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Hisada Y. Dysregulated hemostasis in acute promyelocytic leukemia. Int J Hematol 2024; 119:526-531. [PMID: 38341391 DOI: 10.1007/s12185-024-03708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/26/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024]
Abstract
Acute promyelocytic leukemia (APL) is associated with a high incidence of early death, which occurs within 30 days of diagnosis. The major cause of early death in APL is severe bleeding, particularly intracranial bleeding. Although APL is known to be associated with activation of coagulation, hyperfibrinolysis, and thrombocytopenia, the precise mechanisms that cause bleeding have not yet been elucidated. I propose that a combination of four pathways may contribute to bleeding in APL: (1) tissue factor, (2) the urokinase plasminogen activator/urokinase plasminogen activator receptor, (3) the annexin A2/S100A100/tissue plasminogen activator, and (4) the podoplanin/C-type lectin-like receptor 2. A better understanding of these pathways will identify new biomarkers to determine which APL patients are at high risk of bleeding and allow the development of new treatments for APL-associated bleeding.
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Affiliation(s)
- Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, 116 Manning Drive, 8004 Mary Ellen Jones Bldg, Campus Box #7035, Chapel Hill, NC, 27599, USA.
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2
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Prevalence and risk factors of disseminated intravascular coagulation in childhood acute lymphoblastic leukemia. Pediatr Res 2023:10.1038/s41390-023-02475-8. [PMID: 36670158 DOI: 10.1038/s41390-023-02475-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Few studies have examined disseminated intravascular coagulation (DIC) in childhood acute lymphoblastic leukemia (ALL). Our aims were to evaluate the prevalence, risk factors and outcomes of DIC at ALL presentation and during induction chemotherapy. METHODS The medical records of ALL patients aged <15 years were retrospectively reviewed. Logistic regression analysis was used to identify risk factors. The Kaplan-Meier method was used to depict survival. RESULTS Of the 312 patients, 48 (15.4%) and 76 (24.4%) had DIC at presentation and during induction chemotherapy, respectively. Risk factors for DIC at presentation (OR and 95% CI) were antibiotics prior to admission 2.34 (1.17-4.89), white blood cell count ≥100 × 109/L 2.39 (1.04-5.72), platelets <100 × 109/L 5.44 (1.84-23.4) and high National Cancer Institute (NCI) risk 2.68 (1.08-6.62). Risk factors for DIC during induction chemotherapy were antibiotics prior to admission 1.86 (1.07-3.27), high peripheral blasts 1.01 (1.00-1.02) and transaminitis 2.02 (1.18-3.48). Five-year overall survival of patients who had DIC was significantly lower than those who did not (45.0% vs. 74.1%, p <0.001). CONCLUSION Antibiotics prior to admission, hyperleukocytosis, thrombocytopenia and high NCI risk were risk factors of DIC at presentation. Antibiotics prior to admission, high peripheral blasts and transaminitis were risk factors of DIC during induction chemotherapy. IMPACT There are only two studies, both published before 2000, evaluating risk factors of DIC in pediatric ALL patients without reporting outcomes. DIC was associated with lower remission and survival rates in pediatric ALL patients. We identified the risk factors of DIC at presentation as antibiotics prior to admission, hyperleukocytosis, thrombocytopenia and high NCI risk. The risk factors of DIC during induction chemotherapy were antibiotics prior to admission, high peripheral blasts and aspartate transaminitis. Pediatric ALL patients who have the aforementioned risk factors should be closely monitored for DIC secondary to infection, and early treatment with appropriate antimicrobial agents is recommended.
