1
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Laumann RD, Pedersen LL, Andrés-Jensen L, Mølgaard C, Schmiegelow K, Frandsen TL, Als-Nielsen B. Hyperlipidemia in children and adolescents with acute lymphoblastic leukemia: A systematic review and meta-analysis. Pediatr Blood Cancer 2023; 70:e30683. [PMID: 37776083 DOI: 10.1002/pbc.30683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/25/2023] [Accepted: 09/07/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The established association between acute lymphoblastic leukemia (ALL) and hyperlipidemia has, in some studies, been linked to toxicities such as pancreatitis, thrombosis, and osteonecrosis. However, a systematic review investigating the incidence, management, and clinical implications of hyperlipidemia during childhood ALL treatment is lacking. OBJECTIVES Systematically assess the incidence of hyperlipidemia during ALL treatment, explore associations with risk factors and severe toxicities (osteonecrosis, thrombosis, and pancreatitis), and review prevalent management strategies. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data synthesis was descriptive, and a meta-analysis of hypertriglyceridemia and risk of severe toxicities was performed. RESULTS We included 13 studies with 3,425 patients. Hyperlipidemia incidence varied widely (6.7%-85%) but with inconsistent definitions and screening strategies across studies. Evidence regarding risk factors was conflicting, but age (> 10 years) and treatment with asparaginase and glucocorticosteroids seem to be associated with hyperlipidemia. Hypertriglyceridemia (grade 3/4) increased the risk for osteonecrosis (odds ratio (OR): 4.27, 95% confidence interval (CI): 2.77-6.61). No association could be established for pancreatitis (OR: 1.60, 95% CI: 0.53-4.82) or thrombosis (OR: 2.45, 95% CI: 0.86-7.01), but larger studies are needed to confirm this. CONCLUSION The overall evidence of this systematic review is limited by the small number of studies and risk of bias. Our review suggests that hypertriglyceridemia increases the risk for osteonecrosis. However, larger studies are needed to explore the clinical implications of hyperlipidemia and randomized trials investigating hyperlipidemia management and its impact on severe toxicities.
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Affiliation(s)
- Renate Dagsdottir Laumann
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Louise Lindkvist Pedersen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Liv Andrés-Jensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Pediatric Nutrition Unit, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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2
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Poirée M, Neumann F, Thomas C, Simon P, Lunven AFR, Plantaz D, Doulet ST, Strullu M. [Prevention and management of pegaspargase associated-toxicities (excluding coagulation abnormalities). Recommendations of the French Society of Children and Adolescent Cancers (Leukemia committee)]. Bull Cancer 2022; 109:1125-1131. [PMID: 35987855 DOI: 10.1016/j.bulcan.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/07/2022] [Accepted: 06/12/2022] [Indexed: 02/05/2023]
Abstract
Pegaspargase (Oncaspar®), a pegylated form of native Escherichia Coli-derived L-asparaginase is an essential component chemotherapy used in the treatment of acute lymphoblastic leukemia (ALL) in pediatric and adult patients. Its particular toxicity profile requires a specific management to improve safety and tolerability and optimize treatment outcome and therefore survival. Within the framework of workshops of practice harmonization of the French Society of Children and Adolescent Cancers, diagnostic and management of the most commonly occuring toxicities (excluding coagulation abnormalities) during Pegaspargase treatment were reviewed according to the analysis of published studies.
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Affiliation(s)
- Marilyne Poirée
- CHU, service d'oncologie et hématologie pédiatrique, Nice, France.
| | - Florent Neumann
- CHU, service d'immuno hémato oncologie pédiatrique, Dijon, France
| | - Caroline Thomas
- CHU, service d'oncologie et d'immunologie pédiatrique, Nantes, France
| | - Pauline Simon
- CHRU, service d'hémato oncologie pédiatrique, Besançon, France
| | - Anne France Ray Lunven
- AP-HP, hôpital universitaire Robert-Debré, service d'hémato-immunologie pédiatrique, Paris, France
| | - Dominique Plantaz
- CHU, hôpital Couple enfant, clinique universitaire de pédiatrie, Grenoble, France
| | | | - Marion Strullu
- AP-HP, hôpital universitaire Robert-Debré, service d'hémato-immunologie pédiatrique, Paris, France
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3
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Parrella A, Iannuzzi A, Annunziata M, Covetti G, Cavallaro R, Aliberti E, Tortori E, Iannuzzo G. Haematological Drugs Affecting Lipid Metabolism and Vascular Health. Biomedicines 2022; 10:biomedicines10081935. [PMID: 36009482 PMCID: PMC9405726 DOI: 10.3390/biomedicines10081935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 01/19/2023] Open
Abstract
Many drugs affect lipid metabolism and have side effects which promote atherosclerosis. The prevalence of cancer-therapy-related cardiovascular (CV) disease is increasing due to development of new drugs and improved survival of patients: cardio-oncology is a new field of interest and research. Moreover, drugs used in transplanted patients frequently have metabolic implications. Increasingly, internists, lipidologists, and angiologists are being consulted by haematologists for side effects on metabolism (especially lipid metabolism) and arterial circulation caused by drugs used in haematology. The purpose of this article is to review the main drugs used in haematology with side effects on lipid metabolism and atherosclerosis, detailing their mechanisms of action and suggesting the most effective therapies.
