title: Recurrent chemotherapy-induced tumor lysis syndrome (TLS) with renal failure in a patient with chronic lymphocytic leukemia - successful treatment and prevention of TLS with low-dose rasburicase.
abstract: BACKGROUND
  Rasburicase is a recombinant urate oxidase that is produced by a genetically modified Saccharomyces cerevisiae and has been approved for prophylaxis and treatment of tumor lysis syndrome in 2001. In several studies, rasburicase, given at a dose of 0.15-0.2 mg/kg for up to 7 d, proved to be highly effective in lowering urate levels.
  
  
  METHODS
  We report the case of a patient with chronic lymphatic leukemia (CLL) who experienced tumor lysis syndrome (TLS) with acute renal failure after fludarabine/cyclophosphamide chemotherapy and after bendamustine treatment. During the first episode of TLS, after fludarabine/cyclophosphamide (creatinine 3.3 mg/dL, urate 24.6 mg/dL), the patient received rasburicase 0.2 mg/kg for 3 d. Urate levels decreased below the lower limit of normal and renal function recovered. After bendamustine therapy, given for disease progression 8 months later, TLS with acute oliguric renal failure re-occurred (creatinine 3.1 mg/dL, urate 20.8 mg/dL). The patient was treated with hyperhydration and two doses of rasburicase (0.056 mg/kg), resulting in a prompt decrease of the urate level and recovery of renal function. Both episodes of TLS were successfully treated with rasburicase in a lower dose than recommended by the manufacturer. During a second bendamustine course, TLS was successfully treated by low doses of rasburicase (0.056 mg/kg for 2 d).
  
  
  CONCLUSIONS
  This is the first report of TLS in CLL after bendamustine chemotherapy reported in the literature. Treatment and prevention of TLS by low doses of rasburicase is possible and cost-effective.
authors.affiliation: III. Medizinische Klinik, Klinikum Mannheim, University of Heidelberg, Mannheim, Germany. margit.hummel@med3.ma.uni-heidelberg.de
authors.forename: Margit
authors.initials: M
authors.lastname: Hummel
authors.forename: Dieter
authors.initials: D
authors.lastname: Buchheidt
authors.forename: Sebastian
authors.initials: S
authors.lastname: Reiter
authors.forename: Jörg
authors.initials: J
authors.lastname: Bergmann
authors.forename: Katja
authors.initials: K
authors.lastname: Adam
authors.forename: Rüdiger
authors.initials: R
authors.lastname: Hehlmann
mesh_terms: D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000009:adverse effects; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage / Q000009:adverse effects*; D000069461:Bendamustine Hydrochloride; D003404:Creatinine / Q000652:urine; D003520:Cyclophosphamide / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D015451:Leukemia, Lymphocytic, Chronic, B-Cell / Q000150:complications / Q000188:drug therapy* / Q000652:urine; D008297:Male; D008875:Middle Aged; D009588:Nitrogen Mustard Compounds / Q000008:administration & dosage / Q000009:adverse effects; D011994:Recombinant Proteins / Q000008:administration & dosage; D051437:Renal Insufficiency / Q000209:etiology / Q000517:prevention & control* / Q000652:urine; D015275:Tumor Lysis Syndrome / Q000209:etiology / Q000517:prevention & control* / Q000652:urine; D014503:Urate Oxidase / Q000008:administration & dosage*; D014527:Uric Acid / Q000652:urine; D014740:Vidarabine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives
chemical_list: D000970:Antineoplastic Agents; D009588:Nitrogen Mustard Compounds; D011994:Recombinant Proteins; C469709:rasburicase; D014527:Uric Acid; D003520:Cyclophosphamide; D000069461:Bendamustine Hydrochloride; D003404:Creatinine; D014503:Urate Oxidase; D014740:Vidarabine; C024352:fludarabine