1
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Takata K, Nakashima Y, Shakado S, Takamatsu Y, Hirai F. A Case of L-Asparaginase-Induced Severe Hepatic Steatosis With Decreased Serum Cholinesterase Levels. Cureus 2023; 15:e49787. [PMID: 38161559 PMCID: PMC10757814 DOI: 10.7759/cureus.49787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
L-asparaginase (L-Asp) is a useful antileukemic agent for acute lymphoblastic leukemia (ALL); however, it often causes severe liver injury with marked fatty liver. Here, we present a case of L-Asp-induced fatty liver disease in a 21-year-old female patient with ALL. Serum cholinesterase levels, which are usually elevated in fatty liver, decrease at the onset of liver injury. After treatment with L-carnitine and vitamin B complex, the liver injury rapidly improved, resulting in the patient being able to continue subsequent chemotherapy.
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Affiliation(s)
- Kazuhide Takata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Yuta Nakashima
- Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Yasushi Takamatsu
- Department of Internal Medicine, Fukuoka University Faculty of Medicine, Fukuoka, JPN
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Fukuoka, JPN
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2
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Sandley M, Angus J. Asparaginase therapy in patients with acute lymphoblastic leukemia: expert opinion on use and toxicity management. Leuk Lymphoma 2023; 64:776-787. [PMID: 36781296 DOI: 10.1080/10428194.2023.2171267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The addition of asparaginase to acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) treatment regimens provides significant patient benefits. Asparaginase therapies vary in origin (Escherichia coli- or Erwinia-derived) and preparation (native or pegylated), conferring distinct pharmacokinetic and immunogenic profiles. Clinical hypersensitivity reactions (HSRs) are commonly reported in patients and range from localized erythema to systemic anaphylaxis. Due to its favorable pharmacokinetic profile and reduced immunogenicity compared to native E. coli preparations, pegaspargase is the first-line asparaginase therapeutic option. Switching to an Erwinia-derived asparaginase is recommended for patients who experience HSRs or antibody-mediated inactivation to achieve the significant clinical benefit observed in patients who complete asparaginase treatment. Previous global shortages of asparaginase Erwinia chrysanthemi necessitated conversion mitigation strategies such as premedication protocols, desensitization, and asparaginase activity level monitoring. Here, we discuss the efficacy, safety, pharmacokinetics, current use, and administration of asparaginase therapies for pediatric and adolescent patients with ALL/LBL.
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Affiliation(s)
- Melissa Sandley
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA
| | - Jonathan Angus
- Department of Pharmacy, Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA, USA
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3
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Poorbagher MRM, Karimi E, Oskoueian E. Hepatoprotective effect of nanoniosome loaded Myristica fragrans phenolic compounds in mice-induced hepatotoxicity. J Cell Mol Med 2022; 26:5517-5527. [PMID: 36226354 PMCID: PMC9639044 DOI: 10.1111/jcmm.17581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/14/2022] [Accepted: 09/06/2022] [Indexed: 11/28/2022] Open
Abstract
In this study, nanoniosome‐loaded Myristica fragrans' (MF) phenolic compounds (NLMP) were synthesized and characterized for their physical properties, and hepatoprotective effects on mice with liver toxicity induced by L‐asparaginase (LA) injection. According to the results, NLMP has a spherical shape with a 263 nm diameter, a zeta potential of −26.55 mV and a polydispersity index (PDI) of 0.192. The weight and feed intake of mice induced with hepatotoxicity were significantly (p ≤ 0.05) increased after they were treated with NLMP (2.5 mg/kg body weight of mice). In addition, the blood levels of triglyceride (TG), cholesterol (Chol), liver enzymes (aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP)) and total bilirubin were significantly (p ≤ 0.05) decreased. A significant increase (p ≤ 0.05) in the blood levels of the antioxidant defence system (glutathione peroxidase (GPX), superoxide dismutase (SOD) and catalase (CAT)) were also reported after NLMP treatment. NLMP was also led to a significant decrease (p ≤ 0.05) in inflammatory‐related gene expression of inducible nitric oxide synthase (iNOS) and Interferon‐gamma (IFN‐γ) in the liver, as well as a meaningful (p ≤ 0.05) increase in the expression of SOD as an antioxidant status biomarker. Consequently, the NLMP is recommended as a potential dietary supplement to alleviate the symptoms of LA‐induced hepatotoxicity.