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Affiliation(s)
- Antonio Parrella
- Department of Medicine and Medical Specialties, A. Cardarelli Hospital, 80131 Naples, Italy
| | - Arcangelo Iannuzzi
- Department of Medicine and Medical Specialties, A. Cardarelli Hospital, 80131 Naples, Italy
| | | | - Giuseppe Covetti
- Department of Medicine and Medical Specialties, A. Cardarelli Hospital, 80131 Naples, Italy
| | - Raimondo Cavallaro
- Department of Medicine and Medical Specialties, A. Cardarelli Hospital, 80131 Naples, Italy
| | - Emilio Aliberti
- North Tees University Hospital, Stockton-on-Tees TS19 8PE, UK
| | - Elena Tortori
- Pharmacy Unit, Ospedale del Mare, 80147 Naples, Italy
| | - Gabriella Iannuzzo
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
- Correspondence:
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4
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El-Khoury H, Saifi O, Haddad S, Chahrour M, Ghanem KM, Mubarak Y, Tamim H, Makki M, Zakka C, Chan AK, Mahfouz R, Tarek N, El-Solh H, Abboud MR, Saab R, Muwakkit SA. Treatment-induced cerebral sinus venous thrombosis in childhood acute lymphoblastic malignancies: New risk factors to consider. Pediatr Blood Cancer 2021; 68:e29210. [PMID: 34327817 DOI: 10.1002/pbc.29210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/16/2021] [Accepted: 06/04/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cerebral sinus venous thrombosis (CSVT) is one of the many side effects encountered during acute lymphoblastic leukemia (ALL) therapy. Due to the rarity of cases, lack of data, and consensus management, no recommendations exist to target the population at risk. METHODS This is a retrospective chart review of 229 consecutive patients diagnosed with ALL with an age range of 1-21 years, treated at the Children's Cancer Center of Lebanon between October 2007 and February 2018. RESULTS The incidence of CSVT was 10.5%. Using univariate analysis, increased risk of CSVT was observed with male gender, age >10 years, T-cell immunophenotype, intermediate/high-risk disease, maximum triglyceride (TG) level of >615 mg/dl, presence of mediastinal mass, and larger body surface area (BSA). With multivariate analysis, the only statistically significant risk factors were maximum TG level, BSA, presence of mediastinal mass, and risk stratification (intermediate/high risk). CONCLUSION Our study was able to unveil TG level of >615 mg/dl, mediastinal mass, and a larger BSA as novel risk factors that have not been previously discussed in the literature.
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Affiliation(s)
- Habib El-Khoury
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Omran Saifi
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Salame Haddad
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Mohamad Chahrour
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Khaled M Ghanem
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yaacoub Mubarak
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Department of Pediatrics, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Maha Makki
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Cyril Zakka
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Anthony K Chan
- Department of Pediatrics, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Rami Mahfouz
- Molecular Diagnostics Laboratory, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nidale Tarek
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hassan El-Solh
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Miguel R Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Raya Saab
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samar A Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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5
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Lau SCD, Loh CK, Alias H. Case Report: The Use of Intravenous SMOFlipid Infusion to Treat Severe Asparaginase-Induced Hypertriglyceridemia in Two Pediatric Acute Lymphoblastic Leukemia Patients. Front Pediatr 2021; 9:660627. [PMID: 33968859 PMCID: PMC8100240 DOI: 10.3389/fped.2021.660627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022] Open
Abstract
Asparaginase-induced hypertriglyceridemia can have a spectrum of clinical presentations, from being asymptomatic to having life-threatening thrombosis or hyperviscosity syndrome. At present, there is no recommendation on routine lipid monitoring during asparaginase-containing treatment phase, nor a standardized guideline on its management. Two cases are presented here to illustrate the effects of concurrent infection on asparaginase-induced hypertriglyceridemia in patients with high-risk ALL and the use of SMOFlipid infusion as a treatment option in an acute situation.