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3
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Wang TF, Makar RS, Antic D, Levy JH, Douketis JD, Connors JM, Carrier M, Zwicker JI. Management of hemostatic complications in acute leukemia: Guidance from the SSC of the ISTH. J Thromb Haemost 2020; 18:3174-3183. [PMID: 33433069 PMCID: PMC7909744 DOI: 10.1111/jth.15074] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/29/2022]
Abstract
Patients with acute leukemia frequently develop thrombocytopenia and hemostatic complications caused by coagulopathy. Coagulopathy complicates the management of these patients and can lead to significant morbidity and mortality. This guidance document aims to review and provide guidance on the management of hemostatic complications in adult patients with acute leukemia, addressing four main issues, including platelet transfusion, disseminated intravascular coagulation, L-asparaginase-related hypofibrinogenemia, and the use of antifibrinolytic agents.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robert S. Makar
- Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Darko Antic
- Clinic for Hematology, Clinical Center Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Jean M. Connors
- Division of Hematology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeffrey I. Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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4
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Yokoyama H, Takahashi N, Katsuoka Y, Inomata M, Ito T, Meguro K, Kameoka Y, Tsumanuma R, Murai K, Noji H, Ishizawa K, Ito S, Onishi Y, Harigae H. Evaluation of the safety and efficacy of recombinant soluble thrombomodulin for patients with disseminated intravascular coagulation associated with acute leukemia: multicenter prospective study by the Tohoku Hematology Forum. Int J Hematol 2017; 105:606-613. [PMID: 28176226 DOI: 10.1007/s12185-017-2190-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 11/28/2022]
Abstract
It has been suggested that use of recombinant soluble thrombomodulin (rTM) is superior to conventional drugs in treatment of disseminated intravascular coagulation (DIC) complicating acute leukemia. However, its safety and efficacy have not been fully examined in prospective studies. Here, we performed a multicenter prospective study to examine outcomes of rTM treatment for DIC in patients with acute leukemia. Of 33 patients registered in this study, 13 had acute myeloid leukemia (AML), three had acute lymphoblastic leukemia (ALL), and 17 had acute promyelocytic leukemia (APL). The cumulative rates of DIC resolution at day 7 and day 35 were 56 and 81% in AML/ALL and 53 and 77% in APL, respectively. The median time from the initiation of rTM to DIC resolution was 4 days in AML/ALL and 6 days in APL patients. Adverse events related to hemorrhage occurred in two AML/ALL patients (13%) and three APL patients (18%). Of these, one AML/ALL patient died with intracranial hemorrhage, and two APL patients died with intracranial hemorrhage and pulmonary hemorrhage. These results suggest that rTM may improve the survival of acute leukemia patients with DIC by inhibiting early death related to hemorrhagic events, as reported previously.
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Affiliation(s)
- Hisayuki Yokoyama
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan.
| | - Naoto Takahashi
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuna Katsuoka
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan
| | - Mitsue Inomata
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan
| | - Toshihiro Ito
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan
| | - Kuniaki Meguro
- Department of Hematology, Sendai Medical Center, National Hospital Organization, 2-8-8, Miyagino, Miyagino-ku, Sendai, 983-8520, Japan
| | - Yoshihiro Kameoka
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Riko Tsumanuma
- Department of Hematology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Kazunori Murai
- Department of Hematology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Hideyoshi Noji
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | - Kenichi Ishizawa
- Department of Hematology and Cell Therapy, Yamagata University Graduate School of Medicine, Yamagata, Japan
| | - Shigeki Ito
- Department of Hematology/Oncology, Iwate Medical University School of Medicine, Morioka, Japan
| | - Yasushi Onishi
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Lou Y, Suo S, Tong H, Qian W, Mai W, Meng H, Yu W, Wei J, Jin J. Hypofibrinogenemia as a clue in the presumptive diagnosis of acute promyelocytic leukemia. Leuk Res 2016; 50:11-16. [DOI: 10.1016/j.leukres.2016.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 08/20/2016] [Accepted: 09/04/2016] [Indexed: 11/27/2022]
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Dixit A, Chatterjee T, Mishra P, Kannan M, Choudhry DR, Mahapatra M, Choudhry VP, Saxena R. Disseminated Intravascular Coagulation in Acute Leukemia at Presentation and During Induction Therapy. Clin Appl Thromb Hemost 2016; 13:292-8. [PMID: 17636191 DOI: 10.1177/1076029607302435] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Between January 2001 and December 2003, 67 patients with acute leukemia were evaluated prospectively for hemostatic abnormality at presentation, of which 43 (64.2%) had acute lymphoblastic leukemia and 24 (35.8%) had acute myelogenous leukemia. At presentation, 27 patients (40.3%) had bleeding manifestations. Thrombocytopenia was present in 57 patients (85%), and 33(49.3%) had some abnormality of global coagulation markers. Disseminated intravascular coagulation was defined by International Society of Thrombosis and Hemostasis criteria. Disseminated intravascular coagulation was more often associated with bleeding manifestations in acute myelogenous leukemia cases than in acute lymphoblastic leukemia cases. Two patients presented disseminated intravascular coagulation on day 7 of chemotherapy, without any bleeding manifestations. Four of 15 evaluated cases who had a bleeding or infection complication after day 7 of induction therapy also had disseminated intravascular coagulation. It is recommended that all patients with leukemia be investigated for disseminated intravascular coagulation at presentation.