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Affiliation(s)
| | - Ehsan Karimi
- Department of Biology, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Ehsan Oskoueian
- Department of Biology, Mashhad Branch, Islamic Azad University, Mashhad, Iran.,Department of Research and Development, Arka Industrial Cluster, Mashhad, Iran
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4
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Defina M, Lazzarotto D, Guolo F, Minetto P, Fracchiolla NS, Giglio F, Forghieri F, Vitale A, Chiaretti S, Papayannidis C, Piccini M, Mulè A, Bocchia M, Leoncin M, Gurrieri C, Aprile L, Lunghi M, Bonifacio M, Pasciolla C, Cerrano M, Fumagalli M, Foà R, Candoni A. Levocarnitine supplementation for asparaginase-induced hepatotoxicity in adult acute lymphoblastic leukemia patients: A multicenter observational study of the campus all group. Leuk Res 2022; 122:106963. [PMID: 36155352 DOI: 10.1016/j.leukres.2022.106963] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Marzia Defina
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy.
| | - Davide Lazzarotto
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata Friuli Centrale (ASUFC), Udine, Italy
| | - Fabio Guolo
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Paola Minetto
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Nicola Stefano Fracchiolla
- Department of Hematology-Oncology and BMT Unit, IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Forghieri
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Antonella Vitale
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Sabina Chiaretti
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Cristina Papayannidis
- Institute of Hematology "L. and A". Seragnoli, University Hospital S. Orsola-Malpighi, Bologna, Italy
| | - Matteo Piccini
- Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Antonino Mulè
- Department of Hematology I, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - Matteo Leoncin
- Hematology Unit, Azienda Ulss3 Serenissima, Ospedale dell'Angelo, Venezia-Mestre, Venice, Italy
| | - Carmela Gurrieri
- Dipartimento Strutturale Aziendale Medicina, University of Padova, Padova, Italy
| | - Lara Aprile
- S.C. Ematologia, Ospedale S.G. Moscati, Taranto, Italy
| | - Monia Lunghi
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | | | | | - Marco Cerrano
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Turin, Turin, Italy
| | | | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Anna Candoni
- Division of Hematology and Bone Marrow Transplantation, Azienda Sanitaria Universitaria Integrata Friuli Centrale (ASUFC), Udine, Italy
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5
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Douer D, Gökbuget N, Stock W, Boissel N. Optimizing use of L-asparaginase–based treatment of adults with acute lymphoblastic leukemia. Blood Rev 2021; 53:100908. [DOI: 10.1016/j.blre.2021.100908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 01/19/2023]
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Schulte R, Hinson A, Huynh V, Breese EH, Pierro J, Rotz S, Mixon BA, McNeer JL, Burke MJ, Orgel E. Levocarnitine for pegaspargase-induced hepatotoxicity in older children and young adults with acute lymphoblastic leukemia. Cancer Med 2021; 10:7551-7560. [PMID: 34528411 PMCID: PMC8559504 DOI: 10.1002/cam4.4281] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 12/19/2022] Open
Abstract
Background Pegaspargase (PEG‐ASP) is an integral component of therapy for acute lymphoblastic leukemia (ALL) but is associated with hepatotoxicity that may delay or limit future therapy. Obese and adolescent and young adult (AYA) patients are at high risk. Levocarnitine has been described as potentially beneficial for the treatment or prevention of PEG‐ASP‐associated hepatotoxicity. Methods We collected data for patients age ≥10 years who received levocarnitine during induction therapy for ALL, compared to a similar patient cohort who did not receive levocarnitine. The primary endpoint was conjugated bilirubin (c.bili) >3 mg/dl. Secondary endpoints were transaminases >10× the upper limit of normal and any Grade ≥3 hepatotoxicity. Results Fifty‐two patients received levocarnitine for prophylaxis (n = 29) or rescue (n = 32) of hepatotoxicity. Compared to 109 patients without levocarnitine, more patients receiving levocarnitine were obese and/or older and had significantly higher values for some hepatotoxicity markers at diagnosis and after PEG‐ASP. Levocarnitine regimens varied widely; no adverse effects of levocarnitine were identified. Obesity and AYA status were associated with an increased risk of conjugated hyperbilirubinemia and severe transaminitis. Multivariable analysis identified a protective effect of levocarnitine on the development of c.bili >3 mg/dl (OR 0.12, p = 0.029). There was no difference between groups in CTCAE Grade ≥3 hepatotoxicity. C.bili >3 mg/dl during induction was associated with lower event‐free survival. Conclusions This real‐world data on levocarnitine supplementation during ALL induction highlights the risk of PEG‐ASP‐associated hepatotoxicity in obese and AYA patients, and hepatotoxicity's potential impact on survival. Levocarnitine supplementation may be protective, but prospective studies are needed to confirm these findings.
