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CHAPTER 92: Acute Leukemia 865

complication is catheter-related blood stream infections and sepsis; one CHAPTER Acute Leukemia
series observed systemic infections in up to 12% of patients undergoing
plasma exchange for TTP and HUS. Although routine surveillance Karen-Sue B. Carlson
221
cultures are not recommended, the critical care physician should have a 92
high suspicion of systemic infection in this population with indwelling
central venous catheters as occult infections have been described in this
population. Lastly, catheter-related thrombosis or obstruction has been
222
reported in this series as a complication of plasma treatment. The risks KEY POINTS
221
associated with plasma transfusion including allergic reaction, TRALI
and citrate toxicity are among the complications of plasma exchange • Untreated acute leukemia is rapidly fatal, but a percentage of
for TTP and HUS. Citrate toxicity, causing hypocalcemia and metabolic patients can be cured. In the absence of cure, many can achieve a
alkalosis, can be avoided by routine administration of calcium gluconate significant duration of high-quality life depending on preleukemia
during plasma exchange therapy. Serial monitoring of ionized calcium comorbidities, and should therefore be considered for therapy.
levels is also recommended. The diagnosis of TRALI should be suspected • Medical complications of the acute leukemias are often reversed
in patients undergoing therapeutic plasma exchange who develop respi- with treatment of the underlying disease.
ratory deterioration. 223-225 Cessation of plasma infusion and blood bank • Bleeding or infectious complications account for the majority of
workup such as antibody testing should be performed in suspected cases.
deaths in patients with acute leukemias.
• Laboratory findings define and are prominent in tumor lysis syn-
drome and include hyperkalemia, hyperphosphatemia, hyperuri-
KEY REFERENCES cemia, and hypocalcemia.
• Rasburicase can be used to treat hyperuricemia, but must be
• Caprioli J, Noris M, Brioschi S, et al. Genetics of HUS: the impact avoided for patients with known hypersensitivity, methemoglobin-
of MCP, CFH, and IF mutations on clinical presentation, response emia, or G6PD deficiency.
to treatment, and outcome. Blood. 2006;108(4):1267-1279.
• Urinary alkalinization is not recommended for prevention of
• Fujimura Y, Matsumoto M. Registry of 919 patients with throm- tumor lysis syndrome.
botic microangiopathies across Japan: database of Nara Medical
University during 1998-2008. Intern Med. 2010;49(1):7-15. • Cytogenetics and molecular studies are important prognostic indi-
cators in AML and ALL.
• George JN. How I treat patients with thrombotic thrombocytope-
nic purpura: 2010. Blood. 2010;116(20):4060-4069. • Prophylactic platelet transfusion is indicated for thrombocytope-
nia associated with acute leukemia.
• Levy GG, Nichols WC, Lian EC, et al. Mutations in a member of • Disseminated intravascular coagulation (DIC) should be aggres-
the ADAMTS gene family cause thrombotic thrombocytopenic sively treated with transfusion support with fresh frozen plasma
purpura. Nature. 2001;413(6855):488-494. and cryoprecipitate during the initial treatment of acute leukemias.
• Moake JL, Rudy CK, Troll JH, et al. Unusually large plasma • Acute promyelocytic leukemia (APL) should be suspected in
factor VIII: von Willebrand factor multimers in chronic relaps- patients with pancytopenia and severe DIC.
ing thrombotic thrombocytopenic purpura. N Engl J Med.
1982;307(23):1432-1435. • All-trans retinoic acid (ATRA) therapy should be rapidly initiated if
• Noris M, Mescia F, Remuzzi G. STEC-HUS, atypical HUS and APL is suspected, and invasive procedures including placement of a
central venous catheter should be avoided until the DIC has resolved.
TTP are all diseases of complement activation. Nat Rev Nephrol.
2012;8(11):622-633. • Rapid cytoreduction by hydroxyurea and leukapheresis are main-
stays of therapy for hyperleukocytosis.
• Tsai HM, Lian EC. Antibodies to von Willebrand factor-cleaving
protease in acute thrombotic thrombocytopenic purpura. N Engl J
Med. 1998;339(22):1585-1594. INTRODUCTION
• Würzner R, Riedl M, Rosales A, Orth-Höller D. Treatment of
enterohemorrhagic Escherichia coli-induced hemolytic uremic Acute leukemias are a collection of bone marrow and lymphoid dis-
syndrome (eHUS). Semin Thromb Hemost. 2014; Epub ahead orders that result from establishment of a malignant stem cell popula-
PMID 24802085. tion. Presentation of a patient to medical care with a suspected acute
• Zheng XL, Chung D, Takayama T, Majerus E, Sadler J, leukemia should be considered a medical emergency, and rapidly
involve a specialist in hematologic malignancies and referral to a tertiary
Fujikawa K. Structure of von Willebrand factor-cleaving pro-
tease (ADAMTS13), a metalloprotease involved in thrombotic care facility with expertise in treatment of patients with acute leukemia.
Left untreated, acute leukemias are rapidly fatal within days to weeks of
thrombocytopenic purpura. J Biol Chem. 2001;276(44):
41059-41063. presentation, but with appropriate supportive measures and therapeutic
interventions a significant number of patients are cured. For those in
• Zheng XL, Sadler JE. Pathogenesis of thrombotic microangiopa- whom a cure cannot be achieved, there is still the potential for a sub-
thies. Annu Rev Path Mech Dis. 2008;3:249-277. stantial period of good quality life. Because of the acuity of these diseases
• Zipfel PF, Neumann HP, Jozsi M. Genetic screening in haemolytic and consequences of their treatment, it is not infrequent that patients
uraemic syndrome. Curr Opin Nephrol Hypertens. 2003;12(6): with acute leukemias are seen in the setting of a medical ICU. It is espe-
45
653-657. cially important to understand that acute leukemias develop rapidly and
the disease itself profoundly compromises an individual’s performance
status and comorbidities; however, with rapid and appropriate therapy,
these leukemia-induced complications are often reversed. In order to
REFERENCES appropriately target care from the perspective of the intensivist, it is
important to understand the disease pathophysiology, overall prognostic
Complete references available online at www.mhprofessional.com/hall evaluation, and complications unique to leukemia treatment regimens.

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