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Affiliation(s)
- Ashish Dixit
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
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Disseminated intravascular coagulation at diagnosis is a strong predictor for thrombosis in acute myeloid leukemia. Blood 2016; 128:1854-1861. [PMID: 27354723 DOI: 10.1182/blood-2016-02-701094] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 06/19/2016] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism is a common complication in patients with cancer, but only limited data are available in acute myeloid leukemia (AML). In a prospective study in a cohort of 272 adult patients (aged 18-65) and an independent validation cohort of 132 elderly adults (aged >60) with newly diagnosed AML, we assessed markers of disseminated intravascular coagulation (DIC) (fibrinogen, D-dimer, α-2-antiplasmin, antitrombin, prothrombin time, and platelet count) and the DIC score according the International Society of Thrombosis and Haemostasis and their associations with the occurrence of venous and arterial thrombosis during follow-up. The prevalence of thrombosis was 8.7% (4.7% venous, 4.0% arterial) in the younger adults over a median follow-up of 478 days and 10.4% (4.4% venous, 5.9% arterial) in elderly patients. Most thrombotic events (66%) occurred before the start of the second course of chemotherapy. The calculated DIC score significantly predicted venous and arterial thrombosis with a hazard ratio (HR) for a high DIC score (≥5) of 4.79 (1.71-13.45). These results were confirmed in the validation cohort of elderly patients with AML (HR 11.08 [3.23-38.06]). Among all DIC parameters, D-dimer levels are most predictive for thrombosis with an HR of 12.3 (3.39-42.64) in the first cohort and an HR of 7.82 (1.95-31.38) in validation cohort for a D-dimer >4 mg/L vs ≤4 mg/L. It is concluded that venous and arterial thrombosis may develop in ∼10% of AML patients treated with intensive chemotherapy, which to a large extent can be predicted by the presence of DIC at time of AML diagnosis.
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Takezako N, Sekiguchi N, Nagata A, Homma C, Takezako Y, Noto S, Natori K, Miwa A. Recombinant human thrombomodulin in the treatment of acute myeloid leukemia patients complicated by disseminated intravascular coagulation: retrospective analysis of outcomes between patients treated with heparin and recombinant human thrombomodulin therapy. Thromb Res 2015; 136:20-3. [PMID: 25934464 DOI: 10.1016/j.thromres.2015.03.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 02/23/2015] [Accepted: 03/30/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Recombinant thrombomodulin (rTM) is a promising anticoagulant. Improvements in disseminated intravascular coagulation (DIC) and the amelioration of bleeding complications in DIC patients were reported to be greater with rTM therapy than with unfractionated heparin therapy. However, it remains unknown whether rTM therapy affects the outcomes of patients with acute myeloblastic leukemia (AML). DESIGN AND METHOD We retrospectively analyzed 103 patients with AML and compared outcomes between patients treated with low molecular weight heparin therapy and rTM. The diagnostic criteria for DIC were previously proposed by the Japanese Ministry of Health and Welfare. Comparisons between qualitative variables were carried out using the χ(2) test. Survival probabilities were estimated by the Kaplan-Meier method, and differences in survival distributions were evaluated using the log-rank test. RESULTS Forty-seven patients developed DIC due to chemotherapy or their disease status. Fourteen patients were treated with rTM, while 33 patients were treated with low-molecular-weight heparin (LMWH). The log-rank test revealed that overall survival was significantly worse in the DIC group than in the non-DIC group (P=0.003), and was signfiacntly better in the rTM group than the LMWH group (P=0.016). CONCLUSION rTM was more efficient than LMWH because of the improvements it induced in overall survival.
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Affiliation(s)
- Naoki Takezako
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan; Department of Medical Informatics, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan.
| | - Naohiro Sekiguchi
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan
| | - Akihisa Nagata
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan
| | - Chiho Homma
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan
| | - Yayoi Takezako
- Department of General Internal Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan; Division of Community and Family Medicine, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi-ken, 329-0498, Japan
| | - Satoshi Noto
- Department of Hematology, National Hospital Organization Disaster Medical Center of Japan, 3256 Midori-cho, Tachikawa, Tokyo, 190-0014, Japan
| | - Kazuhiko Natori
- Department of Hematology and Oncology, Toho University Medical Centre, 6-11-1 Oomorinishi, Oota-ku, Tokyo, 143-8541, Japan
| | - Akiyoshi Miwa
- Department of Hematology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655, Japan
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Phelan JT, Broder J, Kouides PA. Near-fatal uterine hemorrhage during induction chemotherapy for acute myeloid leukemia: a case report of bilateral uterine artery embolization. Am J Hematol 2004; 77:151-5. [PMID: 15389826 DOI: 10.1002/ajh.20113] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe transfusion-dependent uterine hemorrhage is a relatively uncommon complication of induction chemotherapy for acute myeloid leukemia (AML). Even less common is the failure of systemic conjugated estrogens in this setting. We report a case of life-threatening uterine hemorrhage in a 38-year-old woman in the setting of transfusion-refractory thrombocytopenia after completing induction chemotherapy for AML. She experienced dramatic breakthrough uterine hemorrhage despite multiple platelet transfusions, conjugated estrogens, recombinant factor VIIa, epsilon-aminocaproic acid, and intracavitary thrombin-soaked gauze tamponade. At the point of near-exsanguination in the setting of hypotension, hematocrit of 14%, and a platelet count of 3,000/microL, she underwent bilateral uterine artery embolization which proved immediately successful. We review the literature and indications for this procedure in the oncologic patient care setting.
