Acute kidney injury in patients with newly diagnosed high-grade hematological malignancies: impact on remission and survival

Abstract

Background: Optimal chemotherapy with minimal toxicity is the main determinant of complete remission in patients with newly diagnosed hematological malignancies. Acute organ dysfunctions may impair the patient's ability to receive optimal chemotherapy.

Design and methods: To compare 6-month complete remission rates in patients with and without acute kidney injury (AKI), we collected prospective data on 200 patients with newly diagnosed high-grade malignancies (non-Hodgkin lymphoma, 53.5%; acute myeloid leukemia, 29%; acute lymphoblastic leukemia, 11.5%; and Hodgkin disease, 6%).

Results: According to RIFLE criteria, 137 (68.5%) patients had AKI. Five causes of AKI accounted for 91.4% of cases: hypoperfusion, tumor lysis syndrome, tubular necrosis, nephrotoxic agents, and hemophagocytic lymphohistiocytosis. Half of the AKI patients received renal replacement therapy and 14.6% received suboptimal chemotherapy. AKI was associated with a lower 6-month complete remission rate (39.4% vs. 68.3%, P<0.01) and a higher mortality rate (47.4% vs. 30.2%, P<0.01) than patients without AKI. By multivariate analysis, independent determinants of 6-month complete remission were older age, poor performance status, number of organ dysfunctions, and AKI.

Conclusion: AKI is common in patients with newly diagnosed high-grade malignancies and is associated with lower complete remission rates and higher mortality.

Figure 1. Flow-chart of the 200 patients with high-grade newly diagnosed hematological malignancies included in the study (53.5% non-Hodgkin lymphoma, 29% acute myeloid leukemia, 11.5% acute lymphoblastic leukemia, 6% Hodgkin disease).

AKI, acute kidney injury; ICU, intensive care unit; RRT, renal replacement therapy; CR, complete remission. AKI was defined based on RIFLE criteria.

Figure 2. Effects of RIFLE classification on complete remission at 6 months.

RIFLE classification scheme for acute kidney injury (AKI). The classification system includes separate criteria for creatinine and urine output (UO). A patient can fulfill the criteria through changes in serum creatinine (SCreat) or changes in UO, or both within 7 days. The criteria that lead to the worst possible classification should be used. R, RIFLE risk category: increased SCreat×1.5 or Glomerular filtration Rate (GFR) decrease >25% or UO <0.5 ml/kg/h×6 hours. I, RIFLE injury category: increased SCreat×2 or GFR decrease >50% or UO <0.5 ml/kg/h×12 hours. F, RIFLE failure category: increased SCreat×3 or SCreat greater than 4.0 mg/dl (350 µmol/l) with an acute increase of at least 0.5 mg/dl (44 µmol/l) or GFR decrease >75% or UO <0.3 ml/kg/h×24 hours or anuria×12 hours.

Figure 3. 6-month outcome probabilities in patients with newly diagnosed hematological malignancies.

A three-state model was used: alive with hematological malignancy, alive in complete remission, and dead. All patients start in state alive with hematological malignancy. The black line represents the overall survival and the dashed line current survival free of malignancy, defined as the probability of being alive and in complete remission. Results are presented for the whole cohort and stratified according to the presence of AKI at day 1. AKI, acute kidney injury; ICU, intensive care unit.