Kidney Week

Abstract: PUB193

A Perfect Storm: Concurrent Infectious and Obstructive Renal Insults Exacerbating Tumor Lysis Syndrome in an Adolescent with Relapsed B-Cell Acute Lymphoblastic Leukemia (B-ALL)

Session Information

• Publication Only

Category: Onconephrology

• 1600 Onconephrology

Authors

• Onokalah, Nonye Andrea, UNC Health, Chapel Hill, North Carolina, United States

Nonye Andrea Onokalah, MD

• Buckley, Ryanne, UNC Health, Chapel Hill, North Carolina, United States

Ryanne Buckley, MD

• Pavlovich, Stephanie S., UNC Health, Chapel Hill, North Carolina, United States

Stephanie S. Pavlovich, MD, PhD

• Dancel, Ria, UNC Health, Chapel Hill, North Carolina, United States

Ria Dancel, MD

• Kotzen, Elizabeth, UNC Health, Chapel Hill, North Carolina, United States

Elizabeth Kotzen, MD, MSc

Introduction

Tumor lysis syndrome (TLS) describes the life-threatening release of intracellular potassium, phosphate, and uric acid by tumor cells. This case describes TLS in a patient with congenital hydronephrosis and acute pyelonephritis, where point of care ultrasound (POCUS) expedited identification of obstructing nephrolithiasis.

Case Description

A 13 y.o. female with relapsed B-ALL and congenital hydronephrosis due to uteropelvic junction obstruction (UPJO) presented for chemotherapy. Urine culture grew E. coli and she received cefepime and vancomycin after developing a fever. On day 2, labs showed severe TLS and acute kidney injury (AKI): potassium 7.3 mmol/L, phosphorus 10.4 mg/dL, calcium 6.0 mg/dL, uric acid 2.8 mg/dL (on allopurinol), CO₂ 15.0 mmol/L, and creatinine 0.91 mg/dL (0.37 mg/dL < 24 hours prior). Exam and POCUS suggested volume overload (had received 1.5x maintenance IV fluids). She developed tachycardia, hypotension, and tachypnea. Hyperkalemia was treated (IV fluids, IV furosemide, insulin with dextrose, albuterol, and cautious use of sodium bicarbonate), but electrolyte abnormalities persisted despite good urine output, raising concern for additional AKI etiologies. She was transferred to the ICU for urgent continuous kidney replacement therapy (CKRT). Arterial lactate peaked at 6.8 mmol/L, requiring vasopressors for uroseptic shock. Renal ultrasound showed bilateral medullary nephrocalcinosis (Figure 1, panels A and B) and right hydronephrosis to the ureteropelvic junction (Figure 1, panel C), prompting urgent ureteral stent placement. Electrolytes normalized after 4 days of CKRT.

Discussion

TLS requires balanced fluid hydration and diuresis. This case illustrates how concurrent infections, obstructions, and structural abnormalities can impair renal clearance and increase TLS severity. Clinicians must maintain heightened surveillance for TLS, avoid alkali therapy, and have a low threshold to initiate CKRT. POCUS is a useful tool to rapidly assess volume status and evaluate for obstruction.