Metabolic disorders in acute myeloid leukaemia

Severe electrolyte derangements from lysozymuria in acute myeloid leukemia

Renal dysfunction in patients with acute myeloid leukemia (AML) can be multifactorial. We present the case of a 72-year-old male with relapsed myelomonocytic AML who presented with transient acute kidney injury (AKI) and severe persistent electrolyte derangements. In the setting of nephrotic-range proteinuria and electrolyte wasting without significant albuminuria or glucosuria, a diagnosis of lysozymuria was made. Lysozymuria is a rare paraneoplastic complication of AML and chronic myelomonocytic leukemia characterized by lysozyme. This represents the first case of lysozymuria presenting primarily with refractory electrolyte derangements rather than severe AKI. Lysozymuria portends a poor clinical prognosis even with aggressive management.

Electrolyte and acid-base disorders in cancer patients and its impact on clinical outcomes: evidence from a real-world study in China

Background: This study aims to delineate the incidence of electrolyte and acid-base disorders (EAD) in cancer patients, to figure out the risk factors of EAD, then to assess the impact of EAD on patients' in-hospital clinical outcomes.Methods: Patients with the diagnosis of malignancies hospitalized during 1 October 2014 and 30 September 2015 were recruited in Zhongshan Hospital, Fudan University in Shanghai of China. Demographic characteristics, comorbidities, and clinical data, including survival, length of stay and hospital cost, were extracted from the electronic medical record system. Electrolyte and acid-base data were acquired from the hospital laboratory database.Results: Of 25,881 cancer patients with electrolyte data, 15,000 (58.0%) cases had at least one electrolyte and acid-base abnormity. Hypocalcemia (27.8%) was the most common electrolyte disorder, followed by hypophosphatemia (26.7%), hypochloremia (24.5%) and hyponatremia (22.5%). The incidence of simple metabolic acidosis (MAC) and metabolic alkalosis (MAL) was 12.8% and 22.1% respectively. Patients with mixed metabolic acid-base disorders (MAC + MAL) accounted for 30.2%. Lower BMI score, preexisting hypertension and diabetes, renal dysfunction, receiving surgery/chemotherapy, anemia and hypoalbuminemia were screened out as the major risk factors of EAD. In-hospital mortality in patients with EAD was 2.1% as compared to those with normal electrolytes (0.3%). The risk of death significantly increased among patients with severe EAD. Similarly, the length of stay and hospital cost also tripled as the number and grade of EAD increased.Conclusion: EAD is commonly encountered in cancer patients and associated with an ominous prognosis. Patients with comorbidities, renal/liver dysfunction, and anti-tumor therapy have a higher risk of EAD. Regular monitoring of electrolytes, optimum regimen for intravenous infusion, timely correction of modifiable factors and appropriate management of EAD should not be neglected during anti-tumor treatment.

Acute kidney injury in the patient with cancer

Dramatic advances in the care of patients with cancer have led to significant improvement in outcomes and survival. However, renal manifestations of the underlying cancer as well as the effects of anti-neoplastic therapies leave patients with significant morbidity and chronic kidney disease risks. The most common renal manifestations associated with cancer include acute kidney injury (AKI) in the setting of multiple myeloma, tumor lysis syndrome, post-hematopoietic stem cell therapy, and AKI associated with chemotherapy. Knowledge of specific risk factors, modification of risk and careful attention to rapid AKI diagnosis are critical for improving outcomes.

Acute kidney injury and electrolyte disorders in the critically ill patient with cancer

PURPOSE OF REVIEW

Patients with cancer increasingly make up a significant proportion of patients receiving care in the intensive care unit (ICU). Acute kidney injury and cancer-associated electrolyte disorders are encountered in many of these patients and can significantly impact both short-term and long-term outcomes.

RECENT FINDINGS

Advances in chemotherapeutic regimens as well as in our understanding of cancer-associated kidney disease highlight the need for specialized knowledge of the unique causes and therapies required in this subset of critically ill patients. This is especially the case as targeted cancer therapies may have off-target effects that need to be recognized in a timely manner.

