Analysis of risk factors for fatal hemorrhage during induction therapy of patients with acute promyelocytic leukemia.

ABSTRACT

Acute promyelocytic leukemia (APL), an uncommon subtype of acute myelogenous leukemia (AML), has a high incidence of early hemorrhagic death during induction therapy; however, patients with APL surviving induction and obtaining complete remission have a good prognosis, with a longer remission duration than other subtypes of AML. We sought to determine if changes in selected clinical and laboratory coagulation parameters during induction therapy were significantly associated with fatal hemorrhage in that week, or were predictive of fatal hemorrhage in the following week. The first six weeks of induction therapy were studied in 65 patients, during which time 23 patients (35%) died from hemorrhagic complications. Time intervals analyzed were week 1, week 2, weeks 3 and 4, and weeks 5 and 6. There was no significant difference in the prevalence of severe hypofibrinogenemia (less than 150 mg%), prolongation of the prothrombin time (greater than 14 s), or presence of infection between patients who sustained fatal hemorrhage versus those who did not, for any given time period. The most significant parameter was the inability to obtain a posttransfusion platelet count of over 40,000/microliters in at least one half of the platelet transfusions administered in that week (p less than 0.001). This last parameter was the only variable that was also significantly associated with an increased risk of fatal hemorrhage for the following week (p less than 0.005). Clinical trials investigating management of coagulopathy in APL should evaluate the effect of therapy on response to platelet transfusion as well as on other laboratory parameters.