Hemolytic uremic syndrome secondary to the treatment of acute lymphoblastic leukemia

Thrombotic Microangiopathy Due to Progressive Disseminated Histoplasmosis in a Child With Down Syndrome and Acute Lymphoblastic Leukemia

Histoplasmosis, a common mycosis in the south-central United States, may be life threatening in immunocompromised patients. We describe a 4-year-old female with Down syndrome and acute lymphoblastic leukemia who developed hemolytic anemia, thrombocytopenia, and renal failure, consistent with thrombotic microangiopathy. Bone marrow biopsy revealed non-necrotizing granulomas with GMS staining demonstrating budding yeast. Serum Histoplasma antigen testing was positive, providing further evidence for the diagnosis of progressive disseminated histoplasmosis. Treatment with amphotericin B, plasma exchange, and ventilator, vasopressor, and renal replacement support led to a full recovery. Providers should have a low threshold for histoplasmosis testing in ill immunocompromised patients, who are at greater risk for infection-related morbidity.

Rare Presentation of Atypical Hemolytic Uremic Syndrome in a Child With Acute Lymphocytic Leukemia and Pancreatitis

Atypical hemolytic uremic syndrome (aHUS) is associated with significant mortality and morbidity, including acute renal injury, anemia and thrombocytopenia. Rare cases of aHUS in a child with acute leukemia before diagnosis or during chemotherapy have been reported. We report a pediatric case of B-cell acute lymphoblastic leukemia complicated by pancreatitis with concomitant aHUS following induction chemotherapy.

A Limited Course of Eculizumab in a Child with the Atypical Hemolytic Uremic Syndrome and Pre-B Acute Lymphoblastic Leukemia on Maintenance Therapy: Case Report and Literature Review

Acute lymphoblastic leukemia (ALL) is considered a possible risk for the occurrence of thrombotic microangiopathies. We present a girl with pre-B ALL successfully treated according to the BFM ALL IC-2009 protocol on maintenance therapy followed by aHUS occurrence. This is the seventh case of HUS/aHUS on ALL maintenance therapy and the first with clearly documented eculizumab use in the early stage of aHUS/secondary TMA. Standard and additional parameters were used in aHUS monitoring alongside the reticulocyte production index adjusted for age (RPI/A) and the aspartate aminotransferase-to-platelet ratio index (APRI) as markers of hemolysis and rapid response following treatment. RPI/A and APRI are markers of bone marrow response to anemia serving as red blood cell vs. platelet recovery markers. Together they mark the exact recovery point of thrombotic microangiopathy and serve as a prognostic marker of eculizumab treatment success. During the 8-month treatment and 6-month follow-up, no recurrence of hemolysis, ALL relapse, or renal damage were observed. A systematic review of the literature revealed 14/312 articles; five children had aHUS before the onset of ALL, and two children had both diseases concurrently. At least 3/7 patients are attributed to aHUS, of whom 2/7 have renal damage. Potential undiagnosed/unpublished cases may be assumed.

Recurrent Atypical Hemolytic Uremic Syndrome in Children With Acute Lymphoblastic Leukemia Undergoing Maintenance Chemotherapy

Chemotherapy-associated myelosuppression and renal dysfunction is not uncommon during childhood acute lymphoblastic leukemia (ALL) therapy. Here we report 2 cases of atypical hemolytic uremic syndrome (aHUS) presenting with pancytopenia and renal dysfunction that developed during maintenance chemotherapy characterized by hypocomplementemia. Both cases experienced recurrence after resolution of the initial aHUS episode upon resumption of chemotherapy, raising a possible contributory role for chemotherapy in the disease pathogenesis.