SUMMARY

This review outlines key knowledge areas for critical care physicians and nephrologists caring for patients with cancer and associated kidney issues such as acute kidney injury and electrolyte disorders. Specifically, understanding kidney-specific effects of new chemotherapeutic approaches is outlined, and provides an up-to-date compendium of these effects.

Kidney involvement in leukemia and lymphoma

Leukemia and lymphoma are hematologic malignancies that can affect any age group. Disease can be aggressive or indolent, often with multiorgan system involvement. Kidney involvement in leukemia and lymphoma can be quite extensive. Acute kidney injury (AKI) is quite prevalent in these patients, with prerenal and acute tubular necrosis being the most common etiologies. However other prerenal, intrinsic, and obstructive etiologies are possible. AKI can be a direct effect of the malignancy, a complication of the malignancy, or the consequence or side effect of chemotherapy. Nephrotic syndrome and glomerulonephritis, often presenting without overt kidney failure, have also been seen in all forms of leukemia and lymphoma. Lastly, the direct effects of the malignancy and complications from the tumor often result in numerous electrolyte disturbances and acid-base disorders, with life-threatening consequences if left untreated.

Electrolyte disturbances and acute kidney injury in patients with cancer

The interrelation between kidney disease and cancer is complex and reciprocal. Among the most frequent cancer-associated kidney diseases are the electrolyte and acid-base disturbances, which occur frequently and often are associated with an ominous prognosis, and acute kidney injury. Tumor lysis syndrome is a potentially life-threatening condition that frequently occurs in patients with a high tumor burden and high cellular turnover after cytotoxic therapy (including steroids in steroid-sensitive hematologic malignancies). Electrolyte and acid-base disturbances are the consequence of neoplastic spread, anticancer treatment, or, more rarely, paraneoplastic phenomena of all types of tumors. This article reviews hyponatremia and hypernatremia, hypokalemia and hyperkalemia, hypomagnesemia, hypercalcemia and hypocalcemia, hypophosphatemia, and the most important disturbances in acid-base balance in cancer patients. Acute kidney injury (AKI) is a frequent occurrence in cancer patients and has the potential to substantially alter the outcome of patients with cancer and jeopardize their chances of receiving optimal cancer treatment and a potential cure. As in many other circumstances, the etiology of AKI in cancer patients is multifactorial. Initiation and/or continuation of dialysis in the AKI cancer patient should be based on the general clinical condition and overall life expectancy and the personal patient expectations on quality of life after eventual recovery.

Alterations in electrolyte equilibrium in patients with acute leukemia

BACKGROUND AND AIM

A wide array of disturbances in electrolyte equilibrium is commonly seen in patients with acute leukemia (AL). These abnormalities present a potential hazard in these patients, as that of enhancing the cardiotoxic effects of certain chemotherapeutic regimens. The literature dealing with AL-related electrolyte abnormalities and their interactions in leukemic patients was reviewed.

DATA SYNTHESIS

Sources included MEDLINE and EMBASE. The search strategy was based on the combination of 'acute leukemia', 'electrolyte abnormalities', 'acid-base disorders', 'potassium', 'sodium', 'magnesium', 'calcium', and 'phosphorus'. References of retrieved articles were also screened. A decrease in serum potassium, mainly owing to lysozyme-induced tubular damage, appears to be one of the most frequent and potentially hazardous abnormalities. Other clinically significant metabolic perturbations include hyponatremia and hypercalcemia.

CONCLUSION

A broad spectrum of electrolyte abnormalities is encountered in the clinical setting of AL, which are related to the disease process per se and/or to the therapeutic interventions. Clinicians should be vigilant for early detection and appropriate management of these disorders before the initiation of chemotherapy regimens as well as during treatment.

