儿童淋巴系统恶性肿瘤急性肿瘤细胞溶解综合征发生高危因素及防治策略

Risk factors associated with acute tumor lysis syndrome in children with lymphocytic maligˉnancy and feasible means for prophylaxis and treatment

目的探讨急性肿瘤细胞溶解综合征 (ATLS)发生的高危因素及可行的防治方法。方法对216例初发的急性淋巴细胞白血病 (ALL)和Ⅳ期非霍杰金淋巴瘤 (NHL)患儿 ,在初期化疗时加予水化、碱化、别嘌呤醇治疗 ;监测治疗前白细胞数、血清乳酸脱氢酶 (LDH)和1～2周内的电解质、血尿酸、肌酐 (Cr)、尿素氮 (BUN)、DIC指标变化。按Cohen提出的ATLS的诊断标准 ,统计ATLS的发生率 ,分析其与WBC计数、LDH水平和肿瘤细胞免疫分型的关系。结果216例患儿中因代谢紊乱诊断ATLS者17例 (占7.9 % ) ,以血液生化改变为主 ,包括高尿酸血症、高磷、高钾、低钙、高尿素氮或高肌酐。169例ALL和47例Ⅳ期NHL患儿ATLS发生率分别为5.3 %和17.0 % ,Ⅳ期NHL的ATLS发生率大于ALL(P<0.05) ,120例B系和96例T系淋巴系统恶性肿瘤ATLS的发生率分别为5.8 %和10.4 % ,差异无显著性 (P>0.05) ;WBC≥50×109/L者66例 ,WBC<50×109/L者150例 ,ATLS的发生率分别为15.2 %和4.7 % ,差异有显著性 (P<0.05) ;LDH≥2000U/L者40例 ,LDH<2000U/L者176例 ,ATLS的发生率分别为40.0 %和0.6 % ,差异有非常显著性 (P<0.01)。17例ATLS患儿经前期预防、早期诊断、及时干预治疗 ,预后良好 ,无少尿、无尿需要透析者 ,无严重出血或心率失常危及生命者。结论高WBC计数。

Objective To investigate risk factors associated with acute tumor lysis syndrome(ATLS) in children with lymphocytic malignancy and to explore feasible means for the prophylaxis and treatment. Methods Data from216children(aged6months to17years,including150males and66females)with either ALL orⅣ_stage non_Hodgkin’s lymphoma(NHL)diagnosed newly were evaluated from August1998to Au_ gust2003.All patients underwent hydration(intravenous hydration with hypotonic saline solution at2500to3000ml/m 2 ·24h),alkalinization(intravenous5%NaHCO 3 3～5ml/kg·d)and received allopurinol(oral,10mg/kg·d)routinely during the initial2weeks of chemotherapy.The white blood cell(WBC)counts,serum lactic dehydrogenase(LDH),blood uric acid,serum creatinine,urea nitrogen,and electrolyte were moniˉtored.The relationship between the incidence of ATLS and WBC counts(≥or<50×10 9 /L),LDH levels(≥or<2000U/L),and immunotype(B_cell ALL/Ⅳ_stage NHL or T_cell ALL/Ⅳ_stage NHL)were analyzed reˉspectively according to ATLS criteria formulated by Cohen.Results17cases(7.9%)of216children with either ALL orⅣ_ NHL were diagnosed as ATLS.All17patients had developed metabolic disturbances,cha_ racterized by biochemical abnormalities including hyperuricemia,hyperphosphatemia,hypocalcaemia,and uremia.Altogether,the incidences of ATLS were5.3%in169children with ALL and17%in47children withⅣ_NHL(P<0.05);and5.8%in120cases with B_cell lymphatic malignant tumors and10.4%in96cases with T_cell lymphatic malignant tumors(P>0.05),respectively.Furthermore,incidences of ATLS were15.2%in60children with WBC≥50×10 9 /L and4.7%in150children with WBC<50×10 9 /L(P<0.05);and40.0%in40children with LDH≥2000U/L and0.6%in176children with LDH<2000U/L(P<0.01),respectively.All17patients due to receiving early prophylaxis,diagnosis and treatment presented better prognosis.None of them developed oliguria,anuria or needing hemodialysis.Also,nobody occurred severe bleeding,arrhythmia or other life_threatening complications.Conclusions Higher WBC counts,higher LDH andⅣ_stage NHL were high_risk factors for the development of ATLS in children with lymphocytic malignancy.It is safe and effective to use together hydration,alkalinization and allopurinol and important to monitor closely and manage timely water_electrolytes disturbances for the prophylaxis and treatment of ATLS,the severe clinical consequences can hence be avoided and the early mortality rate can be expected to reduce in children with lymˉphocytic malignancy.