Abstract
Background
Morbidity and mortality in tumor lysis syndrome (TLS) remains high despite increasing efforts for prevention, early detection and treatment in recent years. The current risk stratification system and treatment guidelines are largely consensus based without strong evidence. There is paucity of data on the in-hospital mortality and predictors of poor clinical outcome in this population.
Methods
We used the 2009-2011 Nationwide Inpatient Sample database to identify hospitalizations in patients ≥18 years with a diagnosis of TLS (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 277.88). Nationwide Inpatient Sample is the largest all-payer publicly available inpatient care database in the US. It contains data from five to eight million hospital stays from about 1,000 hospitals across the country and approximates a 20% sample of all US hospitals. The interval 2009-2011 was selected as ICD-9-CM code 277.88 for TLS was only introduced from the year 2009 onwards. Univariate and multivariate logistic regression were used to determine the independent predictors of in-hospital mortality. Data analysis was done using STATA version 13.0 (College Station, TX).
Results
Among the 997 admissions (mean age ± SD 67.58±3.33, 62.6 % males, and 80.4 % white) with TLS, in-hospital mortality was 14.44 %. Based on the results of univariate analyses (table 1), we used obesity, coronary artery disease, cardiac dysrhythmias, acute kidney injury and sepsis in the final regression model. We found that cardiac dysrhythmias (OR 4.79; 95% CI, 1.67-13.77; p=0.004) and sepsis (OR 19.70; 95% CI, 5.33-72.78; p<0.001) were independent predictors of increased in-hospital mortality in patients with TLS. Although certain myeloid and lymphoid malignancies are associated with higher risk of tumor lysis syndrome, we did not observe any statistically significant increased risk of mortality with one specific type of malignancy over the other. Similarly, none of the demographic characteristics (age <40 vs ≥40, sex or race), or hospital characteristics (rural vs urban, teaching vs non-teaching, small vs large bed-size or geographic region) predicted increased in-hospital mortality in these patients.
Conclusion
In this study of large national database, patients with TLS had an in-hospital mortality of 14.44 %. Independent predictors of in-hospital mortality were cardiac dysrhythmias and sepsis. Our findings might help physicians to identify sub-group of patients with TLS that are at increased risk of in-hospital mortality.
Characteristics . | . | Survivors (n=853) . | Non-survivors (n=144) . | p . |
---|---|---|---|---|
Age( in years) | Mean | 68.40±3.06 | 67.58±3.33 | 0.73 |
Male sex | 62.1 | 65.8 | 0.69 | |
Race | 0.16 | |||
White | 81.52 | 73.54 | ||
Black | 14.98 | 22.8 | ||
Hispanic | 2.27 | 0 | ||
Others/unknown | 1.22 | 3.66 | ||
Insurance status | 0.41 | |||
Medicare | 65.55 | 48.15 | ||
Medicaid | 5.56 | 13.34 | ||
Private insurance | 24.89 | 32.58 | ||
Self-Pay | 0.65 | 2.99 | ||
No charge | 0.63 | 0 | ||
Other | 2.72 | 2.93 | ||
Region | 0.13 | |||
Northeast | 27.59 | 37.74 | ||
Midwest | 28.23 | 12.92 | ||
South | 31.34 | 39.9 | ||
West | 12.84 | 9.44 | ||
