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AN AUDIT OF THE USE OF RASBURICASE FOR THE PREVENTION AND TREATMENT OF TUMOUR LYSIS SYNDROME IN PATIENTS RECEIVING TREATMENT AT THE NORTHERN CENTRE FOR CANCER CARE, NEWCASTLE UPON TYNE, UK.
Author(s):
Emily Watts
,
Emily Watts
Affiliations:
Haematology,Freeman Hospital, Newcastle Upon Tyne.,Newcastle upon Tyne,United Kingdom
Sumantha Gabriel
,
Sumantha Gabriel
Affiliations:
Haematology,Freeman Hospital, Newcastle Upon Tyne.,Newcastle upon Tyne,United Kingdom
Gail Jones
,
Gail Jones
Affiliations:
Haematology,Freeman Hospital, Newcastle Upon Tyne.,Newcastle upon Tyne,United Kingdom
Rauri Clark
,
Rauri Clark
Affiliations:
Renal Medicine,Freeman Hospital, Newcastle Upon Tyne.,Newcastle upon Tyne,United Kingdom
Sophie Holmes
Sophie Holmes
Affiliations:
Haematology,Freeman Hospital, Newcastle Upon Tyne.,Newcastle upon Tyne,United Kingdom
(Abstract release date: 05/18/17) EHA Library. Watts E. 05/18/17; 182454; PB1740
Emily Watts
Emily Watts
Contributions
PDF Abstract
Abstract

Abstract: PB1740

Type: Publication Only

Background
Tumour Lysis Syndrome (TLS) is a known complication of haemato-oncological treatment. Although clinical TLS is rare, the consequences are significant, with one third of affected patients requiring dialysis and an overall mortality rate of around 15%1,2.

A new British Society for Haematology (BSH) guideline was published in April 2015 to guide physicians on how to risk stratify patients (based upon the Cairo Risk Stratification 20103), choice of prophylaxis, and treatment of established TLS4.
We audited all patients who received rasburicase at the Northern Centre for Cancer Care from 16th April 2015 to 3rd February 2016, and compared their management with BSH guidelines4 .

Aims
To compare our practice with BSH guidelines.

Methods
Retrospective review of electronic patient presciption records, biochemistry results, and paper notes.

Results
27 patients received rasburicase in the study period.

20 patients met Cairo criteria/BSH criteria as having High Risk Disease (HRD) or Intermediate Risk Disease(IRD)/Low Risk Disease (LRD)with renal impairment, and therefore should have received 3mg rasburicase prophylaxis if no evidence of TLS according to the guideline. Of those 20, 11 had laboratory TLS, and therefore BSH guidelines would recommend 0.2mg/kg/day [JG1] rasburicase, however only 3/11 were given the drug at treatment doses. 1/3 had clinical TLS at presentation and received treatment according to the guideline. The 2 other patients received larger doses of rasburicase but less than the BSH would recommend.
A further 7 patients with IRD received rasburicase prophylaxis but on review did not meet the criteria for rasburicase as set out in the guidelines.
5 patients died during the study period. 2 patients died on ITU of multi-organ failure <7 days into chemotherapy. A third patient died of sepsis, and the other 2 deaths were in deteriorating patients where a decision was made to palliate.

Conclusion
When assessed against BSH standards, all patients in this cohort who should have received rasburicase prophylaxis, were given the drug. 2 patients with lab TLS developed clinical TLS. 8 others with lab TLS received lower doses than the BSH would recommend, but did not progress to clinical TLS. Although there were 5 deaths in our cohort, none were directly attributable to TLS.