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Affiliation(s)
- Sie Chong Doris Lau
- Pediatric Hematology and Oncology Unit, Department of Pediatrics, UKM Medical Centre, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - C-Khai Loh
- Pediatric Hematology and Oncology Unit, Department of Pediatrics, UKM Medical Centre, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia
| | - Hamidah Alias
- Pediatric Hematology and Oncology Unit, Department of Pediatrics, UKM Medical Centre, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia
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6
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Mayerhofer C, Speckmann C, Kapp F, Teufel-Schäfer U, Kluwe W, Schneider J, Flotho C. Lipid Apheresis to Manage Severe Hypertriglyceridemia during Induction Therapy in a Child with Acute Lymphoblastic Leukemia. Pediatr Hematol Oncol 2020; 37:530-538. [PMID: 32374222 DOI: 10.1080/08880018.2020.1756999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PEG asparaginase is an important and established drug in the treatment of pediatric acute lymphoblastic leukemia (ALL). Severe hypertriglyceridemia is a rare complication of PEG asparaginase in combination with glucocorticoids. We report a case of excessive hypertriglyceridemia in a child during ALL induction therapy successfully treated by lipid apheresis and give a literature review on the management of hypertriglyceridemia in children treated for ALL.
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Affiliation(s)
- Christina Mayerhofer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carsten Speckmann
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedrich Kapp
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrike Teufel-Schäfer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Gastroenterology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfram Kluwe
- Department of Pediatric Surgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johanna Schneider
- Department of Internal Medicine, Division of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Flotho
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Freiburg, Germany
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7
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Zawitkowska J, Lejman M, Zaucha-Prażmo A, Sekuła N, Greczkowska-Chmiel T, Drabko K. Severe drug-induced hypertriglyceridemia treated with plasmapheresis in children with acute lymphoblastic leukemia. Transfus Apher Sci 2019; 58:634-637. [PMID: 31515171 DOI: 10.1016/j.transci.2019.08.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/05/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
Asparaginase (ASP) and steroids are a main part of treatment for ALL, in both front-line and relapse setting. It is known, that ASP can cause several toxicities such as hypersensitivity, pancreatitis, as well as severe lipid and coagulation disturbances. Administered steroids can result in diabetes, obesity, hyponatremia and also mild hyperlipemia, which can intensify side effects of asparaginase. When triglyceride elevation is greater than 1000 mg/dl, the risk of pancreatitis is significantly increased. We report two patients who were hospitalized in Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin in Poland and developed severe hypertriglyceridemia after receiving asparaginase and steroid therapy for acute lymphoblastic leukemia. These patients were treated using plasmapheresis. This procedure was performed with a venous catheter in the femoral vein and 5% albumin or fresh frozen plasma as the replacement fluid. We analysed the laboratory and clinical data of these children. Plasmapheresis was well tolerated in both cases and a decrease of hypertriglyceridemia was quickly observed. However, the girl developed pancreatitis. In our opinion, plasmapheresis appears to be safe and effective in reducing hypertriglyceridemia. We could recommend that this procedure should be performed early, as soon as the triglyceride level is above 1000 mg/dl, in order to prevent severe complications. Patients should continue chemotherapy without ASP. It is important to regularly monitor of the lipid profile, pancreatic enzymes and coagulation during ASP and steroids therapy.
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Affiliation(s)
- Joanna Zawitkowska
- Department of Pediatric Hematology, Oncology and Transplantation, Medical University, Lublin, Poland.
