From the Guidelines
Managing Chronic Myelomonocytic Leukemia (CMML) in patients with impaired renal function requires careful medication adjustments and close monitoring, with hypomethylating agents like azacitidine or decitabine being first-line options, but with necessary dose reductions for severe renal impairment. Treatment should begin with a thorough assessment of renal function using estimated glomerular filtration rate (eGFR) and creatinine clearance to guide dosing decisions. For CMML patients with renal impairment, the goal is to balance disease control with minimizing further kidney damage, as both the disease itself and its treatments can impact renal function 1.
Key Considerations
- Hypomethylating agents like azacitidine (at 75 mg/m² for 7 days every 28 days) or decitabine (at 20 mg/m² for 5 days every 28 days) are recommended, but require dose reductions of 25-50% for severe renal impairment (eGFR <30 mL/min) 1.
- Hydroxyurea can be used for cytoreduction at a starting dose of 500-1000 mg daily with adjustments based on blood counts and renal function 1.
- Supportive care is essential, including erythropoiesis-stimulating agents for anemia (with careful monitoring of hemoglobin levels), prophylactic antibiotics for neutropenia, and transfusion support as needed 1.
- Nephrotoxic medications should be avoided, and all drugs should be reviewed for necessary renal adjustments.
Monitoring and Adjustments
- Regular monitoring of renal function (every 1-2 weeks initially), complete blood counts, and electrolytes is crucial 1.
- Hydration must be maintained, and patients should be educated about medication adherence, infection prevention, and symptoms requiring immediate medical attention.
- The treatment strategy should be decided based on the disease hematologic phenotype and the number of blasts in the bone marrow, with adjustments made as necessary to balance disease control and renal function 1.
From the Research
Management of Chronic Myelomonocytic Leukemia (CMML) with Impaired Renal Function
- CMML is a hematologic disorder that can be associated with autoimmune and inflammatory diseases, and can cause kidney involvement, including acute kidney injury (AKI) and chronic kidney disease (CKD) 2.
- The main pathological findings in CMML patients with kidney disease are lysozyme nephropathy and renal infiltration by the CMML 2.
- Treatment of CMML with impaired renal function may involve the use of hypomethylating agents, such as azacitidine, which has been shown to be effective in the treatment of CMML 3, 4.
- Azacitidine has been associated with a significant response rate in CMML patients, including those with proliferative CMML, and has been well-tolerated 3, 4.
- In some cases, CMML can progress to acute myeloid leukemia (AML), which can present with acute kidney injury, and requires prompt treatment 5.
- Renal involvement by CMML can be severe and may require drastic measures, such as nephroureterectomy, to control symptoms like gross hematuria 6.
- Close monitoring of kidney function is essential in patients with CMML, as kidney involvement can be a significant complication of the disease 2.
- The treatment of CMML with impaired renal function should be individualized, taking into account the patient's overall health, the severity of the kidney disease, and the potential risks and benefits of different treatment options 2, 3, 4.