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Affiliation(s)
- Rachael Schulte
- Division of Pediatric Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashley Hinson
- Division of Pediatric Hematology and Oncology, Levine Children's Atrium Health, Charlotte, North Carolina, USA
| | - Van Huynh
- Division of Pediatric Oncology, University of California Irvine College of Medicine, CHOC Children's Hospital, Orange, California, USA
| | - Erin H Breese
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joanna Pierro
- Division of Pediatric Hematology/Oncology, NYU Grossman School of Medicine, Perlmutter Cancer Center, Hassenfeld Children's Hospital at NYU Langone Health, New York, New York, USA
| | - Seth Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Benjamin A Mixon
- Department of Pediatrics, University of Tennessee College of Medicine Chattanooga and Children's Hospital at Erlanger, Chattanooga, Tennessee, USA
| | - Jennifer L McNeer
- Section of Pediatric Hematology, Oncology, and Stem Cell Transplant, University of Chicago Comer Children's Hospital, Chicago, Illinois, USA
| | - Michael J Burke
- Division of Pediatric Hematology/Oncology and Blood and Marrow Transplantation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Etan Orgel
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles/University of Southern California, Los Angeles, California, USA
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7
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Schmiegelow K, Rank CU, Stock W, Dworkin E, van der Sluis I. SOHO State of the Art Updates and Next Questions: Management of Asparaginase Toxicity in Adolescents and Young Adults with Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:725-733. [PMID: 34511319 DOI: 10.1016/j.clml.2021.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 01/23/2023]
Abstract
A wider use of L-asparaginase in the treatment of children with acute lymphoblastic leukemia has improved cure rates during recent decades and hence led to introduction of pediatric-inspired treatment protocols for adolescents and young adults. In parallel, a range of burdensome, often severe and occasionally life-threatening toxicities have become frequent, including hypersensitivity, hepatotoxicity, hypertriglyceridemia, thromboembolism, pancreatitis, and osteonecrosis. This often leads to truncation of asparaginase therapy, which at least in the pediatric population has been clearly associated with a higher risk of leukemic relapse. Many of the asparaginase induced toxicities are far more common in older patients, but since their relapse rate is still unsatisfactory, the decision to discontinue asparaginase therapy should balance the risk of toxicity with continued asparaginase therapy against the risk of relapse in the individual patient. The underlying mechanisms of most of the asparaginase induced side effects are still unclear. In this review we address the individual toxicities, known risk factors, and their clinical management.
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Affiliation(s)
- Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet Copenhagen University Hospital, 2100 Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Cecilie Utke Rank
- Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Wendy Stock
- Department of Medicine, University of Chicago Medicine and Comprehensive Cancer Center, Chicago, IL
| | - Emily Dworkin
- Department of Medicine, University of Chicago Medicine and Comprehensive Cancer Center, Chicago, IL
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8
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Comparison of CALGB 10403 (Alliance) and COG AALL0232 toxicity results in young adults with acute lymphoblastic leukemia. Blood Adv 2021; 5:504-512. [PMID: 33496745 DOI: 10.1182/bloodadvances.2020002439] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/30/2020] [Indexed: 11/20/2022] Open
Abstract
Adolescents and young adults (AYAs) with acute lymphoblastic leukemia have improved outcomes when treated with pediatric-inspired regimens. CALGB 10403 was the largest prospective study to evaluate the feasibility of using a pediatric regimen in AYAs with acute lymphoblastic leukemia up to 40 years of age. This article presents the toxicity events observed in the CALGB 10403 study and compares these toxicities vs those observed among AYAs treated on the same arm of the companion Children's Oncology Group (COG) AALL0232 study. Toxicities in CALGB 10403 were similar to those observed in COG AALL0232. Some grade 3 to 4 adverse events were more often reported in CALGB 10403 compared with COG AALL0232 (hyperglycemia, hyperbilirubinemia, transaminase elevation, and febrile neutropenia). Adverse events correlated with body mass index ≥30 kg/m2 and some with increasing age. The mortality rate in CALGB 10403 was low (4%) and similar to that in the COG AALL0232 trial. A caveat to this analysis is that only 39% of CALGB 10403 patients completed all planned protocol treatment. In COG AALL0232, although 74% of patients aged <18 years completed treatment, only 57% of patients aged ≥18 years completed treatment. This scenario suggests that issues associated with age and treating physician may be a factor. Due to its improved survival rates compared with historical controls, the CALGB 10403 regimen is now a standard of care. The hope is that the rate of protocol completion will increase as more familiarity is gained with this regimen. These trials were registered at www.clinicaltrials.gov as #NCT00558519 (CALGB 10403) and #NCT00075725 (COG AALL0232).
