Disseminated intravascular coagulation in adult acute lymphoblastic leukemia: frequent complications with fibrinogen levels less than 100 mg/dl

Simplified predictive scores for thrombosis and bleeding complications in newly diagnosed acute leukemia patients

BACKGROUND

Bleeding and thrombotic complications are the leading causes of death in acute leukemia patients. The Conventional International Society of Thrombosis and Haemostasis Disseminated Intravascular Coagulation (ISTH DIC) scoring system is utilized to assess DIC diagnoses in various conditions. Nevertheless, limited studies have tested the system's accuracy in predicting thrombo-hemorrhagic events in individuals with acute leukemia. This study aimed to (1) validate the ISTH DIC scoring system and (2) propose a new Siriraj Acute Myeloid/Lymphoblastic Leukemia (SiAML) bleeding and thrombosis scoring system for thrombohemorrhagic risk assessment in acute leukemia.

METHODS

We conducted a retro-prospective observational study of newly diagnosed acute leukemia patients between March 2014 and December 2019. We recorded thrombohemorrhagic episodes within 30 days postdiagnosis and DIC profiles, including prothrombin time, platelet level, D-dimer, and fibrinogen. The sensitivities, specificities, positive and negative predictive values, and areas under receiver operating characteristic curves for the ISTH DIC and SiAML scoring systems were calculated.

RESULTS

In all, 261 acute leukemia patients were identified: 64% with acute myeloid leukemia, 27% with acute lymphoblastic leukemia, and 9% with acute promyelocytic leukemia. Overall bleeding and thrombotic events were 16.8% and 6.1%, respectively. With a cutoff of 5 for the ISTH DIC score, the sensitivity and specificity for bleeding prediction were 43.5% and 74.4%, respectively, while the corresponding values for thrombotic prediction were 37.5% and 71.8%, respectively. D-dimer > 5000 µg FEU/L and fibrinogen ≤ 150 mg/dL were significantly associated with bleeding. A SiAML-bleeding score was calculated using these factors, with a sensitivity and specificity of 65.2% and 65.6%, respectively. Conversely, D-dimer > 7000 µg FEU/L, platelet > 40 × 10⁹/L, and white blood cell level > 15 × 10⁹/L were significant variables related to thrombosis. Using these variables, we established a SiAML-thrombosis score with a sensitivity and specificity of 93.8% and 66.1%, respectively.

CONCLUSIONS

The proposed SiAML scoring system might be valuable for prognosticating individuals at risk for bleeding and thrombotic complications. Prospective validation studies are needed to verify its usefulness.

Prevalence and risk factors of disseminated intravascular coagulation in childhood acute lymphoblastic leukemia

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.

Prediction of life-threatening and disabling bleeding in patients with AML receiving intensive induction chemotherapy

Bleeding in patients with acute myeloid leukemia (AML) receiving intensive induction chemotherapy is multifactorial and contributes to early death. We sought to define the incidence and risk factors of grade 4 bleeding to support strategies for risk mitigation. Bleeding events were retrospectively assessed between day-14 and day +60 of induction treatment according to the World Health Organization (WHO) bleeding assessment scale, which includes grade 4 bleeding as fatal, life-threatening, retinal with visual impairment, or involving the central nervous system. Predictors were considered pretreatment or prior to grade 4 bleeding. Using multivariable competing-risk regression analysis with grade 4 bleeding as the primary outcome, we identified risk factors in the development cohort (n = 341), which were tested in an independent cohort (n = 143). Grade 4 bleeding occurred in 5.9% and 9.8% of patients in the development and validation cohort, respectively. Risk factors that were independently associated with grade 4 bleeding included baseline platelet count ≤40 × 109/L compared with >40 × 109/L, and baseline international normalized ratio of prothrombin time (PT-INR) >1.5 or 1.3 > 1.5 compared with ≤1.3. These variables were allocated points, which allowed for stratification of patients with low- and high-risk for grade 4 bleeding. Cumulative incidence of grade 4 bleeding at day+60 was significantly higher among patients with high- vs low-risk (development: 31 ± 7% vs 2 ± 1%; P < .001; validation: 25 ± 9% vs 7 ± 2%; P = .008). In both cohorts, high bleeding risk was associated with disseminated intravascular coagulation (DIC) and proliferative disease. We developed and validated a simple risk model for grade 4 bleeding, which enables the development of rational risk mitigation strategies to improve early mortality of intensive induction treatment.