Nephrotoxicity of anticancer treatment

Severe adverse systemic drug events occur commonly as a result of treatment of cancer patients. Nephrotoxicity of chemotherapeutic agents remains a significant complication limiting the efficacy of the treatment. A variety of renal disease and electrolyte disorders can result from the drugs that are used to treat malignant disease. The kidneys are a major elimination pathway for many antineoplastic drugs and their metabolites. Tumour lysis syndrome, an emergency in haematooncology, occurs most often after the initiation of cytotoxic therapy in patients with high-grade lymphomas and acute lymphoblastic leukaemia. Chemotherapeutic agents can affect the glomerulus, tubules, interstitium and renal microvasculature, with clinical manifestations that range from asymptomatic elevation of serum creatinine to acute renal failure requiring dialysis. Some factors such as intravascular volume depletion, as well as concomitant use of other drugs or radiographic ionic contrast media, can potentiate or contribute to the nephrotoxicity. Cytotoxic agents can cause nephrotoxicity by a variety of mechanisms. The most nephrotoxic chemotherapeutic drug is cisplatin, which is often associated with acute kidney injury. Many other drugs such as alkylating agents, antimetabolites, vascular endothelial growth factor pathway inhibitors and epidermal growth factor receptor pathway inhibitors may have toxic effects on the kidneys. The aim of this review is to discuss the issue of nephrotoxicity associated with chemotherapy. In routine clinical practice, monitoring of kidney function is mandatory in order to identify nephrotoxicity early, allowing dosage adjustments or withdrawal of the offending drug.

Haemolytic uraemic syndrome in a patient with acute lymphoblastic leukaemia

We describe a patient diagnosed with haemolytic uraemic syndrome (HUS) during long-term maintenance therapy for childhood acute lymphoblastic leukaemia (ALL). He rapidly developed renal failure, hypertension and profound thrombocytopenia. Despite suffering a large intracerebral haemorrhage, he made a full recovery without residual neurological or renal deficit. His case raises the question of whether ALL or its treatments predispose an individual to developing HUS.

Simultaneous occurrence of atypical hemolytic uremic syndrome and acute lymphoblastic leukemia: a case report and literature review

A 3.5-year-old girl with fever had a pancytopenic blood smear that also showed schistocytes and blast cells. Bone marrow examination resulted in a diagnosis of acute lymphoblastic leukemia (ALL). Although creatinine on admission was normal, she had mild hematuria and moderate proteinuria. Chemotherapy was started, but she was initially given only steroids (dexamethasone) due to high liver enzymes. Her renal parameters worsened, and her creatinine doubled. She also developed nephrotic-range proteinuria and hypertension. Renal biopsy showed thrombotic microangiopathy that was clinically consistent with hemolytic uremic syndrome (HUS). Some reports of HUS preceding ALL do exist. However, to the best of our knowledge, this is the first case that describes ALL and HUS presenting simultaneously.

Atypical haemolytic uraemic syndrome as a complication of induction chemotherapy for acute lymphoblastic leukaemia

This report describes a case of fatal haemolytic uraemic syndrome (HUS) developing in a child with acute lymphoblastic leukaemia (ALL) during induction chemotherapy. The aetiology in this case is uncertain but it may have resulted from treatment with L-asparaginase or vincristine. The possibility of HUS during induction chemotherapy for ALL should be considered early on in the treatment regimen, if clinical signs and symptoms suggest this diagnosis, so that appropriate treatment can be instituted.

Acute leukemia: an association with atypical hemolytic uremic syndrome

A 5-year-old boy was admitted for anemia, thrombocytopenia, and azotemia. Bone marrow examination demonstrated only erythroid hyperplasia, and he was diagnosed with an atypical form of hemolytic uremic syndrome (HUS). He was treated with daily prednisolone, and hematological profiles and renal function normalized 1 month later. However, heavy proteinuria persisted, and renal biopsy findings were consistent with HUS. Four months later, pancytopenia developed with recurrence of azotemia, and a second bone marrow examination revealed acute lymphoblastic leukemia (ALL). The remission of proteinuria with no recurrences of HUS after antileukemic treatment suggests that the HUS was associated with the ALL.