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9
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Riley DO, Schlefman JM, Vitzthum Von Eckstaedt V HC, Morris AL, Keng MK, El Chaer F. Pegaspargase in Practice: Minimizing Toxicity, Maximizing Benefit. Curr Hematol Malig Rep 2021; 16:314-324. [PMID: 33978914 DOI: 10.1007/s11899-021-00638-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW The incorporation of pegaspargase in chemotherapy regimens has significantly improved the prognosis of ALL in adults. However, pegaspargase use poses many challenges due to its unique toxicity profile. Here, we review pegaspargase's most clinically significant toxicities, and provide guidance for their prevention and management in order to avoid unnecessary drug discontinuation and achieve maximum clinical benefit. RECENT FINDINGS Clinically significant toxicities of pegaspargase include thrombosis, hypersensitivity and inactivation, hepatotoxicity, pancreatitis, and hypertriglyceridemia. The majority of these toxicities are temporary, nonfatal, and can be managed supportively without permanent pegaspargase discontinuation. Special attention should be paid to inactivation, which can lead to treatment failure, as well as pancreatitis, which necessitates complete cessation of asparaginase therapy. The question of how to best proceed in patients who cannot tolerate pegaspargase remains unanswered, and is an important area of future investigation. Pegaspargase is an essential component of the pediatric-inspired regimens that have improved survival in adult ALL. Although pegaspargase's toxicity profile is unique, it is also highly manageable and should not be a barrier to achieving maximum clinical benefit using this drug.
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Affiliation(s)
- David O Riley
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA
| | - Jenna M Schlefman
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Amy L Morris
- Department of Pharmacy Services, UVA Health, Charlottesville, VA, USA
| | - Michael K Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA.
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10
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Bender C, Maese L, Carter-Febres M, Verma A. Clinical Utility of Pegaspargase in Children, Adolescents and Young Adult Patients with Acute Lymphoblastic Leukemia: A Review. Blood Lymphat Cancer 2021; 11:25-40. [PMID: 33907490 PMCID: PMC8064615 DOI: 10.2147/blctt.s245210] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/12/2021] [Indexed: 01/19/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is a heterogenous hematological malignancy representing 25% of all cancers in children less than 15 years of age. Significant improvements in survival and cure rates have been made over the past four decades in pediatric ALL treatment. Asparaginases, derived from Escherichia coli and Erwinia chrysanthemi, have become a critical component of ALL therapy since the 1960s. Asparaginases cause depletion of serum asparagine, leading to deprivation of this critical amino acid for protein synthesis, and hence limit survival of lymphoblasts. Pegaspargase, a conjugate of monomethoxypolyethylene glycol (mPEG) and L-asparaginase, has become an integral component of pediatric upfront and relapsed ALL protocols due to its longer half-life and improved immunogenicity profile compared to native asparaginase preparations. Over the past two decades great strides have been made in outcomes for pediatric ALL due to risk stratification, incorporation of multiagent chemotherapy protocols, and central nervous system prophylaxis with pegaspargase having played an important role in this success. However, adolescents and young adults (AYA) with ALL when treated on contemporaneous trials using adult ALL regimens, continue to have poor outcomes. There is increasing realization of adapting pediatric trial regimens for treating AYAs, especially those incorporating higher intensity of chemotherapeutic agents with pegaspargase being one such agent. Dose or treatment-limiting toxicity is observed in 25-30% of patients, most notable being hypersensitivity reactions. Other toxicities include asparaginase-associated pancreatitis, thrombosis, liver dysfunction, osteonecrosis, and dyslipidemia. Discontinuation or subtherapeutic levels of asparaginase are associated with inferior disease-free survival leading to higher risk of relapse, and in cases of relapse, a higher risk for remission failure. This article provides an overview of available evidence for use of pegaspargase in pediatric acute lymphoblastic leukemia.