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Affiliation(s)
- John T Phelan
- Lipson Cancer Center and Center for Blood Disorders, Rochester General Hospital, Rochester, New York 14625, USA.
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Chojnowski K, Treliński J, Wawrzyniak E, Robak T. The influence of low molecular weight heparin on the intravascular activation of the coagulation system in patients with acute leukemia during induction chemotherapy--report of a prospective randomized study. Leuk Lymphoma 2002; 43:1021-8. [PMID: 12148881 DOI: 10.1080/10428190290022164] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
UNLABELLED Intravascular activation of the coagulation system can already be observed in the majority of patients with acute leukemia (AL) at the time of diagnosis. This activation can be further enhanced by chemotherapy. The study comprised of 46 patients with AL, randomly divided into two groups. Twenty-three patients received prophylactic doses of nadroparin (Fraxiparine). Thrombin-antithrombin complexes (TAT), prothrombin fragment (F1 + 2), D-dimer (DD), plasmin-antiplasmin complexes (PAP) and antithrombin III (AT III) activity were determined in all patients. The tests were performed before treatment, and on the 3rd and 8th days of chemotherapy. The TAT, F1 + 2, DD and PAP concentrations were found to be elevated in 83% of patients already at the time of diagnosis. No significant difference between either groups test results was noted when either tested before treatment or on the third day of therapy. DIC (disseminated intravascular coagulation) syndrome appeared in two patients receiving heparin prophylaxis and in three patients to whom this treatment was not administered. The concentrations of activation markers on the eighth day of chemotherapy were lower than at the beginning of treatment in most of the patients receiving nadroparin. At this time there were no laboratory signs of DIC in any of the patients receiving heparin prophylaxis. IN CONCLUSION although the application of prophylactic doses of nadroparin does not prevent DIC syndrome during first days of chemotherapy, it may limit the intravascular activation of the coagulation system during later chemotherapy.
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Affiliation(s)
- Krzysztof Chojnowski
- Department of Hematology, Institute of Internal Medicine, Medical University of Lódź, Poland.
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Chojnowski K, Wawrzyniak E, Treliński J, Niewiarowska J, Cierniewski C. Assessment of coagulation disorders in patients with acute leukemia before and after cytostatic treatment. Leuk Lymphoma 1999; 36:77-84. [PMID: 10613452 DOI: 10.3109/10428199909145951] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Coagulation disorders are often the reason for fatal bleeding in acute promyelocytic leukemia. Their occurrence as well as pathogenesis and prognostic significance in other subtypes of acute myelogenous leukemia and acute lymphoblastic leukemia is less known. Tests were carried out in 70 patients including 49 with AML and 21 with ALL. In all patients thrombin-antithrombin complexes (TAT), D-dimer (DD) and plasmin-antiplasmin complexes (PAP), antithrombin III activity, fibrinogen/fibrin degradation products, APTT and PT were determined. The tests were performed on diagnosis and after cytostatic treatment. The level of TAT, DD and PAP was elevated in 83% of the patients on diagnosis and in 90% after treatment. The highest values were observed in AML M3 patients. Among leukemic patients with normal levels of TAT, DD and PAP at diagnosis, cytostatic treatment had a negligible effect on the level of these markers. During remission the levels of these markers returned to the normal values while in patients without remission they were either elevated or returned to normal values. No correlation between the levels of activation markers and remission rate was reported. DIC was diagnosed in 13 patients including three after chemotherapy. The DIC was acute or subacute in AML and chronic in ALL patients. In the majority of acute leukemia patients there were already changes on diagnosis indicating coagulation activation. Except for AML M3, these usually had a subclinical course. The TAT, DD and PAP tests are not reliable markers of remission in acute leukemias.
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Affiliation(s)
- K Chojnowski
- Department of Hematology, Institute of Internal Medicine, Medical University of Lodź, Poland
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Madlener K, Pötzsch B. Disseminierte intravasale Gerinnung. Hamostaseologie 1999. [DOI: 10.1007/978-3-662-07673-6_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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