Tumor Lysis Syndrome

After our yesterday’s didactic re: cancer and kidney disorders, I saw an interesting case about pancreatic adenocarcinoma and acute kidney failure.

An 86-year-old woman with a medical history of hyperlipidemia, hypertension, and pancreatic cysts was admitted to the hospital due to progressive fatigue.

Initial assessments showed abnormal kidney function and liver enzyme levels, along with elevated markers indicative of pancreatic cancer. (creatinine of 3.2 (baseline of 1.0), alanine aminotransferase of 146 U/L, aspartate aminotransferase of 338 U/L, alkaline phosphatase of 377 U/L, total bilirubin of 3.7 mg/dL, lactate dehydrogenase (LDH) of 2,350 U/L, carcinoembryonic antigen of 2,316 ng/mL, and carbohydrate antigen 19-9 of 468 U/mL.)

Imaging revealed pancreatic abnormalities, and further investigation based on lymph node biopsy and immunohistochemical staining confirmed the presence of metastatic pancreatic adenocarcinoma.

On day 4 postadmission, the patient developed oliguric renal failure, with creatinine rising to 4.7 mg/dL and urine output under 150 mL/d with highly elevated Uric acid levels. These findings raised suspicion for spontaneous tumor lysis syndrome (STLS) secondary to pancreatic adenocarcinoma (Laboratory results showed an increased LDH at 3,410 U/L, uric acid at 21.8 mg/dL, phosphate at 5.4 mg/dL, sodium at 129 mmol/L, potassium at 5.7 mmol/L, calcium at 8.8 mg/dL, and bilirubin at 6.7 mg/dL with 5.5 mg/dL direct ).

The patient was treated for STLS with 6 mg intravenous rasburicase, 300 mg allopurinol, lactated Ringer solution, sodium zirconium cyclosilicate, insulin, dextrose, and intravenous furosemide for hyperkalemia.

Despite treatment attempts, the patient developed severe complications, including tumor lysis syndrome (STLS) and multiorgan failure. Unfortunately, her condition deteriorated rapidly; she was transferred to comfort care, and she passed away shortly after that.

It`s interesting to learn about the rare occurrence of STLS secondary to pancreatic adenocarcinoma, which is characterized by exceptionally high uric acid levels and escalating LDH levels.

And,we should always consider STLS  on our differential list in patients with advanced cancer and unexplained kidney injury.

Here is the link to the case published in ACG case report journal: Gusdorf, Jason MD¹; Markovitz, Netana H. MD²; Ricketts, Cleveland MD³; Ono, Yuho MD³; Lam, Barbara D. MD⁴; Berry, Jonathan MD⁴; Dockterman, Jacob MD, PhD²; Reddy, Sheela MD⁵. Spontaneous Tumor Lysis Syndrome Secondary to Metastatic Pancreatic Adenocarcinoma. ACG Case Reports Journal 11(4):p e01305, April 2024. | DOI: 10.14309/crj.0000000000001305

https://journals.lww.com/acgcr/fulltext/2024/04000/spontaneous_tumor_lysis_syndrome_secondary_to.2.aspx