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Affiliation(s)
- Cynthia Bender
- Department of Pharmacy, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Luke Maese
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Maria Carter-Febres
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Anupam Verma
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, UT, USA
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Noroozi B, Hadi A, Shahrami B, Ardabili A, Yoonesi F, Emami K, Sharifnia H, Mojtahedzadeh M. Sepsis-Associated Cholestasis: The Impact of Mitochondrial Dysfunction (A Case Report). ACTA ACUST UNITED AC 2021. [DOI: 10.37319/iqnjm.3.1.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Hyperbilirubinemia – a condition of elevated serum bilirubin above the reference
range, is common in hospitalized patients. The reasons for the increase in the bilirubin level can
be pre-hepatic, hepatic, and post-hepatic. Sepsis is one of the most important causes of
hyperbilirubinemia in critically ill patients.
Case report: We present a 30-year-old woman with no past medical and drug history who was
admitted to the intensive care unit (ICU) due to multiple trauma and fractures due to a fall from
height. During the ICU stay, the patient developed jaundice with a high increase in the bilirubin
level. A diagnosis of sepsis-associated cholestasis was considered after ruling out other possible
pathologies. The hyperbilirubinemia improved with the early management of sepsis concomitant
supportive medical therapy.
Conclusion: Early recognition and treatment of sepsis as a cause of cholestasis should be
considered in ICU patients. Drugs targeting mitochondrial function would provide rapid hepatic
recovery reducing complications and mortality.
Keywords: Cholestasis, Critical illness, Hyperbilirubinemia, Liver failure, Sepsis
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Affiliation(s)
- Behzad Noroozi
- Clinical Pharmacy Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Hadi
- Clinical Pharmacy Department, College of Pharmacy, University of Basra, Basra, Iraq
| | - Bita Shahrami
- Clinical Pharmacy Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Ayda Ardabili
- Anesthesiology and Intensive Care Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Yoonesi
- Anesthesiology and Intensive Care Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Emami
- Anesthesiology and Intensive Care Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Sharifnia
- Anesthesiology and Intensive Care Department, Tehran University of Medical Sciences, Tehran, Iran
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12
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Lussana F, Minetto P, Ferrara F, Chiaretti S, Specchia G, Bassan R. National Italian Delphi panel consensus: which measures are indicated to minimize pegylated-asparaginase associated toxicity during treatment of adult acute lymphoblastic leukemia? BMC Cancer 2020; 20:956. [PMID: 33008391 PMCID: PMC7532578 DOI: 10.1186/s12885-020-07461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND L-asparaginase (L-ASP) is a key component of acute lymphoblastic leukemia (ALL) treatment, but its use in clinical practice raises challenges to clinicians due to a relatively high incidence of drug-related adverse events, mainly in adult patients. In the past years the use of ASP in adult population has been mainly limited due to a poor knowledge of its safety profile and to an approximate management of ASP-related toxicity. Recently the development of pediatric-inspired treatment protocols for adult ALL has led to a wider use of ASP and since 2010 in Italy three national treatment protocols including Pegylated asparaginase (Peg-ASP) have been sequentially developed for adolescents, young adults and adults with Philadelphia-negative (Ph-) ALL. METHODS With the aim to better understand the approach adopted in Italian centers for the management and prevention of Peg-ASP toxicity in adult ALL and to provide practical, consensus-based recommendations, a board of 6 Italian clinicians, with known expertise in adult ALL, designed 41 consensus statements on current challenges on the management of Peg-ASP associated toxicity. A group of 19 clinical experts in the field then rated these statements using the 5-point Likert-type scale (1 = strongly disagree; 5 = strongly agree). RESULTS The main Peg-ASP related issues identified by the board included: 1) clinician's attitudes; 2) toxicity profile; 3) hypersensitivity reactions; 4) hepatic toxicity; 5) hepatic and/or metabolic toxicity; 6) hemorrhagic/thrombotic toxicity; 7) pancreatitis; 8) metabolic toxicity management and prevention; 9) activity levels monitoring. Overall, participants agreed on most statements, except those addressing the potential contraindications to the treatment with Peg-ASP, such as patients with a diagnosis of chronic liver disease or the subsequent administrations of the drug in patients who had previously developed chemical pancreatitis or severe metabolic toxicity. Participants agreed that adult patients with ALL should receive Peg-Asp because this drug is essential to improve treatment results. CONCLUSIONS The panel agreed that a critical evaluation of specific risk factors for each patient is crucial in order to reduce the risk of adverse events and specific advices in the management of Peg-ASP toxicities are reported.