| | - Monika Lejman
- Department of Pediatric Hematology, Oncology and Transplantation, University Children's Hospital, Genetic Diagnostic Laboratory, Lublin, Poland
| | - Agnieszka Zaucha-Prażmo
- Department of Pediatric Hematology, Oncology and Transplantation, Medical University, Lublin, Poland
| | - Natasza Sekuła
- Department of Pediatric Hematology, Oncology and Transplantation, University Children's Hospital, Lublin, Poland
| | - Teresa Greczkowska-Chmiel
- Department of Pediatric Hematology, Oncology and Transplantation, University Children's Hospital, Lublin, Poland; Department of Blood Treatment, University Children's Hospital, Lublin, Poland
| | - Katarzyna Drabko
- Department of Pediatric Hematology, Oncology and Transplantation, Medical University, Lublin, Poland
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8
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Salvador C, Entenmann A, Salvador R, Niederwanger A, Crazzolara R, Kropshofer G. Combination therapy of omega-3 fatty acids and acipimox for children with hypertriglyceridemia and acute lymphoblastic leukemia. J Clin Lipidol 2018; 12:1260-1266. [PMID: 30055974 DOI: 10.1016/j.jacl.2018.05.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lipemic alterations are commonly seen in pediatric patients with acute lymphoblastic leukemia (ALL) treated with corticosteroids and L-asparaginase. OBJECTIVE In these children, hypertriglyceridemia rarely causes symptoms and mostly responds well to a low-fat diet. Only few patients demand further therapy, which is not clearly approved in the literature to date. Therefore, it may be important to compile generally accepted standard procedures for lipid-lowering therapy in the pediatric ALL population. METHODS We performed a study on 119 newly diagnosed pediatric patients with ALL, all treated according to the ALL-BFM 2000 protocol at our institution between the years 2000 and 2009, to evaluate the incidence of hypertriglyceridemia and the efficacy of a combination therapy with omega-3 fatty acids and acipimox in hypertriglyceridemic patients who did not respond to diet. RESULTS We observed hypertriglyceridemia in 34.5% of patients in this collective. In the majority, normalization of triglycerides was successfully managed by administration of a low-fat diet. However, 7.6% of patients (related to total study population) with hypertriglyceridemia did not show diminished lipid levels during diet and/or presented with symptoms such as abdominal pain, dyspnea, or anginal chest pain. In these cases, we performed a lipid-lowering combination therapy with omega-3 fatty acids and acipimox. We observed a prompt decline of serum triglycerides to normal values and an improvement of symptoms within days after onset of this therapy without occurrence of any side effects. CONCLUSION In summary, the combination treatment with omega-3 fatty acids and acipimox could represent an alternative to other reported lipid-lowering therapies without severe adverse reactions.
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Affiliation(s)
- C Salvador
- Division of Pediatric Hematology and Oncology, Department of Pediatrics I, Innsbruck Medical University, Innsbruck, Tyrol, Austria.
| | - A Entenmann
- Division of Gastroenterology and Hepatology, Department of Pediatrics I, Innsbruck Medical University, Innsbruck, Tyrol, Austria
| | | | - A Niederwanger
- Department of Internal Medicine, Innsbruck Medical University, Innsbruck, Tyrol, Austria
| | - R Crazzolara
- Division of Pediatric Hematology and Oncology, Department of Pediatrics I, Innsbruck Medical University, Innsbruck, Tyrol, Austria
| | - G Kropshofer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics I, Innsbruck Medical University, Innsbruck, Tyrol, Austria
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9
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Raja RA, Schmiegelow K, Sørensen DN, Frandsen TL. Asparaginase-associated pancreatitis is not predicted by hypertriglyceridemia or pancreatic enzyme levels in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2017; 64:32-38. [PMID: 27555294 DOI: 10.1002/pbc.26183] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/04/2016] [Accepted: 07/07/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND l-Asparaginase is an important drug for treatment of childhood acute lymphoblastic leukemia (ALL), but is associated with serious toxicities, including pancreatitis and hypertriglyceridemia (HTG). Asparaginase-associated pancreatitis (AAP) is a common reason for stopping asparaginase treatment. The aim of this study was to explore if HTG or early elevations in pancreatic enzymes were associated with the subsequent development of AAP. METHOD Children (1.0-17.9 years) diagnosed with ALL, treated with asparaginase for 30 weeks, according to the NOPHO ALL2008 protocol at the University Hospital Rigshospitalet, Copenhagen, Denmark, were eligible. Pancreatic enzymes, triglycerides, and cholesterol were measured regularly. RESULTS Thirty-one patients were included. Seven patients were diagnosed with AAP. HTG was most evident when PEG-asparaginase and dexamethasone were administered concomitantly. Overall, there was no significant difference in triglyceride levels in patients who experienced AAP and patients who did not. An increase in triglyceride levels during concomitant dexamethasone therapy in delayed intensification was significantly associated with an increase in pancreas-specific amylase levels two weeks later (P = 0.005). CONCLUSIONS AAP does not seem to be associated with HTG. Continuous monitoring of pancreas enzymes does not predict AAP.
