Urate Oxidase Should Remain Mandatory in Patients at High Risk of Tumor Lysis Syndrome

Abstract

We read with great interest the meta-analysis by Dr Lopez-Olivo and colleagues.1Lopez-Olivo M.A. Pratt G. Palla S.L. Salahudeen A. Rasburicase in tumor lysis syndrome of the adult: a systematic review and meta-analysis.Am. J. Kidney Dis. 2013; 62: 481-492Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Although the authors adequately discuss the limitations of the studies evaluating recombinant urate oxidase (rasburicase), we believe that their conclusions should be viewed with caution. The authors themselves note that evaluating urate oxidase treatment may require additional studies. First, previous studies suggest that acute kidney injury (AKI) complicated with tumor lysis syndrome increases the likelihood of death by as much as 5-fold.2Darmon M. Guichard I. Vincent F. Schlemmer B. Azoulay E. Prognostic significance of acute renal injury in acute tumor lysis syndrome.Leuk Lymphoma. 2010; 51: 221-227Crossref PubMed Scopus (59) Google Scholar, 3Montesinos P. Lorenzo I. Martín G. et al.Tumor lysis syndrome in patients with acute myeloid leukemia: identification of risk factors and development of a predictive model.Haematologica. 2008; 93: 67-74Crossref PubMed Scopus (142) Google Scholar These results are in accordance with several studies that suggest that AKI per se may be associated with a poor outcome.4Chertow G.M. Burdick E. Honour M. Bonventre J.V. Bates D.W. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients.J Am Soc Nephrol. 2005; 16: 3365-3370Crossref PubMed Scopus (2512) Google Scholar In patients with cancer, AKI also may decrease the chance of achieving complete remission.5Canet E. Zafrani L. Lambert J. et al.Acute kidney injury in patients with newly diagnosed high-grade hematological malignancies: impact on remission and survival.PLoS ONE. 2013; 8: e55870Crossref PubMed Scopus (87) Google Scholar As stated by Lopez-Olivo et al,1Lopez-Olivo M.A. Pratt G. Palla S.L. Salahudeen A. Rasburicase in tumor lysis syndrome of the adult: a systematic review and meta-analysis.Am. J. Kidney Dis. 2013; 62: 481-492Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar the effect of rasburicase in decreasing serum urate level, an important risk factor for AKI in these patients, is tremendous. Additionally, recombinant urate oxidase was found to be highly cost-effective in children, as well as cost-effective in adult patients with acute lymphoid leukemia and non-Hodgkin lymphoma.6Annemans L. Moeremans K. Lamotte M. et al.Pan-European multicentre economic evaluation of recombinant urate oxidase (rasburicase) in prevention and treatment of hyperuricaemia and tumour lysis syndrome in haematological cancer patients.Support Care Cancer. 2003; 11: 249-257PubMed Google Scholar The lack of cost-effectiveness in adult patients with acute myeloid leukemia resulted mainly from assumptions for life expectancy (2.4 years) that included every prognosis subgroup of patients and a full-dose administration regimen.6Annemans L. Moeremans K. Lamotte M. et al.Pan-European multicentre economic evaluation of recombinant urate oxidase (rasburicase) in prevention and treatment of hyperuricaemia and tumour lysis syndrome in haematological cancer patients.Support Care Cancer. 2003; 11: 249-257PubMed Google Scholar, 7Löwenberg B. Acute myeloid leukemia: the challenge of capturing disease variety.Hematology Am Soc Hematol Educ Program. 2008; : 1-11Crossref PubMed Scopus (94) Google Scholar Several subsequent studies have demonstrated efficacy and potential cost-savings with decreased dose or duration regimens.8Vines A.N. Shanholtz C.B. Thompson J.L. Fixed-dose rasburicase 6 mg for hyperuricemia and tumor lysis syndrome in high-risk cancer patients.Ann Pharmacother. 2010; 44: 1529-1537Crossref PubMed Scopus (34) Google Scholar, 9McDonnell A.M. Lenz K.L. Frei-Lahr D.A. Hayslip J. Hall P.D. Single-dose rasburicase 6 mg in the management of tumor lysis syndrome in adults.Pharmacotherapy. 2006; 26: 806-812Crossref PubMed Scopus (66) Google Scholar, 10Feng X. Dong K. Pham D. Pence S. Inciardi J. Bhutada N.S. Efficacy and cost of single-dose rasburicase in prevention and treatment of adult tumour lysis syndrome: a meta-analysis.J Clin Pharm Ther. 2013; http://dx.doi.org/10.1111/jcpt.12061Google Scholar Although we fully agree that optimal dosage and treatment duration remain unknown and few studies have focused on hard clinical end points, we nevertheless believe that this treatment remains mandatory in patients at high risk for tumor lysis syndrome. Financial Disclosure: The authors declare that they have no relevant financial interests. Rasburicase in Tumor Lysis Syndrome of the Adult: A Systematic Review and Meta-analysisAmerican Journal of Kidney DiseasesVol. 62Issue 3PreviewThe use of rasburicase has been evaluated extensively in children, but not in adults. We review the current literature to evaluate its effect on adults. Full-Text PDF