In BCR-ABL1 Positive B-Cell Acute Lymphoblastic Leukemia, Steroid Therapy Induces Hypofibrinogenemia

Hypofibrinogenemia (HF) in adult acute lymphoblastic leukemia (ALL) of B lineage is uncommon and mostly associated with asparaginase (ASP) delivery. Since we noticed a significant reduction in fibrinogen (FBG) plasma levels even before the first ASP dose, we aim to assess the levels of FBG during induction treatment and explore if the FBG fall correlated with therapies other than asparaginase and/or specific leukemia biological features. We retrospectively analyzed FBG levels in 115 patients with B-ALL. In 74 (64%) out of 115 patients FBG decline occurred during the steroid prephase. In univariate analysis, such a steroid-related HF was significantly associated with BCR-ABL1 rearrangement (p = 0.00158). None of those experiencing HF had significant modifications of liver function tests during induction treatment. Our retrospective study suggests that in B-ALL, steroid therapy can also induce HF and that such an event is preferentially observed in patients carrying BCR-ABL1 rearrangements. The pathogenesis of this phenomenon is still unclear. We attempt to explain it by applying the International Society of Thrombosis and Hemostasis-Disseminated Intravascular Coagulation score (ISTH-DIC score); nonetheless additional studies are needed to clarify further the mechanisms of HF in this subset of patients.

Clinical Features of Disseminated Intravascular Coagulation According to the French-American-British Classification in Patients With Acute Leukemia and Thrombomodulin Alfa Treatment-A Cohort Study Using a Postmarketing Surveillance Database

The aims of this study were to analyze the clinical features of a large number of cases with disseminated intravascular coagulation (DIC) associated with acute leukemia and to assess the safety and efficacy of thrombomodulin alfa (TM-α) using the French-American-British (FAB) classification of hematological malignancies. We retrospectively examined 644 patients with acute leukemia in postmarketing surveillance for TM-α. M3, M2, M4, M1, and M5 subtypes of acute myeloid leukemia (AML) and L2 and L1 subtypes of acute lymphoblastic leukemia (ALL) have been found more frequently among patients with DIC. Bleeding symptoms at baseline were more frequent in M3 and M7 subtypes. Fibrinogen concentrations were lower, and plasmin-plasmin inhibitor complex values were higher in M3 and Philadelphia-positive (Ph+) ALL. Overall DIC resolution rate was 60.2%, higher in L1 and Ph+ ALL, lower in M1, and generally higher in ALL than in AML. Overall survival rate was generally high, at 79.8%, with higher rates in L3, Ph+ ALL, and M3. Regardless of FAB subgroup, TM-α showed improved bleeding symptoms and DIC scores in clinical practice for DIC patients with acute leukemia.

Management of hemostatic complications in acute leukemia: Guidance from the SSC of the ISTH

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.

Acquired Hypofibrinogenemia Before Asparaginase Exposure During Induction Therapy for Pediatric Acute Lymphoblastic Leukemia: A Report of 2 Cases and Review of the Literature

Coagulopathy in pediatric leukemia patients is typically associated with acute promyelocytic leukemia or after asparaginase use in acute lymphoblastic leukemia. Rarely seen in acute lymphoblastic leukemia, we report 2 patients who presented with normal coagulation markers, but subsequently developed severe hypofibrinogenemia and bleeding in induction before administration of asparaginase. In both cases, cryoprecipitate was administered as initial treatment for bleeding associated with the hypofibrinogenemia. One patient was refractory to cryoprecipitate replacement and required treatment with human fibrinogen concentrate due to the persistence of hypofibrinogenemia with significant bleeding. The hypofibrinogenemia was transient in both cases and resolved within a few weeks.