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Affiliation(s)
- Raheel Altaf Raja
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ditte Nørbo Sørensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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10
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Plasmapheresis for Preventing Complication of Hypertriglyceridemia: A Case Report and Review of Literature. Am J Ther 2016; 23:e288-91. [PMID: 25285671 DOI: 10.1097/mjt.0000000000000079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Severe hypertriglyceridemia is a common indication for the need of plasma exchange in treatment of hypertriglyceridemic-induced pancreatitis when normal therapies fail to garner a response. Application of plasmapheresis to prevent complication of hypertriglyceridemia is limited because of its cost and availability. We present a case of a 44-year-old man with metabolic syndrome and a medical history of secondary polycythemia in obesity hypoventilation syndrome, whose laboratory tests revealed a triglycerides value of 3965 mg/dL. To prevent the complication of pancreatitis due to hypertriglyceridemia, we performed plasma exchange 3 times when conventional treatments did not sufficiently reduce the high level of triglycerides. A review of the current available literature was therefore conducted to provide an overview of the present data on apheretic treatment for patients with severe hypertriglyceridemia. Several case reports and case series have used plasmapheresis in acute treatment of hypertriglyceridemia pancreatitis related. In our case, the choice of plasmapheresis was applied in prevention of possible complications of hypertriglyceridemia.
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11
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Hijiya N, van der Sluis IM. Asparaginase-associated toxicity in children with acute lymphoblastic leukemia. Leuk Lymphoma 2015; 57:748-57. [PMID: 26457414 PMCID: PMC4819847 DOI: 10.3109/10428194.2015.1101098] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asparaginase is an integral component of multiagent chemotherapy regimens for the treatment of children with acute lymphoblastic leukemia. Positive outcomes are seen in patients who are able to complete their entire prescribed course of asparaginase therapy. Toxicities associated with asparaginase use include hypersensitivity (clinical and subclinical), pancreatitis, thrombosis, encephalopathy, and liver dysfunction. Depending on the nature and severity of the toxicity, asparaginase therapy may be altered or discontinued in some patients. Clinical hypersensitivity is the most common asparaginase-associated toxicity requiring treatment discontinuation, occurring in up to 30% of patients receiving Escherichia coli-derived asparaginase. The ability to rapidly identify and manage asparaginase-associated toxicity will help ensure patients receive the maximal benefit from asparaginase therapy. This review will provide an overview of the common toxicities associated with asparaginase use and recommendations for treatment management.
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Affiliation(s)
- Nobuko Hijiya
- a Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Inge M van der Sluis
- b Department of Pediatric Oncology/Hematology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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12
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Asparaginase-Induced Hypertriglyceridemia Presenting as Pseudohyponatremia during Leukemia Treatment. Case Rep Pediatr 2014; 2014:635740. [PMID: 25405049 PMCID: PMC4227320 DOI: 10.1155/2014/635740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 09/27/2014] [Indexed: 01/19/2023] Open
Abstract
Asparaginase is a chemotherapeutic agent used to induce disease remission in children with acute lymphoblastic leukemia (ALL). We describe the cases of two females with ALL who developed pseudohyponatremia as a presentation of hypertriglyceridemia following asparaginase treatment. Nine similar published cases of asparaginase-induced hypertriglyceridemia and its complications are also discussed. Possible mechanisms of action include inhibition of lipoprotein lipase, decreased hepatic synthesis of lipoprotein, and increased synthesis of VLDL. Effects of asparaginase-induced hypertriglyceridemia range from asymptomatic to transaminasemia, pancreatitis, and life-threatening thrombosis or hyperviscosity syndrome. All cases of hypertriglyceridemia described resolved following cessation of asparaginase treatment ± further treatments.
