Low-dose cytarabine-induced hepatic and renal dysfunction in a patient with myelodysplastic syndrome

Detection of pediatric drug-induced kidney injury signals using a hospital electronic medical record database

Background: Drug-induced kidney injury (DIKI) is one of the most common complications in clinical practice. Detection signals through post-marketing approaches are of great value in preventing DIKI in pediatric patients. This study aimed to propose a quantitative algorithm to detect DIKI signals in children using an electronic health record (EHR) database.

Methods: In this study, 12 years of medical data collected from a constructed data warehouse were analyzed, which contained 575,965 records of inpatients from 1 January 2009 to 31 December 2020. Eligible participants included inpatients aged 28 days to 18 years old. A two-stage procedure was adopted to detect DIKI signals: 1) stage 1: the suspected drugs potentially associated with DIKI were screened by calculating the crude incidence of DIKI events; and 2) stage 2: the associations between suspected drugs and DIKI were identified in the propensity score-matched retrospective cohorts. Unconditional logistic regression was used to analyze the difference in the incidence of DIKI events and to estimate the odds ratio (OR) and 95% confidence interval (CI). Potentially new signals were distinguished from already known associations concerning DIKI by manually reviewing the published literature and drug instructions.

Results: Nine suspected drugs were initially screened from a total of 652 drugs. Six drugs, including diazepam (OR = 1.61, 95%CI: 1.43–1.80), omeprazole (OR = 1.35, 95%CI: 1.17–1.54), ondansetron (OR = 1.49, 95%CI: 1.36–1.63), methotrexate (OR = 1.36, 95%CI: 1.25–1.47), creatine phosphate sodium (OR = 1.13, 95%CI: 1.05–1.22), and cytarabine (OR = 1.17, 95%CI: 1.06–1.28), were demonstrated to be associated with DIKI as positive signals. The remaining three drugs, including vitamin K1 (OR = 1.06, 95%CI: 0.89–1.27), cefamandole (OR = 1.07, 95%CI: 0.94–1.21), and ibuprofen (OR = 1.01, 95%CI: 0.94–1.09), were found not to be associated with DIKI. Of these, creatine phosphate sodium was considered to be a possible new DIKI signal as it had not been reported in both adults and children previously. Moreover, three other drugs, namely, diazepam, omeprazole, and ondansetron, were shown to be new potential signals in pediatrics.

Conclusion: A two-step quantitative procedure to actively explore DIKI signals using real-world data (RWD) was developed. Our findings highlight the potential of EHRs to complement traditional spontaneous reporting systems (SRS) for drug safety signal detection in a pediatric setting.

Acute Hepatotoxicity After High-Dose Cytarabine for the Treatment of Relapsed Acute Myeloid Leukemia: A Case Report

Purpose: Cytarabine is considered the standard of care for induction therapy in patients with acute myeloid leukemia (AML) who are preparing for bone marrow transplant. Summary: We report a case of a 72-year-old female presenting to the intensive care unit with hepatic failure after high-dose cytarabine (HiDAC) for the treatment of relapsed AML. The patient's liver function tests (LFTs) were elevated acutely, with a mildly elevated bilirubin and a normal alkaline phosphatase. HiDAC was discontinued but her LFTs remained high for 9 days post discontinuation, and the patient eventually expired due to sepsis and multiple organ failure. We estimated the probability of the hepatotoxicity observed with HiDAC as probable based on a score of 5 on the Naranjo scale. Conclusion: Clinicians should be aware of the potential hepatotoxicity associated with HiDAC for patients with AML, specifically in the elderly population.

The management of prolonged, isolated hyperbilirubinemia following cytarabine-based chemotherapy for acute myeloid leukaemia

BACKGROUND

Patients diagnosed with Acute Myeloid Leukaemia (AML) often receive cytarabine-based chemotherapy as standard treatment. Cytarabine is usually given in combination with other agents such as idarubicin. Such treatments are known to cause hepatic dysfunction characterized by a combination of jaundice, hyperbilirubinemia and increases in liver enzymes. Isolated hyperbilirubinemia is rarely reported. It is often difficult to identify a causative agent for the hepatic dysfunction, as there are often complicating factors such as sepsis.