A Revised Fibrinogen Cutoff Value in the Chinese Disseminated Intravascular Coagulation Scoring System May Provide a Better Prognostic Value for Hematological Malignancies

To retrospectively validate the prognostic value of the latest Chinese disseminated intravascular coagulation (DIC) scoring system (CDSS) in hematological malignancies, 260 patients with confirmed hematological malignancies and suspected DIC in West China Hospital between 2011 and 2015 were included in this study. We evaluated via univariate and multivariate analyses the diagnostic biomarkers, and the cutoff levels used in the CDSS, except those for fibrinogen, were found to be valid. In subgroup analyses, the value of fibrinogen was found to be mainly unfit for the acute promyelocytic leukemia group. Forty-six patients (17.7%) had elevated fibrinogen levels (>4 g/L) and tended to have a poor prognosis, and thus we redetermined the cutoff value of fibrinogen (<1 g/L or >4 g/L was defined as abnormal). As a result, all of the markers used in the CDSS had prognostic value (including for the promyelocytic leukemia group); meanwhile, this modification also resulted in a larger area under the receiver operating characteristic curve compared to the CDSS and the International Society on Thrombosis and Haemostasis score. We believe that, with regard to prognosis prediction, this cutoff value modification for fibrinogen is preferable for DIC patients with a tendency toward severe hypofibrinogenemia. However, a multicenter, prospective study is needed to validate this possibility.

Disseminated intravascular coagulation at diagnosis is a strong predictor for thrombosis in acute myeloid leukemia

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.

Prediction model for mortality after intracranial hemorrhage in patients with leukemia

Intracranial hemorrhage (ICH) is associated with great morbidity and mortality in patients with acute leukemia. We identified 118 patients with ICH from a total of 2,421 patient with leukemia who were treated at our institution between 2005-2009, and assessed the prognostic factors for mortality in the ICH cohort. Median age at time of ICH was 58 years, 49% were male, and 60% had acute myeloid leukemia. The relative incidence of ICH was highest in patients with chronic myeloid leukemia in blast crisis (12.1%). Mental status changes were the most common symptom which prompted work-up for ICH. Median survival for all patients after onset of ICH was 20 days. In multivariate analyses, four clinical characteristics were identified as independent adverse factors for mortality in patients with ICH: albumin <3.5 g/dL, lactate dehydrogenase (LDH) >835 U/L, age > 60 years, and relapsed disease status. Based on the number of risk factors, mortality after ICH was: 25% (0 risk factor), 47% (1), 78% (2), and >97% (3 or 4). In conclusion, patients with leukemia who develop ICH do not have universally poor outcomes, and a simple scoring system could serve to advise physicians and families of the prognosis and the potential benefit of aggressive treatment options.

Utility of the fibrinogen/C-reactive protein ratio for the diagnosis of disseminated intravascular coagulation

Although the presence of decreased plasma fibrinogen has been regarded as an indicator of ongoing disseminated intravascular coagulation (DIC), fibrinogen, which is one of the acute phase reactants, is often increased in the patients with DIC. We investigated the diagnostic and prognostic utility of a new parameter [the fibrinogen/C-reactive protein (CRP) ratio] for predicting DIC in 1,056 patients with suspected DIC and who also had underlying disorders associated with DIC. Among the 535 patients with overt DIC, 46 patients (8.6%) showed low plasma fibrinogen (<100 mg/dl), suggesting that the plasma fibrinogen level is not a sensitive marker for DIC. There was a strong correlation between the increased DIC scores and increased number of patients with low (<104) fibrinogen/CRP ratios. Among the three groups with different serum fibrinogen/fibrin degradation product levels, the fibrinogen/CRP ratio showed a higher difference than did the fibrinogen level. The DIC score was highly correlated with the 28-day mortality and the number of patients with low fibrinogen/CRP ratios. The odds ratio (the relative risk of 28-day mortality) of the low fibrinogen/CRP ratio was 6.15, while the odds ratio of the low fibrinogen level was 2.13. The area under the receiver-operating characteristic curve of the fibrinogen/CRP ratio, when this was used for predicting mortality, showed significantly better discriminative power than did that of the fibrinogen level. This study demonstrates that the fibrinogen/CRP ratio may provide more discriminating power for identifying the patients with active coagulation consumption, and the fibrinogen/CRP ratio has a good predictive value concerning the 28-day mortality in the patients suspected of having DIC. The results of our study suggest that replacement of fibrinogen by the fibrinogen/CRP ratio for calculating the DIC score may lead to enhance diagnostic and prognostic power for DIC.