Acid-base and electrolyte abnormalities in patients with acute leukemia

Disturbances of acid-base balance and electrolyte abnormalities are commonly seen in patients with acute leukemia. Our study aimed at illuminating the probable pathogenetic mechanisms responsible for these disturbances in patients with acute leukemia admitted to our hospital. We studied 66 patients (24 men and 44 women) aged between 17 and 87 years old on their admission and prior to any therapeutic intervention. Patients with diabetes mellitus, acute or chronic renal failure, hepatic failure, patients receiving drugs that influence acid-base status and electrolyte parameters during the last month, such as corticosteroids, cisplatin, diuretics, antacids, aminoglycosides, amphotericin, penicillin, and K(+), PO(4)(3-), or Mg(2+) supplements were excluded. Forty-one patients had at least one acid-base or electrolyte disturbance. There were no significant differences in the incidence of acid-base balance and electrolyte abnormalities between patients with acute myeloid leukemia (AML) and patients with acute lymphoblastic leukemia (ALL). The most frequent electrolyte abnormality was hypokalemia, observed in 41 patients (63%), namely in 34 patients with AML, and 7 with ALL; the main underlying pathophysiologic mechanism was inappropriate kaliuresis. Furthermore, hypokalemic patients more frequently experienced concurrent electrolyte disturbances (i.e., hyponatremia, hypocalcemia, hypophosphatemia, and hypomagnesemia), as well as various acid-base abnormalities compared to normokalemic patients. Hypokalemia in patients with acute leukemia may serve as an indicator of multiple concurrent, interrelated electrolyte disturbances, especially in patients with AML.

Life threatening hypophosphataemia in a patient with Philadelphia chromosome-positive chronic myelogenous leukaemia in acute blastic crisis

Life-threatening hypophosphataemia developed in a 47 year old woman with blastic crisis of chronic myelogenous leukaemia. The patient's hospitalization was characterized by reciprocal relationship between her white cell count and the serum phosphorus levels. The patient did not demonstrate any of the usual causes of profound hypophosphataemia. The postulated mechanism of this patient's hypophosphataemia is uptake by the rapidly dividing leukaemic cells. To the best of our knowledge this is the first case in the English literature of hypophosphataemia associated with blast crisis of Philadelphia chromosome-positive chronic myelogenous leukaemia.

Hypocalcaemia in autoimmune haemolytic anaemia and pernicious anaemia

A 71 year old woman presented with hypocalcaemia in association with autoimmune haemolytic anaemia and pernicious anaemia. The hypocalcaemia resolved only when the haemolytic anaemia and pernicious anaemia were successfully treated. The possible pathogenic mechanisms are discussed.

The use and significance of biologic markers in the evaluation and staging of a child with cancer

Cellular and humoral markers of malignancy play several roles at many levels in the evaluation and staging of children with cancer. Cytogenetic analysis of constitutional cells can be used to determine the genetic risk of developing certain cancers, such as retinoblastoma and Wilms' tumor in high-risk families. Urinary metabolites of neuroblastoma have been studied not only for accurate diagnostic ability in children with "small round cell" tumors, but as a screen for the presence of the tumor in large normal populations. Markers are valuable as prognostic factors at the time of cancer diagnosis; for example, the use of cell surface antigens and cytogenetics in leukemia phenotyping, leading to alterations in initial therapy. Once found at diagnosis, both specific and nonspecific markers can then be utilized to follow the regression and recurrence of a malignancy, such as serum ferritin in neuroblastoma or lactate dehydrogenase in non-Hodgkin's lymphoma. Presence of cell surface antigens to which monoclonal antibodies can be directed are becoming increasingly helpful in both tumor localization, such as in radioisotope scanning, and in therapeutic intervention, such as in purging autologous bone marrow of malignant cells prior to use as a rescue after massive cytoreduction. Finally, cellular markers have lead to a better understanding of the basic biology of particular neoplasms; for example, gene rearrangements in lymphoma, which will ultimately lead to better diagnostic and therapeutic ability.

Acute nonlymphocytic leukemia with eosinophilic differentiation

Four cases of de novo acute nonlymphocytic leukemia (ANLL) with early eosinophilic differentiation are described. The clinical course did not differ from that of the usual forms of ANLL. Morphologic and cytochemical features that can support this diagnosis are discussed. Particularly, the cyanide-resistant peroxidase stain appeared to be a specific marker of eosinophilic differentiation. Acute eosinophilic leukemia is a distinct entity, and this unusual subtype of ANLL can be set apart from other forms of ANLL characterized by hypereosinophilia.

