Can acute myeloid leukemia cause renal failure?

Can Acute Myeloid Leukemia Cause Renal Failure?

Yes, acute myeloid leukemia (AML) can cause renal failure through multiple mechanisms, occurring in approximately 30-36% of patients either at diagnosis or during treatment, and represents a significant complication that requires urgent recognition and management.

Mechanisms of Renal Injury in AML

Tumor Lysis Syndrome

• Patients with excessive leukocytosis at presentation and clinical signs of leukostasis are at particular risk of tumor lysis syndrome under induction chemotherapy, which can precipitate hyperuricemia and subsequent renal failure. 1
• Rasburicase may be considered as a single injection to prevent hyperuricemia-induced renal failure in high-risk patients, though data are insufficient to support a firm recommendation. 1

Direct Leukemic Infiltration

• Leukemic blast cells can directly infiltrate the renal parenchyma, causing tubulointerstitial nephropathy and acute kidney injury, though this mechanism is relatively rare. 2, 3
• Renal infiltration should be considered when AML patients present with renal impairment, as the renal failure often responds well to chemotherapy. 3

Leukostasis and Microvascular Insufficiency

• Severe leukostasis with microvascular insufficiency represents a rare but important mechanism of renal failure in AML, particularly in patients with markedly elevated white blood cell counts. 2
• Emergency leukapheresis coordinated with the start of chemotherapy may be required for patients with excessive leukocytosis and clinical signs of leukostasis. 1

Treatment-Related Nephrotoxicity

• Nephrotoxic antibiotics (particularly aminoglycosides and vancomycin), amphotericin B formulations, and other supportive care medications contribute significantly to acute kidney injury during AML treatment. 4
• Approximately 36% of AML patients develop acute kidney injury during induction chemotherapy, with independent risk factors including age ≥55 years, mechanical ventilation, use of vancomycin, diuretics, amphotericin B, vasopressors, leukopenia, and hypoalbuminemia. 4

Sepsis and Hemodynamic Instability

• Sepsis with complicating hypotension and hypovolemia represents a major cause of acute renal failure in AML patients, particularly during periods of neutropenia following chemotherapy. 5
• Patients aged ≥60-65 years are more susceptible to severe infections and treatment complications, contributing to higher risk of renal failure. 1

Clinical Significance and Prognosis

Incidence and Mortality Impact

• Renal complications occur in approximately 30% of AML patients treated with chemotherapy alone and in 50% of patients undergoing bone marrow transplantation. 6
• The 8-week mortality rates stratified by RIFLE criteria are 3.8% for no AKI, 13.6% for Risk category, 19.6% for Injury category, and 61.7% for Failure category, demonstrating that even relatively mild elevations in creatinine are associated with higher mortality. 4
• Patients requiring dialysis (8% of AML patients) have a median survival of only 33 days. 4
• Early renal complications have a poor prognostic impact in the chemotherapy group, while acute renal failure is prognostically unfavorable across all patient groups. 6

Risk Factors

• Male sex, advanced age, previous kidney disease, elevated white cell count, and refractory leukemia are significant risk factors for renal complications in AML. 6
• Mechanical ventilation (OR 16), vasopressor use (OR 4.9), and diuretic use (OR 3.0) are particularly strong predictors of acute kidney injury. 4

Prevention and Management Strategies

Pre-Treatment Assessment

• At diagnosis, patients should undergo comprehensive evaluation including serum creatinine, electrolytes, and assessment for active infection before starting intensive chemotherapy. 1
• Coagulation status must be obtained to detect leukemia-related coagulopathy before insertion of central intravenous lines. 1

Prophylactic Measures

• Appropriate monitoring and prophylaxis for tumor lysis syndrome is essential in patients with excessive leukocytosis, including consideration of rasburicase to prevent hyperuricemia. 1
• Strategies to avoid nephrotoxic drugs and prevent fluid overload may reduce the incidence of acute kidney injury. 4
• Adequate hydration and careful management of electrolyte abnormalities should be implemented before and during chemotherapy. 1

Treatment Timing

• In most AML patients, the start of treatment can safely be postponed for several days until all diagnostic material has been collected, allowing time for renal protective measures. 1
• However, patients with clinical signs of leukostasis require emergency intervention and cannot wait. 1

Important Clinical Caveats

• Renal failure occurring as a consequence of terminal multi-organ failure should be distinguished from potentially reversible acute kidney injury, as the latter may respond to appropriate intervention. 6
• Survival of AML patients who achieve complete remission is favorable regardless of the degree of acute kidney injury, emphasizing the importance of continuing appropriate anti-leukemic therapy even in the setting of renal impairment. 4
• Other rare causes of acute renal failure in AML include ureteral obstruction from clots, disseminated fungal infections (particularly aspergillosis), and hypercalcemia. 5