Forty-eight hours after the first cycle of chemotherapy for high-grade non-Hodgkin lymphoma, a patient develops nausea, muscle cramps, tetany, and oliguria. Labs: potassium 6.8 mEq/L, phosphate 9 mg/dL, calcium 6.5 mg/dL, uric acid 22 mg/dL, creatinine 3.1 mg/dL. Which agent directly addresses the principal driver of the renal injury?

• A Rasburicase ✓
• B Insulin-dextrose infusion
• C Calcium gluconate infusion
• D Furosemide bolus

Explanation

Tumor lysis syndrome causes hyperkalemia, hyperphosphatemia, hypocalcemia, and severe hyperuricemia; uric acid crystals precipitating in renal tubules are the main cause of oliguric injury. Rasburicase, a recombinant urate oxidase, converts uric acid to the soluble metabolite allantoin and rapidly lowers urate levels. Calcium and insulin-dextrose treat individual electrolyte consequences but do not remove the underlying urate load driving renal failure.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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