Location/teaching status | 0.59 | |||
Rural | 7.87 | 10.16 | ||
Urban nonteaching | 26.01 | 33.52 | ||
Urban teaching | 66.12 | 56.32 | ||
Bed-size | 0.84 | |||
Small | 11.11 | 8.91 | ||
Medium | 21.04 | 24.55 | ||
Large | 67.85 | 66.54 | ||
Malignancies | ||||
ALL | 1.19 | 6.79 | 0.25 | |
AML | 2.34 | 6.99 | 0.29 | |
CLL | 27.86 | 16.83 | 0.18 | |
CML | 1.85 | 3.19 | 0.68 | |
NHL | 36.33 | 22.37 | 0.1 | |
HD | 0.53 | 0 | 0.32 | |
Multiple Myeloma | 7.39 | 6.56 | 0.82 | |
Other hematologic malignancies | 38.67 | 25.99 | 0.16 | |
Solid tumors | 35.87 | 26.8 | 0.32 | |
Co-morbidities | ||||
Smoking | 15.89 | 21.87 | 0.46 | |
Obesity | 5.16 | 0 | 0.005 | |
Dyslipidemia | 27.8 | 16.86 | 0.18 | |
Hypertension | 54.17 | 49.19 | 0.63 | |
Diabetes mellitus | 27.81 | 16.65 | 0.15 | |
PVD | 1.71 | 3.19 | 0.65 | |
CAD | 13.78 | 3.19 | 0.02 | |
AKI | 60.06 | 79.54 | 0.03 | |
CKD | 28.81 | 25.23 | 0.65 | |
Stroke | 0.63 | 0 | 0.32 | |
Sepsis | 3.58 | 31.81 | 0.003 | |
Cardiac dysrhythmias | 17.96 | 43.42 | 0.04 | |
Acute CHF | 11.44 | 7.08 | 0.43 |
Characteristics . | . | Survivors (n=853) . | Non-survivors (n=144) . | p . |
---|---|---|---|---|
Age( in years) | Mean | 68.40±3.06 | 67.58±3.33 | 0.73 |
Male sex | 62.1 | 65.8 | 0.69 | |
Race | 0.16 | |||
White | 81.52 | 73.54 | ||
Black | 14.98 | 22.8 | ||
Hispanic | 2.27 | 0 | ||
Others/unknown | 1.22 | 3.66 | ||
Insurance status | 0.41 | |||
Medicare | 65.55 | 48.15 | ||
Medicaid | 5.56 | 13.34 | ||
Private insurance | 24.89 | 32.58 | ||
Self-Pay | 0.65 | 2.99 | ||
No charge | 0.63 | 0 | ||
Other | 2.72 | 2.93 | ||
Region | 0.13 | |||
Northeast | 27.59 | 37.74 | ||
Midwest | 28.23 | 12.92 | ||
South | 31.34 | 39.9 | ||
West | 12.84 | 9.44 | ||
Location/teaching status | 0.59 | |||
Rural | 7.87 | 10.16 | ||
Urban nonteaching | 26.01 | 33.52 | ||
Urban teaching | 66.12 | 56.32 | ||
Bed-size | 0.84 | |||
Small | 11.11 | 8.91 | ||
Medium | 21.04 | 24.55 | ||
Large | 67.85 | 66.54 | ||
Malignancies | ||||
ALL | 1.19 | 6.79 | 0.25 | |
AML | 2.34 | 6.99 | 0.29 | |
CLL | 27.86 | 16.83 | 0.18 | |
CML | 1.85 | 3.19 | 0.68 | |
NHL | 36.33 | 22.37 | 0.1 | |
HD | 0.53 | 0 | 0.32 | |
Multiple Myeloma | 7.39 | 6.56 | 0.82 | |
Other hematologic malignancies | 38.67 | 25.99 | 0.16 | |
Solid tumors | 35.87 | 26.8 | 0.32 | |
Co-morbidities | ||||
Smoking | 15.89 | 21.87 | 0.46 | |
Obesity | 5.16 | 0 | 0.005 | |
Dyslipidemia | 27.8 | 16.86 | 0.18 | |
Hypertension | 54.17 | 49.19 | 0.63 | |
Diabetes mellitus | 27.81 | 16.65 | 0.15 | |
PVD | 1.71 | 3.19 | 0.65 | |
CAD | 13.78 | 3.19 | 0.02 | |
AKI | 60.06 | 79.54 | 0.03 | |
CKD | 28.81 | 25.23 | 0.65 | |
Stroke | 0.63 | 0 | 0.32 | |
Sepsis | 3.58 | 31.81 | 0.003 | |
Cardiac dysrhythmias | 17.96 | 43.42 | 0.04 | |
Acute CHF | 11.44 | 7.08 | 0.43 |
AKI=Acute Kidney Injury; ALL=Acute Lymphoblastic Leukemia; AML=Acute Myelogenous Leukemia; CAD=Coronary Artery Disease; CHF=Congestive Heart Failure; CKD=Chronic Kidney Disease; CLL=Chronic Lymphocytic Leukemia; CML=Chronic Myelogenous Leukemia; HD=Hodgkin Disease; NHL=Non Hodgkin Lymphoma; PVD=Peripheral Vascular Disease
No relevant conflicts of interest to declare.
Author notes
Asterisk with author names denotes non-ASH members.