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13
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Tong WH, Pieters R, de Groot-Kruseman HA, Hop WCJ, Boos J, Tissing WJE, van der Sluis IM. The toxicity of very prolonged courses of PEGasparaginase or Erwinia asparaginase in relation to asparaginase activity, with a special focus on dyslipidemia. Haematologica 2014; 99:1716-21. [PMID: 25150254 DOI: 10.3324/haematol.2014.109413] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We prospectively studied the incidence and clinical course of hypertriglyceridemia and hypercholesterolemia during very prolonged use of asparaginase in relation to levels of asparaginase activity in children with acute lymphoblastic leukemia. We also evaluated the incidence of pancreatitis, thrombosis, hyperammonemia and central neurotoxicity and their association with asparaginase activity levels. Eighty-nine patients were treated according to the Dutch Childhood Oncology Group Acute Lymphoblastic Leukemia 10 medium-risk intensification protocol, which includes 15 doses of PEGasparaginase (2,500 IU/m(2)) over 30 weeks. Erwinia asparaginase (20,000 IU/m(2)) was administered when allergy to or silent inactivation of PEGasparaginase occurred. Triglyceride, cholesterol and ammonia levels increased rapidly in children treated with PEGasparaginase and remained temporarily elevated, but normalized after administration of the last asparaginase dose. Among the patients treated with PEGasparaginase, hypertriglyceridemia and hypercholesterolemia (grade 3/4) were found in 47% and 25%, respectively. The correlation between PEGasparaginase activity levels and triglyceride levels was strongest at week 5 (Spearman correlation coefficient = 0.36, P = 0.005). The triglyceride levels were higher in children ≥ 10 years old than in younger patients (<10 years old) after adjustment for type of asparaginase preparation: median 4.9 mmol/L versus 1.6 mmol/L (P<0.001). In patients receiving Erwinia asparaginase, triglyceride levels increased in the first weeks as well, but no grade 3/4 dyslipidemia was found. Hyperammonemia (grade 3/4) was only found in patients treated with Erwinia asparaginase (9%). Thrombosis occurred in 4.5%, pancreatitis in 7%, and central neurotoxicity in 9% of patients using either of the two agents; these toxicities were not related to levels of asparaginase activity or to triglyceride levels. In conclusion, severe dyslipidemia occurred frequently, but was temporary and was not associated with relevant clinical events and should not, therefore, be considered a reason for modifying asparaginase treatment. Dyslipidemia was the only toxicity related to levels of asparaginase activity.
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Affiliation(s)
- Wing H Tong
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rob Pieters
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Wim C J Hop
- Department of Biostatistics, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Joachim Boos
- Department of Pediatric Hematology/Oncology, University Children's Hospital, Mϋnster, Germany
| | - Wim J E Tissing
- Department of Pediatric Oncology and Hematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Inge M van der Sluis
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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Seda G, Meyer JM, Amundson DE, Daheshia M. Plasmapheresis in the management of severe hypertriglyceridemia. Crit Care Nurse 2014; 33:18-23; quiz 24. [PMID: 23908166 DOI: 10.4037/ccn2013346] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Plasmapheresis can benefit a variety of critically ill patients. A woman with diabetic ketoacidosis and severe hypertriglyceridemia was treated with plasmapheresis when conventional treatments did not markedly reduce her triglyceridemia. The patient was admitted to a medical intensive care unit because of diabetic ketoacidosis with severe lipemia. The lipemia-associated interference in laboratory studies made treatment of electrolyte abnormalities extremely difficult. The hypertriglyceridemia was initially treated with insulin, antilipidemic medications, and heparin, but the levels of triglycerides remained elevated, delaying results of needed laboratory studies for hours. After plasmapheresis, the serum level of triglycerides decreased by 77% in less than 24 hours. Severe lipemia interferes with photometric laboratory studies, yielding an underestimation of serum levels of electrolytes. Plasmapheresis is safe, rapid, and effective for emergent management of severe hypertriglyceridemia in critically ill patients. The impact of the procedure on critical care nursing is growing as nurses become involved in the treatment and follow-up care of patients who have plasmapheresis.
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Affiliation(s)
- Gilbert Seda
- Medical Corps, US Navy, Department of Pulmonary and Critical Care Medicine, Naval Medical Center San Diego, San Diego, California, USA.