In order to comply with the guidelines, particular importance must placed on formally assessing the TLS risk score as per Cairo criteria at the outset and analyzing the possible features of laboratory TLS. Although dosing did not always follow BSH guidelines, we did respond to biochemical deterioration. The majority of patients with HRD developed acute kidney injury despite rasburicase. Doses were increased in response to creatinine increases, albeit not as per guideline. It is notable that despite lower than the recommended doses of rasburicase, 6/8 patients with lab TLS did not progress to clinical TLS, and none required dialysis.
The guideline is a good tool for the risk stratifcation and treatment of patients at risk of TLS. In clinical practice 100% compliance is hard to achieve. Responding to trends in creatinine may explain why, despite lower than recommended doses, our outcomes were still good. It would be interesting to see if further work with larger numbers of patients would support this.
Since this audit was completed, the ePrescribing system has been altered to improve practice and a re-audit is planned.

Session topic: 20. Aggressive Non-Hodgkin lymphoma - Clinical

Keyword(s): Tumor lysis, Rasburicase, Lymphoma therapy, Leukemia

Abstract: PB1740

Type: Publication Only

Background
Tumour Lysis Syndrome (TLS) is a known complication of haemato-oncological treatment. Although clinical TLS is rare, the consequences are significant, with one third of affected patients requiring dialysis and an overall mortality rate of around 15%1,2.

A new British Society for Haematology (BSH) guideline was published in April 2015 to guide physicians on how to risk stratify patients (based upon the Cairo Risk Stratification 20103), choice of prophylaxis, and treatment of established TLS4.
We audited all patients who received rasburicase at the Northern Centre for Cancer Care from 16th April 2015 to 3rd February 2016, and compared their management with BSH guidelines4 .

Aims
To compare our practice with BSH guidelines.

Methods
Retrospective review of electronic patient presciption records, biochemistry results, and paper notes.

Results
27 patients received rasburicase in the study period.

20 patients met Cairo criteria/BSH criteria as having High Risk Disease (HRD) or Intermediate Risk Disease(IRD)/Low Risk Disease (LRD)with renal impairment, and therefore should have received 3mg rasburicase prophylaxis if no evidence of TLS according to the guideline. Of those 20, 11 had laboratory TLS, and therefore BSH guidelines would recommend 0.2mg/kg/day [JG1] rasburicase, however only 3/11 were given the drug at treatment doses. 1/3 had clinical TLS at presentation and received treatment according to the guideline. The 2 other patients received larger doses of rasburicase but less than the BSH would recommend.
A further 7 patients with IRD received rasburicase prophylaxis but on review did not meet the criteria for rasburicase as set out in the guidelines.
5 patients died during the study period. 2 patients died on ITU of multi-organ failure <7 days into chemotherapy. A third patient died of sepsis, and the other 2 deaths were in deteriorating patients where a decision was made to palliate.

Conclusion
When assessed against BSH standards, all patients in this cohort who should have received rasburicase prophylaxis, were given the drug. 2 patients with lab TLS developed clinical TLS. 8 others with lab TLS received lower doses than the BSH would recommend, but did not progress to clinical TLS. Although there were 5 deaths in our cohort, none were directly attributable to TLS.

In order to comply with the guidelines, particular importance must placed on formally assessing the TLS risk score as per Cairo criteria at the outset and analyzing the possible features of laboratory TLS. Although dosing did not always follow BSH guidelines, we did respond to biochemical deterioration. The majority of patients with HRD developed acute kidney injury despite rasburicase. Doses were increased in response to creatinine increases, albeit not as per guideline. It is notable that despite lower than the recommended doses of rasburicase, 6/8 patients with lab TLS did not progress to clinical TLS, and none required dialysis.
The guideline is a good tool for the risk stratifcation and treatment of patients at risk of TLS. In clinical practice 100% compliance is hard to achieve. Responding to trends in creatinine may explain why, despite lower than recommended doses, our outcomes were still good. It would be interesting to see if further work with larger numbers of patients would support this.
Since this audit was completed, the ePrescribing system has been altered to improve practice and a re-audit is planned.

Session topic: 20. Aggressive Non-Hodgkin lymphoma - Clinical

Keyword(s): Tumor lysis, Rasburicase, Lymphoma therapy, Leukemia

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