YO12 - Allogeneic hematopoietic stem cell transplant in a case of acute myeloid leukaemia with end stage renal disease

Case summary

A 48-year-old male, presented with painless progressive decreased vision. On evaluation he was diagnosed with central retinal vein occlusion. Evaluation also revealed that he was hypertensive and has pancytopenia (Hb-9.1gm/dl, TLC-2200/μl, Platelets-25000/μl). Renal function tests showed blood urea nitrogen-49.5mg/dl and creatinine-5.14mg/dl. Ultrasonogram revealed bilateral contracted kidneys. Nephrology consult was sought and was diagnosed with end-stage renal disease (ESRD). However, he was non-oliguric and was not started on dialysis. Bone marrow examination showed 30% blasts and flowcytometry (CD34, HLA-DR, CD13, CD33, CD117, CD16, CD56-positive) confirmed the diagnosis as acute myeloid leukaemia-monocytic type. Cytogenetics was normal and stratified as intermediate risk. He was given six cycles of azacitidine in view of his ESRD. Repeat evaluation was suggestive of morphological remission and no measurable residual disease. As the patient had matched sibling donor, he was planned for allogeneic transplant. Considering his ESRD and requirement of nephrotoxic drugs, he was given four sessions of hemodialysis before starting conditioning chemotherapy. Conditioning regimen included fludarabine 24mg/m² for 5 days (day-6 to day-2) and melphalan 140mg/m² single dose (day-1), both dose reduced in view of ESRD. One session of hemodialysis was given 24hours after melphalan. Stem cells were infused on day zero and total CD34 cell dose was 7.6 x 10⁶/kg. Day+1 methotrexate was omitted. Rest of the methotrexate doses were given on day+3, +6 and +11, with hemodialysis 24 hours after each dose of methotrexate. Post-transplant he developed grade III mucositis and febrile neutropenia which were managed with supportive care and antibiotics. Neutrophil engraftment occurred on day+18 while platelet engraftment occurred on day+20 and was subsequently discharged. Bone marrow examination performed on day+30 was in complete morphological remission with no measurable residual disease (MRD<0.1%). Chimerism on day+30, day+60 and day+180 showed 100% donor chimerism. He was kept on weekly follow up and continues to be in complete morphological remission with no graft-versus host disease.

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