AIM

To report a case of isolated hyperbilirubinemia in a patient treated with cytarabine-based chemotherapy for AML.

CLINICAL DETAILS

After a diagnosis of AML the patient was admitted to hospital to receive induction chemotherapy consisting of high-dose cytarabine, idarubicin, and etoposide. All baseline laboratory results were normal, except the full blood evaluation that was consistent with AML. The chemotherapy was delivered over 7 days, and on the eighth day the patient had a bilirubin (BL) level of 27 micromol/L(normal range 522 micromol/L). All other liver function tests (LFT) were normal. This isolated hyperbilirubinemia remained for the rest of the patient's admission, peaking on day 26, with a level of 255 micromol/L. After a stay in the intensive care unit, the patient was discharged on day 45 with a bilirubin level of 33 micromol/L. All other LFT remained unremarkable.

OUTCOME

The isolated hyperbilirubinemia resolved slowly and on day 68, when the patient was re-admitted for further dose-reduced cytarabine, the BL level was 21 micromol/L. The patient was successfully retreated with this lower dose regimen.

CONCLUSION

Isolated hyperbilirubinemia is an uncommon presentation of cytarabine induced liver dysfunction. Resolution does occur but over a prolonged period. A lower dose of cytarabine for future treatment should be considered.

Cancer chemotherapy II: atypical hepatic injuries

Although chemotherapy generally is accompanied by regular testing for liver enzyme abnormalities, atypical reactions may occur that escape ordinary detection, because hepatocyte injury is not the primary event. The presence of fatty liver, mitochondrial changes, and even biliary abnormalities can be associated with normal or nearly normal liver enzyme levels. This article discusses unique aspects of liver damage associated with cancer chemotherapy. These unique reactions merit special attention and a special vigilance from clinicians.

Randomized phase I/II study of troxacitabine combined with cytarabine, idarubicin, or topotecan in patients with refractory myeloid leukemias

PURPOSE

Troxacitabine has significant single-agent activity. This study was conducted to define the dose-limiting toxicities (DLTs) of its combination with cytarabine (ara-C), idarubicin, or topotecan.

PATIENTS AND METHODS

Patients with refractory acute myeloid leukemia (AML), advanced myelodysplastic syndromes (MDS), or chronic myelogenous leukemia in blastic phase (CML-BP) were initially randomly assigned to receive troxacitabine 5.0 mg/m(2) by intravenous (IV) infusion over 30 minutes on days 1 to 5 with ara-C 1.0 g/m(2)/d IV [DOSAGE ERROR CORRECTED] over 2 hours on days 1 to 5, idarubicin 12 mg/m(2) by 5 minute IV infusion on days 1 to 3, or topotecan 1.0 mg/m(2) as an continuous IV infusion on days 1 to 5. Doses were then adjusted to define DLT for each combination.

RESULTS

Eighty-seven patients (68 AML, eight MDS, 11 CML-BP) were treated. DLTs were hepatic transaminitis, hyperbilirubinemia, and hand foot syndrome (HFS) on the troxacitabine plus ara-C combination. The recommended phase II doses were 6 mg/m(2) once a day for 5 days and 1.0g/m(2) once a day for 5 days, respectively. DLTs were diarrhea, rash, and mucositis on the troxacitabine plus topotecan combination. The recommended phase II doses were 4 mg/m(2) once a day for 5 days and 0.75 mg/m(2) once a day for 5 days, respectively. DLTs were HFS, rash, and mucositis on the troxacitabine plus idarubicin combination. The recommended phase II doses were 4 mg/m(2) once a day for 5 days and 9 mg/m(2) once a day for 3 days, respectively. Among 74 evaluable patients with AML or MDS, 10 (13%) achieved complete remission and four (5%) had hematologic improvement. Two of 11 (18%) evaluable patients with CML-BP returned to chronic phase.

CONCLUSION

Troxacitabine-based combinations had significant antileukemic activity.