Spontaneous tumour lysis syndrome secondary to the transformation of chronic myelomonocytic leukaemia into acute myeloid leukaemia

Abstract

A 78-year-old man, with a 6-year history of stable chronic myelomonocytic leukaemia (CMML), presented with general deterioration and worsening pancytopenia. Bone marrow biopsy showed that his disease had transformed into acute myeloid leukaemia (AML). He was started on a supportive transfusion regimen and did not receive any chemotherapy or corticosteroids. Several weeks later, he developed acute renal failure and was admitted to a medical admissions ward. Spontaneous tumour lysis syndrome (sTLS, grade 1) was diagnosed, as per the Cairo and Bishop criteria. He was treated with intravenous fluids, rasburicase and allopurinol. His renal function improved and he recovered from the sTLS. The authors believe that this is the first published case of sTLS occurring as a result of CMML transforming into AML; it highlights the importance of recognising sTLS as a cause of renal failure and electrolyte disturbance before cancer treatment begins.

Transformation of CMML to AML presenting with acute kidney injury

“…Most commonly, cell lysis and the increase in purine byproducts occur with chemotherapy and radiation. However, spontaneous TLS is not an uncommon event in AML, but appears much less described as a presenting feature of CMML transforming to AML with only 1 case in the literature [7]. The Cairo-Bishop definition of tumor lysis syndrome consists of laboratory evidence for tumor lysis plus at least one clinical complication, which include creatinine 1.5 x ULN, cardiac arrhythmia, or seizure.…”

“…There are different mechanisms that can contribute to AKI in this setting, which include hypoperfusion, acute tubular necrosis, kidney infiltration by leukemia, intrarenal leukostasis, tumor lysis syndrome, hyperuricemia, lysozymuria, and obstruction (see Figure 5) [6]. A case report of spontaneous tumor lysis syndrome secondary to the transformation of CMML to AML highlights the importance of recognizing sTLS as a cause of renal failure and electrolyte disturbance before cancer treatment begins [7]. Although our case does not meet the criteria for laboratory or clinical tumor lysis syndrome based on Cairo-Bishop criteria, ours is the only other reported case of severe hyperuricemia and AKI in the setting of CMML transformation to AML.…”