commit 9ac737dd6b876ef83ea35f384206a2a56993c184
parent f60f516aec466e4e75ec48a296f304fe31e00031
Author: Beau Hilton <beau.hilton@vumc.org>
Date: Sun, 22 Aug 2021 15:42:58 -0500
pontificating
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| M | posts/mr-2021.md | | | 69 | +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++-------- |
1 file changed, 61 insertions(+), 8 deletions(-)
diff --git a/posts/mr-2021.md b/posts/mr-2021.md
@@ -88,31 +88,84 @@ Details modified, generalized, and otherwise fudged to be HIPAA-compliant.
- BMBx: hypercellular >90%, no blasts, +trilineage atypica > myeloid, MF-1 fibrosis.
- JAK2 -ve, BCR/ABL -ve
+---
+
## TLS
+The big idea, and a few finer points.
+
[](https://jamanetwork.com/journals/jamaoncology/fullarticle/2680750)
+### Cairo-Bishop classification system
+
+(From [Chapter 4](https://www.asn-online.org/education/distancelearning/curricula/onco/Chapter4.pdf)
+of the American Society of Nephrology online
+[Onco-Nephrology curriculum](https://www.asn-online.org/education/distancelearning/curricula/onco/))
+
### Laboratory TLS
+Chemotherapy plus the two or more of the following
+within 3d before or 7d after initiation
+(so doesn't account for the spontaneous TLS seen in our patient).
| Metabolite/Electrolyte | Criterion |
-| :----------------------- | ----------------------------------------: |
+| :----------------------- | :----------------------------------------: |
| Uric Acid | >=8 mg/dL or 25% increase from baseline |
| Potassium | >=6mEq/L or 25% increase from baseline |
| Phosphorus | >=4.5mg/dL or 25% increase from baseline |
| Calcium | 25% *decrease* from baseline |
+The "25% increase/decrease" part is contested,
+as it may not be clinically meaningful
+if the value stays within the normal range.
+
### Clinical TLS
-- Laboratory TLS and one or more of:
- - creatinine >= 1.5 ULN
- - cardiac arrhythmia or sudden death
- - seizure
+| Laboratory TLS and one or more of |
+| :-------------------------------- |
+| creatinine >= 1.5 ULN (Note: just use AKI criteria) |
+| cardiac arrhythmia or sudden death |
+| seizure |
- risk assessment
-- rasburicase
-- allopurinol
+
+### Treating TLS
+
+IVF, electrolytes, rasburicase.
+
+Rasburicase is the subject of a recent "Things We Do for No Reason."
+
+[Pay-walled article](https://www.journalofhospitalmedicine.com/jhospmed/article/241443/hospital-medicine/things-we-do-no-reasontm-rasburicase-adult-patients-tumor),
+[PDF made available by the authors](https://cdn.mdedge.com/files/s3fs-public/JHM01607424.PDF)
+
+TL;DR:
+the evidence is thin, but could be reasonable to
+- ppx w IVF and allopurinol for low-med risk,
+- use single 3mg dose rasburicase as ppx in high-risk disease (don't use weight-based dosing),
+- tx active TLS (laboratory or clinical) with aggressive fluid resuscitation and electrolyte mgmt,
+possibly single 3mg dose.
+
+Hard outcomes in support of rasburicase are generally lacking, e.g. consistently reducing renal injury, renal failure, length of stay.
+
+It also seems like the classification criteria need revamping,
+with a larger N.
+It's been a while.
+However, like redefining fever,
+it's difficult to get a clean slate,
+because we act on the established criteria so aggressively.
+
+---
## MDS/MPN overlap syndromes
-- something profound
+
+Not much to say here,
+except that the dx is not always clear-cut,
+even with BMBx and NGS data,
+so the clinical picture matters,
+and sometimes we have to shoot in the dark.
+
+
+---
+
+Last updated: 2021-08-22
