
- Cardiac monitor + 12-lead (K⁺)
- 0.9% saline 200–250 mL/h, no K⁺
- Rasburicase 0.15–0.2 mg/kg (G6PD checked)
- Calcium gluconate 10% 10 mL IV if K⁺ ≥6/ECG changes
- Insulin 10 u + 50% dextrose 50 mL
- Phosphate binder with meals
- Strict urine output chart
Monitor
- q4–6 hK⁺, phosphate, Ca²⁺, uric acid (pre-rasburicase), creatinine
- HourlyUrine output — target ≥100 mL/h
- ContinuousCardiac monitor until K⁺ normalised
- DailyWeight, fluid balance, TLS labs until day 3–5
Escalate / ICU
- K⁺ ≥6.0 or any ECG change
- Symptomatic hypocalcaemia
- Oliguria despite fluids
- Rising phosphate uncontrolled — dialysis
Criteria
PreventionFluids + allopurinol (intermediate) / rasburicase (high-risk) BEFORE chemo
ICUK⁺ ≥6, ECG changes, oliguria, or established TLS with AKI
DialysisRefractory hyperK⁺, symptomatic hypoCa²⁺, overload, acidosis
Resume chemoOnce metabolically stable — do not stop curative regimens lightly
Never
- Put potassium or calcium in maintenance fluids
- Give rasburicase in G6PD deficiency — fatal haemolysis/methaemoglobinaemia
- Alkalinise the urine — promotes calcium-phosphate precipitation in tubules
Key
- Prevention beats rescue: hydrate + risk-stratify BEFORE the first chemo dose
- Rasburicase degrades uric acid in the sample tube — pink-top on ice or don't bother rechecking
- Symptomatic hypocalcaemia is the ONLY reason to give calcium in TLS
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- K⁺ ≥6.0, peaked T waves
- Tetany, seizures, QT prolongation
- Urine output <0.5 mL/kg/h
- High-risk tumour starting chemo without prophylaxis
Differentials
- Pre-renal AKI from dehydration
- Sepsis with AKI
- Obstructive uropathy
- Contrast nephropathy
Common mistakes
- Forgetting G6PD before rasburicase
- Rechecking uric acid after rasburicase
- Diuretics to 'force' urine in a dehydrated patient
- Stopping at normal K⁺ while phosphate climbs
Disposition & follow-up
ICU/HDU until metabolically stable ×24–48 h; renal follow-up; coordinate chemo timing with oncology once cleared.
💊 Treatment detail — doses & preparation
0.9% Sodium chloridecrystalloid
DoseTLS maintenance: 3 L/m²/day (≈200–250 mL/h) targeting urine output ~100 mL/h — no K⁺/Ca²⁺ in fluids
Preparation500/1000 mL bags; add KCl only after urine output confirmed
MonitorHyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
Rasburicaseurate oxidase
Dose0.15–0.2 mg/kg IV OD ×3–5 d (TLS, fixed 3 mg or 6 mg dosing used in many protocols)
Preparation1.5/7.5 mg vials reconstitute + dilute in 50 mL NS over 30 min
MonitorCONTRAINDICATED in G6PD deficiency (haemolysis/methaemoglobinaemia) — test first; no serial uric acid after (ex-vivo degradation)
Allopurinol (TLS prevention)xanthine oxidase inhibitor
Dose300 mg OD–BD PO (start 24–48 h BEFORE chemo in intermediate risk); febuxostat is the alternative when allopurinol contraindicated (e.g., G6PD-deficient high-risk patients who cannot take rasburicase)
Preparation100/300 mg tablets
MonitorUric acid, rash; NOT for established high-risk TLS (rasburicase instead)
Calcium gluconate 10%membrane stabiliser
Dose10–30 mL of 10% IV over 2–5 min for hyperK ECG changes; repeat q10 min ×3 PRN
Preparation10 mL ampoules (2.2 mmol Ca²⁺ each), undiluted slow push with cardiac monitor
MonitorECG immediately (QRS narrows); effect 1–3 min, lasts 30–60 min — shift/remove K⁺ in parallel
Insulin + dextrose (hyperK)K⁺ shift therapy
Dose10 units regular insulin IV + 25 g dextrose (50 mL of 50%), onset 15–30 min, lasts 4–6 h
Preparation50 mL 50% dextrose push + 10 U insulin; if glucose >14, give insulin alone; add 10% dextrose infusion if needed
MonitorCapillary glucose q15–30 min ×2 h (hypoglycaemia), K⁺ at 1–2 h
📖 Cairo-Bishop criteria + textbook Ch.31Reviewed July 2026