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15
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Mittal N, Llanos-Chea A, Dighe D, Giordano L. A Teenaged Patient with Severe Asparaginase-Induced Hypertriglyceridemia Safely Re-Challenged During Primary and Relapse Therapy for Acute Lymphoblastic Leukemia. J Adolesc Young Adult Oncol 2014. [DOI: 10.1089/jayao.2013.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Nupur Mittal
- Division of Pediatric Hematology/Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Alejandro Llanos-Chea
- Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
| | - Dipti Dighe
- Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
| | - Lisa Giordano
- Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
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16
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Raja RA, Schmiegelow K, Frandsen TL. Asparaginase-associated pancreatitis in children. Br J Haematol 2012; 159:18-27. [PMID: 22909259 DOI: 10.1111/bjh.12016] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
l-asparaginase has been an element in the treatment for acute lymphoblastic leukaemia (ALL) and non-Hodgkin lymphoma since the late 1960s and remains an essential component of their combination chemotherapy. Among the major toxicities associated with l-asparaginase therapy are pancreatitis, allergic reactions, thrombotic events, hepatotoxicity and hyperlipidaemia. Acute pancreatitis is one of the most common reasons for stopping treatment with l-asparaginase. Short-term complications of asparaginase-associated pancreatitis include development of pseudocysts and pancreatic necrosis. Long-term complications include chronic pancreatitis and diabetes. The pathophysiology of asparaginase-associated pancreatitis remains to be uncovered. Individual clinical and genetic risk factors have been identified, but they are only weak predictors of pancreatitis. This review explores the definition, possible risk factors, treatment and complications of asparaginase-associated pancreatitis.
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Affiliation(s)
- Raheel Altaf Raja
- The Department of Paediatrics and Adolescent Medicine, the University Hospital Rigshospitalet, Copenhagen, Denmark
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17
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Tan M, Wai D, Chng CL, Hwang W. Acarbose is an effective treatment for severe hypertriglyceridemia secondary to l-asparaginase and dexamethasone. Leuk Lymphoma 2012; 53:1245-6. [PMID: 22149169 DOI: 10.3109/10428194.2011.647312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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18
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Malbora B, Avci Z, Ozbek N. Treatment of severe hypertriglyceridemia associated with accidental pegylated asparaginase push in a child with relapsed acute lymphoblastic leukemia. Drug Chem Toxicol 2011; 35:463-6. [PMID: 22149271 DOI: 10.3109/01480545.2011.640684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asparaginase treatment is associated with several adverse effects, including allergy, thromboembolic events, acute pancreatitis, altered liver function, and hyperglycemia. In addition, asparaginase can cause abnormalities in lipid metabolism, predominantly hypercholesterolemia and -triglyceridemia. Herein, we report on the case of a 5-year-old male presenting with acute severe hypertriglyceridemia caused by accidental pegylated asparaginase push during treatment of relapsed acute lymphoblastic leukemia. Hypertriglyceridemia did not occur after appropriate administrations of pegylated asparaginase before and after accidental drug infusions, so we speculate that the rate of pegylated asparaginase administration may have an effect on the serum triglyceride level.
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Affiliation(s)
- Baris Malbora
- Faculty of Medicine, Department of Pediatric Hematology, Baskent University, Ankara, Turkey.
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Bielecka-Dąbrowa A, Hannam S, Rysz J, Banach M. Malignancy-associated dyslipidemia. Open Cardiovasc Med J 2011; 5:35-40. [PMID: 21660223 PMCID: PMC3109950 DOI: 10.2174/1874192401105010035] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/05/2011] [Accepted: 01/06/2011] [Indexed: 11/29/2022] Open
Abstract
Cholesterol and triglycerides, important lipid constituents of cell, are essential to carry out several vital physiological functions. Lipids might be associated with cancers because they play a key role in the maintenance of cell integrity. The pathway for cholesterol synthesis may also produce various tumorigenic compounds and cholesterol serves as a precursor for the synthesis of many sex hormones linked to increased risk of various cancers. In some malignant diseases, blood cholesterol undergoes early and significant changes. The mechanism for the link between cancer and cholesterol remains controversial. The dates from studies are confusing because both hypolipidemia and hypercholesterolemia might be connected with malignancy. Not only cancers but also antineoplastic therapies have an influence on lipid profile. There are also dates suggesting that antihyperlipemic drugs might nfluenced malignancy.