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Affiliation(s)
- Federico Lussana
- Hematology and Bone Marrow Transplant Unit, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo, Italy.
| | - Paola Minetto
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genova, Italy.,IRCCS, Ospedale Policlinico San Martino, Genova, Italy
| | | | - Sabina Chiaretti
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Giorgina Specchia
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology Section, University of Bari, Bari, Italy
| | - Renato Bassan
- Complex Operative Unit of Haematology, dell'Angelo Hospital and Santissimi Giovanni and Paolo Hospital, Mestre and Venice, Italy
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13
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Rank CU, Schmiegelow K. Optimal approach to the treatment of young adults with acute lymphoblastic leukemia in 2020. Semin Hematol 2020; 57:102-114. [PMID: 33256899 DOI: 10.1053/j.seminhematol.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 01/19/2023]
Abstract
Akin to the introduction of tyrosine kinase inhibitors to Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL), pediatric-based asparaginase-heavy approaches have revolutionized the treatment of young adults with the Philadelphia chromosome-negative subset the past decades. Once again, we are approaching a new era. An era of precision medicine with immunotherapy and other molecularly targeted treatments that offers unique opportunities to customize treatment intensity with or without hematopoietic stem cell transplantation, reduce the burden of toxicities, and combat persistent residual disease. Recently approved agents for refractory/relapsed B-cell precursor ALL include the chimeric antigen receptor-modified T-cells, the anti-CD22 monoclonal antibody-drug conjugate, inotuzumab ozogamicin, and the bispecific anti-CD19 T-cell engager, blinatumomab. These agents are expected to move widely into the frontline setting along with the proteasome inhibitors, bortezomib and carfilzomib, as well as tyrosine kinase inhibitors for Philadelphia-like rearrangements that are especially frequent among young adults. To this add the BH3 mimetics, venetoclax and navitoclax, which are being widely explored in refractory/relapsed as well as frontline settings for B- and T-cell ALL. The promising anti-CD38 monoclonal antibody, daratumumab, is entering the scene of refractory/relapsed T-ALL, whereas the old purine analogue, nelarabine, is being evaluated in a new upfront setting. This review focuses on 2 main questions: How do we optimize frontline as well as salvage ALL treatment of young adults in the 2020s? Not least, how do we address the current burden of serious toxicities unique to young adults?
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Affiliation(s)
- Cecilie Utke Rank
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
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14
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Diorio C, Kelly KM, Afungchwi GM, Ladas EJ, Marjerrison S. Nutritional traditional and complementary medicine strategies in pediatric cancer: A narrative review. Pediatr Blood Cancer 2020; 67 Suppl 3:e28324. [PMID: 32614139 DOI: 10.1002/pbc.28324] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/25/2020] [Accepted: 03/22/2020] [Indexed: 12/20/2022]
Abstract
Traditional and complementary medicine (T&CM) strategies are commonly used by pediatric cancer patients. Nutritional approaches to T&CM include bioactive compounds, supplements, and herbs as well as dietary approaches. Pediatric cancer patients and their families commonly request and use nutritional T&CM strategies. We review the potential risks and benefits of nutritional T&CM use in pediatric cancer care and provide an overview of some commonly used and requested supplements, including probiotics, antioxidants, cannabinoids, vitamins, turmeric, mistletoe, Carica papaya, and others. We also discuss the role of specific diets such as the ketogenic diet, caloric restriction diets, whole-food diets, and immune modulating diets. There is a growing body of evidence to support the use of some T&CM agents for the supportive care of children with cancer. However, further study is needed into these agents and approaches. Open communication with families about T&CM use is critical.