Risk score model for fatal intracranial hemorrhage in acute leukemia

To build a risk score (RS) model of fatal intracranial hemorrhage (FICH) in patients with acute leukemia, we retrospectively assessed risk factors in 792 patients newly diagnosed with acute leukemia, 41 of whom had analyzable FICH. We found that female gender (relative risk (RR) = 5.234, P<0.001), acute promyelocytic leukemia (RR = 4.057, P = 0.003), leukocytosis (RR = 3.301, P = 0.004), thrombocytopenia (RR = 3.283, P = 0.005) and prolonged prothrombin time (RR = 3.291, P = 0.016) were significantly associated with occurrence of FICH in multivariate analysis. To calculate RS for FICH, one point was assigned for each risk factor, making the RS between 0 and 5. The RS model segregated patients into three prognostic groups: a low-risk group (LRG) for RS of 0 or 1; an intermediate-risk group (IRG) for RS of 2 or 3; and a high-risk group (HRG) for RS of 4 or 5. Expectation of FICH was well correlated with risk groups (all P-values < 0.001). Overall survival was significantly shorter in the HRG compared with the LRG. The RS model we constructed to predict the occurrence of FICH will be verified through prospective studies.

Thrombotic complications in childhood acute lymphoblastic leukemia: a meta-analysis of 17 prospective studies comprising 1752 pediatric patients

The risk of thrombosis in children with acute lymphoblastic leukemia (ALL) reportedly ranges between 1% and 37%. Epidemiologic studies have usually been hampered by small numbers, making accurate estimates of thrombosis risk in ALL patients very difficult. The aim of this study was to better estimate the frequency of this complication and to define how the disease, its treatment, and the host contribute to its occurrence. We made an attempt to combine and analyze all published data on the association between pediatric ALL and thrombosis, by using a meta-analytic method. The rate of thrombosis in 1752 children from 17 prospective studies was 5.2% (95% CI: 4.2-6.4). The risk varies depending on several factors. Most of the events occurred during the induction phase of therapy. Lower doses of asparaginase (ASP) for long periods were associated with the highest incidence of thrombosis, as were anthracyclines and prednisone (instead of dexamethasone). The presence of central lines and of thrombophilic genetic abnormalities also appeared to be frequently associated with thrombosis. In conclusion, the overall thrombotic risk in ALL children was significant, and the subgroup analysis was able to identify high-risk individuals, a finding that will hopefully guide future prospective studies aimed at decreasing this risk.

Thrombosis associated with L-asparaginase therapy and low fibrinogen levels in adult acute lymphoblastic leukemia

L-asparaginase is a chemotherapeutic agent commonly used in the treatment of both adult and pediatric acute lymphoblastic leukemia (ALL). A major complication is thrombosis, resulting from reduced synthesis of proteins such as antithrombin III. Hypofibrinogenemia, also a side effect, may be a marker of thrombosis and decreased protein synthesis. A retrospective chart review of identically treated patients revealed 9 thrombotic events among 93 patients (10%), 6 (7%) occurring during treatment cycles including L-asparaginase. Twelve (13%) patients had fibrinogen levels <50 mg/dL. Of these, 3 (25%) suffered a thrombotic event. This results in a specificity of 90% and a relative risk of 10 (P = 0.014). Therefore, a fibrinogen <50 mg/dL may serve as a marker for a hypercoagulable state in ALL patients receiving L-asparaginase.

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

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.

Assessment of coagulation disorders in patients with acute leukemia before and after cytostatic treatment

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.