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Affiliation(s)
| | - Simon Hannam
- Department of Child Health, King's College London School of Medicine, London, UK
| | - Jacek Rysz
- Deprtament of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Poland
| | - Maciej Banach
- Department of Hypertension, Medical University of Lodz, Poland
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Cohen H, Bielorai B, Harats D, Toren A, Pinhas-Hamiel O. Conservative treatment of L-asparaginase-associated lipid abnormalities in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2010; 54:703-6. [PMID: 20063421 DOI: 10.1002/pbc.22305] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the incidence and clinical consequences of asparaginase-associated lipid abnormalities in children with acute lymphoblastic leukemia (ALL). METHODS Sixty-five newly diagnosed children and adolescents aged 0.4-21 years with ALL or lymphoblastic lymphoma were retrospectively evaluated for lipid abnormalities. They were treated according to the ALLIC-BFM 2002 protocol between 2002 and 2005. Fasting cholesterol levels were measured in all patients and triglycerides (TG) in 42/65 patients. RESULTS Prior to treatment, mean cholesterol level was 149 +/- 50 mg/dl, and increased to maximal level 274 +/- 124 mg/dl during treatment. Mean TG level during treatment was 459 +/- 526 mg/dl (range 54-3,009). Twelve patients (28%) had TG levels <200 mg/dl, 18 (43%) had 200-400 mg/dl, 3 (7%) had 400-600 mg/dl, 4 (10%) between 600 and 1,000 mg/dl, and 5 (12%) patients had >1,000 mg/dl. No association was found between TG levels and age or gender. One of the 12 patients with TG >400 mg/dl developed left saggital sinus thrombosis and left frontal lobe infarct. TG level at the time of the event was 2,640 mg/dl. None of the five patients with TG levels >1,000 mg/dl developed pancreatitis. Children with TG levels between 400 and 600 mg/dl were treated by fasting. Fibrates and heparin were added to those with levels >600 mg/dl. Lipid abnormalities normalized in all children upon completion of asparaginase treatment. CONCLUSIONS Abnormalities of lipid profile in children with ALL during asparaginase therapy are relatively common. We recommend measuring TG before and during asparaginase treatment. Initiation of conservative treatment could prevent further increase of TG and decrease the risk of potential complications.
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Affiliation(s)
- Hofit Cohen
- The Bert W. Strassburger Lipid Center, Sheba Medical Center, Tel-Hashomer, Israel.
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21
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Losa Frías V, Martín-Sacristán Martín B, Díaz Conejo R, Ramos Corral R, Velasco Arribas MR. [Transient hyperlipidemia secondary to treatment with asparaginase and prednisone]. An Pediatr (Barc) 2009; 72:85-7. [PMID: 19879821 DOI: 10.1016/j.anpedi.2009.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 08/31/2009] [Accepted: 09/01/2009] [Indexed: 01/19/2023] Open
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Abstract
BACKGROUND Acute pancreatitis (AP) is a complication in children with acute lymphoblastic leukemia (ALL) receiving chemotherapy and has often been reported associated with L-asparaginase (L-asp) therapy. OBJECTIVES To determine the incidence, risk factors, clinical data, outcome, and mortality of AP in children with ALL. METHODS Retrospective cohort study was conducted by reviewing the data of total 192 pediatric ALL patients from Pediatric Oncology Registry at Ramathibodi Hospital from 2000 to 2006 to assess incidence, clinical data, outcome, and mortality of AP. Then, a nested case-control study was conducted to identify potential risk factors for AP by recruiting all patients with AP as cases (n=16), and randomly selected patients without AP to serve as controls up to approximately four controls per case with the total of 68 controls. RESULTS The total incidence of AP in children with ALL and L-asp-associated AP was 8.3% and 7.3%, respectively. In patients with L-asp-associated AP, pancreatitis developed after the median 5.5 doses (range: 1 to 20 doses) of L-asp therapy and the median interval from the last dose of L-asp to the onset of AP was 4 days (range: 1 to 13 days). The mortality rate of AP group was significantly higher than the patients without AP (43.8% vs. 19.3%, P=0.02). Mortality was associated with concurrent systemic infection and complications of underlying diseases. Multivariate analysis identified using a high-risk chemotherapy regimen was the only risk factor for AP. CONCLUSIONS Using a high-risk chemotherapy regimen was a risk factor for pancreatitis in patients with ALL. ALL children with AP had higher mortality rate than those without pancreatitis.
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Nakagawa M, Kimura S, Fujimoto K, Atumi H, Imura J, Chikazawa Y, Imamura H, Okuyama H, Yamaya H, Fukushima T, Nakagawa A, Asaka M, Yokoyama H. A Case Report of an Adult With Severe Hyperlipidemia During Acute Lymphocytic Leukemia Induction Therapy Successfully Treated With Plasmapheresis. Ther Apher Dial 2008; 12:509-13. [DOI: 10.1111/j.1744-9987.2008.00647.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Kfoury-Baz EM, Nassar RA, Tanios RF, Otrock ZK, Youssef AM, Albany C, Bazarbachi A, Salem ZM. Plasmapheresis in asparaginase-induced hypertriglyceridemia. Transfusion 2008; 48:1227-30. [DOI: 10.1111/j.1537-2995.2008.01663.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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