What is the best treatment approach for a patient with Hodgkin lymphoma (HL) and concurrent chronic liver disease (CLD), acute kidney injury (AKI), and cardiomyopathy?

Treatment Approach for Hodgkin Lymphoma with Chronic Liver Disease, Acute Kidney Injury, and Cardiomyopathy

For patients with Hodgkin lymphoma complicated by chronic liver disease, acute kidney injury, and cardiomyopathy, modified ABVD chemotherapy without bleomycin is the most appropriate first-line treatment approach, with careful monitoring of organ function and potential dose adjustments based on hepatic and renal function. 1

Initial Assessment and Staging

• Complete staging workup is mandatory, including contrast-enhanced CT scan of neck, chest, and abdomen, with baseline PET if available 1
• Screening for hepatitis B, hepatitis C, and HIV is essential, particularly in patients with liver disease 1
• Cardiac function assessment via echocardiogram or MUGA scan is critical before treatment initiation due to pre-existing cardiomyopathy 1
• Comprehensive liver and kidney function tests are required to determine the severity of organ dysfunction 1

Treatment Strategy Based on Disease Stage

Limited or Intermediate Stage Disease

• For patients with limited/intermediate stage HL with multiple comorbidities, consider modified ABVD (doxorubicin, vinblastine, dacarbazine) without bleomycin followed by involved-site radiotherapy (ISRT) 1
• Bleomycin should be omitted completely due to the risk of pulmonary toxicity, especially in patients with compromised organ function 1
• Consider dose reduction of doxorubicin (25-50%) due to pre-existing cardiomyopathy 2
• Vinblastine dose may need adjustment based on liver function tests 3

Advanced Stage Disease

• For advanced HL with multiple comorbidities, modified ABVD without bleomycin is recommended 1
• BEACOPP regimen is absolutely contraindicated due to intensity and toxicity profile in the setting of organ dysfunction 1
• Consider PET-guided approach after 2 cycles to determine treatment response and guide further therapy 1
• Additional radiotherapy should be confined to patients with residual PET-positive disease after chemotherapy completion 1

Special Considerations for Organ Dysfunction

Chronic Liver Disease Management

• Mechlorethamine-based therapy may be considered as a bridge to more conventional chemotherapy in patients with severe liver dysfunction 4
• Rituximab may be added to the regimen for patients with CD20+ Hodgkin lymphoma variants, particularly nodular lymphocyte-predominant HL 1
• Close monitoring of liver function tests is essential during treatment 4

Cardiomyopathy Considerations

• Cumulative doxorubicin dose should be strictly limited due to risk of worsening cardiomyopathy 2
• Consider doxorubicin dose reduction or substitution with less cardiotoxic agents if cardiac function deteriorates 2
• Regular cardiac monitoring with echocardiogram or MUGA scan during treatment is mandatory 1, 2

Acute Kidney Injury Management

• Dose adjustment of renally cleared chemotherapeutic agents based on creatinine clearance 1
• Aggressive hydration protocols before and after chemotherapy administration 1
• Avoidance of nephrotoxic medications and contrast agents when possible 1

Alternative Approaches

• For patients with severe organ dysfunction who cannot tolerate standard chemotherapy, single-agent therapy with brentuximab vedotin may be considered 1
• Immune checkpoint inhibitors (nivolumab, pembrolizumab) have shown efficacy in relapsed/refractory HL and may be considered in patients with severe liver dysfunction 5
• Gemcitabine-based palliative chemotherapy may be an option for patients with multiple comorbidities who cannot tolerate more intensive regimens 1

Monitoring and Follow-up

• Frequent laboratory monitoring of liver and kidney function before each treatment cycle 1, 4
• Regular cardiac assessment during treatment, especially with anthracycline-containing regimens 1, 2
• PET-CT evaluation after 2 cycles and at completion of treatment to assess response 1
• Close monitoring for treatment-related complications and infections due to compromised organ function 1

Prognosis

• Despite multiple comorbidities, modern treatment approaches can achieve long-term disease control in a significant proportion of patients 1
• Treatment outcomes depend largely on the ability to deliver adequate therapy while managing organ dysfunction 4
• Improvement in liver function during initial therapy is associated with better overall survival 4