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Affiliation(s)
- Caroline Diorio
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kara M Kelly
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | | | - Elena J Ladas
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Medical Center, New York, New York
| | - Stacey Marjerrison
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, Hamilton, Ontario, L8N 3Z5, Canada
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15
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Hashmi SK, Navai SA, Chambers TM, Scheurer ME, Hicks MJ, Rau RE, Gramatges MM. Incidence and predictors of treatment-related conjugated hyperbilirubinemia during early treatment phases for children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2020; 67:e28063. [PMID: 31736183 PMCID: PMC7382403 DOI: 10.1002/pbc.28063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/07/2019] [Accepted: 10/12/2019] [Indexed: 11/12/2022]
Abstract
Conjugated hyperbilirubinemia (CHB) and liver transaminase elevation are known complications of acute lymphoblastic leukemia (ALL) therapy, but host risk factors are poorly understood. Among 373 children diagnosed with ALL between 2011 and 2016, clinically significant CHB and transaminase elevation were observed in 15 (4.0%) and 12 (3.2%) children, respectively, during induction and consolidation. Body mass index ≥95th percentile (odds ratio 9.20, 95% confidence interval 2.56-32.96) was the only host factor independently associated with CHB, and no host factors were associated with transaminase elevation. Obese patients warrant closer monitoring of hepatic function to facilitate early intervention prior to the development of severe, adverse hepatic events.
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Affiliation(s)
- Saman K. Hashmi
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, TX
| | - Shoba A. Navai
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, TX
| | - Tiffany M. Chambers
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, TX
| | - Michael E. Scheurer
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, TX
| | - M. John Hicks
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | - Rachel E. Rau
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, TX
| | - Maria M. Gramatges
- Department of Pediatrics, Section of Hematology and Oncology, Baylor College of Medicine, Houston, TX
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16
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Multiple Severe Toxicities of L-Asparaginase and Their Innovative Management during Induction Therapy of Acute Lymphoblastic Leukemia in an Adult Patient. Case Rep Hematol 2019; 2019:9086570. [PMID: 31827950 PMCID: PMC6886342 DOI: 10.1155/2019/9086570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 11/02/2019] [Indexed: 11/18/2022] Open
Abstract
L-asparaginase is a key chemotherapeutic agent in acute lymphoblastic leukemia (ALL). It is also known for multiple and severe specific toxicities, without consensual management. We report the case of a 51-year-old man treated with L-asparaginase for recently diagnosed T-cell ALL. During the treatment, he developed a coma due to multifactorial diffuse cerebral edema, by hepatic encephalopathy, cerebral venous thrombosis, and hyperammonemia, all linked to toxicity of L-asparaginase. Specific and innovative treatments were employed to manage these toxicities: supplementation with L-carnitine, thiamine, and pyridoxine for hepatic toxicity, perfusion of sodium benzoate to decrease ammonemia, and extrahepatic albumin-based dialysis sessions, along with anticoagulation. The patient improved within two weeks and is currently alive 13 months later, in first complete remission, without sequelae, on an alleviated chemotherapy regimen.
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17
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Natural Killer-Like T-Cell Lymphoma: A Rare Cause of Acute Liver Failure. ACG Case Rep J 2019; 6:e00145. [PMID: 31620542 PMCID: PMC6722367 DOI: 10.14309/crj.0000000000000145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/31/2019] [Indexed: 11/17/2022] Open
Abstract
Acute liver failure is characterized by encephalopathy and disruption of hepatic function, often requiring liver transplantation to prevent fatal consequences. We present a 33-year-old man with recurrent lymphoma presenting with acute liver failure, which was initially thought to be from drug-induced liver injury associated with his chemotherapy medication, asparaginase. However, liver biopsy revealed malignant infiltration by lymphoma. The subtype of lymphoma was natural killer–like T-cell lymphoma, which is an uncommon variant, and has rarely been associated with hepatic infiltration. His condition rapidly worsened with development of multiorgan failure leading to death.
