What are the potential complications of acute myeloid leukemia (AML) in older adults or those with underlying medical conditions?

Complications of Acute Myeloid Leukemia in Older Adults and Those with Comorbidities

Older adults (≥60-65 years) with AML face substantially higher mortality from severe infections, treatment-related toxicity, and disease-related complications compared to younger patients, with pre-existing conditions such as diabetes, coronary heart disease, and chronic pulmonary disease further amplifying these risks. 1

Disease-Related Complications

Hematologic Emergencies

• Leukostasis occurs in patients with excessive leukocytosis (particularly WBC >100,000/μL) and presents with clinical signs of hyperviscosity requiring emergency leukapheresis coordinated with chemotherapy initiation 1

• Coagulopathy, particularly in acute promyelocytic leukemia (APL), must be detected through coagulation screening before insertion of central venous lines to prevent catastrophic bleeding complications 1

• Tumor lysis syndrome represents a critical risk during induction chemotherapy, especially in patients with high leukocyte counts, requiring appropriate monitoring and potentially rasburicase administration to prevent hyperuricemia and renal failure 1

Infection Susceptibility

• Severe, life-threatening, or fatal infections are the predominant complication in older patients (≥60-65 years), who demonstrate markedly increased susceptibility compared to younger patients 1

• Active infections at diagnosis require careful clinical and hematological assessment, with CT scans of chest and abdomen plus radiological imaging of teeth and jaws recommended to identify infectious foci such as dental root granulomas and caries 1

• Chemotherapy initiation may need to be delayed until active infections are adequately treated 1

Patient-Related Complications

Cardiovascular Complications

• Cardiac toxicity from anthracycline-based chemotherapy poses particular risk in patients with pre-existing coronary heart disease, necessitating cardiac risk factor assessment at diagnosis plus clinical examination and echocardiography 1

• Pre-existing coronary heart disease affects the feasibility of intensive chemotherapy and contributes to poor risk stratification 1

Metabolic and Organ Dysfunction

• Diabetes mellitus is recognized as a comorbidity contributing to poor risk and affecting intensive chemotherapy feasibility 1

• Chronic pulmonary obstructive disease must be identified as contributing to poor risk and treatment complications 1

• Renal failure can result from tumor lysis syndrome if hyperuricemia is not prevented during induction chemotherapy 1

Treatment-Related Complications

Chemotherapy Toxicity

• Older patients (≥60-65 years) demonstrate increased susceptibility to treatment complications beyond infections, contributing to higher risk of unfavorable outcomes 1

• The adverse prognosis in elderly patients stems from both increased treatment complications and higher frequency of unfavorable cytogenetics 1

Transfusion Complications

• Hyperviscosity worsening can occur from excessive red blood cell transfusions in patients with hyperleukocytosis, potentially exacerbating symptoms 2

• Central intravenous line insertion requires platelet transfusion support in thrombocytopenic patients 1

Critical Clinical Pitfalls

• Never delay coagulation screening before central line insertion, as undetected coagulopathy (especially in APL) can lead to catastrophic bleeding 1

• Recognize hyperleukocytosis as a medical emergency requiring immediate intervention rather than routine chemotherapy initiation 2

• Avoid starting chemotherapy in patients with active infections until adequate treatment has been provided, as this substantially increases infection-related mortality 1

• Do not underestimate cardiac risk in older patients with pre-existing heart disease, as anthracycline-based regimens carry significant cardiotoxicity 1

Prognostic Impact

• The combination of age ≥60-65 years plus comorbidities (diabetes, coronary heart disease, chronic pulmonary disease) creates a synergistic negative effect on outcomes, with both disease-related factors (unfavorable cytogenetics) and treatment-related complications (severe infections) contributing to excess mortality 1

• Poor performance status and considerable comorbidity in elderly patients may preclude curative treatment, necessitating supportive care approaches 1