Oncologic emergencies I. Metabolic and space-occupying consequences of cancer and cancer treatment

Proper management of the consequences of cancer and cancer treatment is necessary to give affected children the increased chances of survival that recent therapeutic advances offer them. This article discusses the pathophysiology, diagnosis, and management of those metabolic and space-occupying consequences that are likely to face the primary care physician.

Isolation of a sodium transport inhibitory factor, inhibitin, from cultured leukemic promyelocytes

Previous studies have shown that leukemic blood contains a factor that has an inhibitory effect on bidirectional sodium transport in erythrocytes. This study was designed to isolate this factor from cultured leukemic promyelocytes. An extract from the promyelocytes reduced significantly (P less than 0.001) the ouabain-insensitive sodium efflux rate, from 0.096 +/- 0.009 to 0.056 +/- 0.003 SD. Using the inhibition of ouabain-insensitive sodium transport in erythrocytes as an assay to identify the factor, we ran the crude promyelocyte extract through Sephadex G-25 and G-10, with an intermediate ion-exchange step on DE-32, and finally subjected the active fraction to reverse-phase high-performance liquid chromatography. The specific inhibitory activity of the final fraction was 180-fold higher than that of the crude promyelocyte extract. The inhibitory activity could be destroyed by acid hydrolysis and by enzymatic digestion with several proteases but not by heating at 80 degrees C for 30 min; these characteristics suggest that the active factor, called inhibitin, is a peptide. Inhibitin is released by immature myeloid cells but not by differentiated white cells or by leukemic lymphocytes. It has no effect on potassium influx but inhibits sodium/sodium exchange in erythrocytes.

Leukemic cell lysis pneumonopathy. A complication of treated myeloblastic leukemia

The course of acute noninfectious pulmonary infiltrates in five patients with myeloblastic leukemia was evaluated. All had circulating blast cells (range, 245-192,000/mm3) and recently had received chemotherapeutic drugs for their leukemia. Within four days of the nadir of their leukocyte counts, a patchy, often multilobar pneumonitis developed. Cultures for bacteria, fungi, and viruses were all negative, and no clinical response was observed to broad-spectrum antibiotics. On lung biopsy, pathologic changes were characterized by diffuse alveolar damage with degenerating blast cells in the interstitium and in organizing alveolar exudates. No potential pathogenic organisms were seen on light or electron microscopy of the biopsy samples. In each case the pulmonary infiltrate resolved without specific therapy. We postulate that lysis of leukemic cells, with subsequent release of their enzyme contents, led to the diffuse alveolar damage observed pathologically. Leukemic cell lysis pneumonopathy may be one of the potential causes of pulmonary infiltrates in leukemic patients and can be distinguished pathologically by its distinctive pattern.

Hypoparathyroidism and hypocalcaemia during treatment for acute leukaemia

Nine patients with acute leukaemia developed a complex syndrome of hypocalcaemia and hypomagnesaemia during treatment. These metabolic abnormalities developed rapidly in some patients and gave rise to acute symptoms. Immunoreactive parathormone concentrations in these patients were found to be either absolutely or inappropriately low. Hypomagnesaemia and the action of chemotherapeutic agents, especially adriamycin or cytarabine, or both may have contributed to the pathogenesis of this syndrome.

Lysozyme and hypokalaemia

Serum potassium, lysozyme and urinary lysozyme measurements were made in 98 patients with tuberculosis, 18 with sarcoidosis and 30 with acute myeloid leukaemia. Serum K concentration fell below 3·5 mmol/l in 17 of the 30 leukaemic patients and only 7 of these had raised serum lysozyme concentrations. None of the patients in the tuberculosis-sarcoidosis group with lysozymaemia or lysozymuria developed hypokalaemia. This study suggests that raised lysozyme concentrations are not causally related to hypokalaemia.

Acute nonlymphocytic leukemia

The discovery of cytosine arabinoside, and then the anthrocycline antibiotics, 6-thioguanine, vincristine, cyclophosphamide, and other drugs, has added to the armamentarium of known effective agents. The use of combination chemotherapy, the recognition of the need during induction for virtual marrow aplasia to obtain a remission, and recognition of the predilection of the disease for the central nervous system requiring prophylaxis constitute major advances. The impediment to long-term survival is the lack of effective maintenance therapy.