Publication

Abstract : Background Introduction of all-trans retionoic acid (ATRA) has been the major breakthrough in the treatment of Acute promyelocytic leukemia. ATRA is generally well tolerated, some patients develop the retinoic acid syndrome (RAS) with a reported incidence of 6-26%.The reported incidence of renal failure with ATRA is around 11%. Renal replacement therapy is not needed routinely in these patients. We report a case of ATRA induced renal failure necessitating haemodialysis.Material and Results A 32 year old male presented with 15 day history of fever and gum bleeds. Examination revealed a TLC of 82000/cu mm, platelet count 14000/cu mm and hemoglobin 7.2 gm%. Peripheral smear revealed 80% abnormal promyelocytes with classical morphology. RT-PCR for PML-RARA and marrow morphology confi rmed APL. Patient was started on ATRA @ 45 mg/m2/ day and daunomycin @ 60mg/m2/day was added on day3 for 3 days. The initial coagulation parameters were deranged and corrected by day four with blood product support. On day 14 of therapy he developed high grade fever with diffi culty in breathing. Antibiotics were upgraded but patient developed hypoxia and suspecting ATRA syndrome IV Dexamethasone @ 10 mg IV 12 hourly was added. Patient developed oliguria and hypotension by day 16 and ATRA was withheld. Patient’s renal parameters got deranged and by day 18 progressed to uremic encephalopathy. Patient required hemodialysis on 3 sittings and by day 24 encephalopathy resolved and the renal parameters normalized by day 26. ATRA was restarted with escalating doses alongwith monitoring of the renal parameters and patient achieved haematological remission by day 39. Our patient was lost to follow up for almost a year without any therapy and later presented with a relapse and succumbed to intracranial haemorrhage although the renal parameters were normal. Conclusion ATRA induced renal failure is an indication to withhold therapy and may necessitate renal replacement therapy.