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18
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Ford J, Rainey S, Hanson K, Kendhari H. Acute lymphoblastic leukemia presenting as cholestatic jaundice in a 7-year-old boy. SAGE Open Med Case Rep 2019; 7:2050313X19875318. [PMID: 31523431 PMCID: PMC6728663 DOI: 10.1177/2050313x19875318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/19/2019] [Indexed: 11/16/2022] Open
Abstract
This is a case of a 7-year-old boy with acute lymphoblastic leukemia presenting with cholestasis and elevated transaminase levels. Acute lymphoblastic leukemia is the most common malignancy in children and can have variable presenting clinical manifestations. However, cholestasis is less commonly encountered in the pediatric population and can be a diagnostic challenge. We present a case of a 7-year-old boy discovered to have elevated transaminase levels while undergoing an evaluation for motor tics, which subsequently progressed to cholestasis and acute liver failure secondary to acute lymphoblastic leukemia. He demonstrated marked improvement after induction therapy and is in clinical remission. Clinicians should be ever mindful of the potentially unique presentations of childhood leukemia.
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Affiliation(s)
- Jessica Ford
- OSF Healthcare Children's Hospital of Illinois, Peoria, IL, USA.,Department of Pediatrics, The University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Shane Rainey
- OSF Healthcare Children's Hospital of Illinois, Peoria, IL, USA.,Department of Pediatrics, The University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Keith Hanson
- OSF Healthcare Children's Hospital of Illinois, Peoria, IL, USA.,Department of Pediatrics, The University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Harleena Kendhari
- OSF Healthcare Children's Hospital of Illinois, Peoria, IL, USA.,Department of Pediatrics, The University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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19
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Sea JL, Orgel E, Chen T, Paszkiewicz RL, Krall AS, Oberley MJ, Stiles L, Mittelman SD. Levocarnitine does not impair chemotherapy cytotoxicity against acute lymphoblastic leukemia. Leuk Lymphoma 2019; 61:420-428. [PMID: 31526067 DOI: 10.1080/10428194.2019.1666379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Asparaginase (ASNase) is an integral part of pediatric induction chemotherapy that has also been shown to improve adult survival rates; however, pegylated (PEG)-ASNase induces severe hepatotoxicity in this population. Recent case reports describe the incorporation of levocarnitine (LC) supplementation into PEG-ASNase-containing induction regimens to prevent or treat hepatotoxicity. Because LC facilitates the metabolism of free fatty acids (FFA), a primary fuel source for ALL cells, LC could potentially interfere with ALL chemotherapy efficacy. To test this, we employed in vitro and in vivo models of ALL. We show in vitro that LC supplementation does not impact cytotoxicity from vincristine, daunorubicin, dexamethasone, or ASNase on human ALL cells nor lead to an increase in ALL cell metabolic rate. In vivo, we demonstrate LC does not impair PEG-ASNase monotherapy in mice with syngeneic ALL. Together, our findings show that LC supplementation is a safe strategy to prevent/reverse ASNase-induced toxicities in preclinical models.
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Affiliation(s)
- Jessica L Sea
- Division of Pediatric Endocrinology, UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Etan Orgel
- Division of Hematology, Oncology, Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Department of Pediatrics, University of Southern California, Los Angeles, CA, USA
| | - Ting Chen
- Division of Pediatric Endocrinology, UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Rebecca L Paszkiewicz
- Division of Pediatric Endocrinology, UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Abigail S Krall
- Department of Biological Chemistry and the Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA, USA
| | - Matthew J Oberley
- Department of Pediatrics, University of Southern California, Los Angeles, CA, USA.,Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, Los Angeles, CA, USA
| | - Linsey Stiles
- Division of Endocrinology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Steven D Mittelman
- Division of Pediatric Endocrinology, UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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20
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Liu Y, Janke LJ, Li L, Relling MV. L-carnitine does not ameliorate asparaginase-associated hepatotoxicity in a C57BL6 mouse model. Leuk Lymphoma 2019; 60:2088-2090. [PMID: 30714450 DOI: 10.1080/10428194.2019.1571198] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Yiwei Liu
- a Department of Pharmaceutical Sciences , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Laura J Janke
- b Department of Pathology , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Lie Li
- a Department of Pharmaceutical Sciences , St. Jude Children's Research Hospital , Memphis , TN , USA
| | - Mary V Relling
- a Department of Pharmaceutical Sciences , St. Jude Children's Research Hospital , Memphis , TN , USA
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