A 60-year-old man with disseminated testicular germ cell tumour develops acute renal failure after starting chemotherapy. Serum potassium is 6.8 mmol/L, phosphate 3.1 mmol/L, calcium 1.7 mmol/L and uric acid 15 mg/dL. What is the immediate priority in management?

• A Allopurinol orally
• B Intravenous hydration with rasburicase ✓
• C Calcium gluconate infusion as definitive therapy
• D Sodium bicarbonate to alkalinise the urine

Explanation

This is tumour lysis syndrome from rapid cell breakdown after cytotoxic therapy in a highly chemosensitive tumour. Management is aggressive isotonic saline hydration plus rasburicase (recombinant urate oxidase) when uric acid is markedly elevated or renal failure exists. Allopurinol prevents new urate formation but does not lower pre-existing uric acid quickly enough here. Urinary alkalinisation promotes calcium phosphate deposition and is no longer recommended.

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

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