Hemolytic uremic syndrome following prolonged gemcitabine therapy: report of four cases from a single institution

Schütt, Philipp; Bojko, Peter; Nowrousian, M. R.; Hense, Jörg; Seeber, S.; Möritz, Thomas

doi:10.1007/s00277-004-0938-8

Cited by 62 publications

(48 citation statements)

References 19 publications

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“…There is no specific treatment for this clinical condition even though it is always recommended to discontinue the treatment. Antiplatelets drugs and steroids have been used but their effects controversial [6]. Transfusions are contraindicated [7].…”

Section: Discussionmentioning

confidence: 99%

Gemcitabine and Hemolytic Uremic Syndrome: a Case Report

Nl¹,

Merzouki²,

Ns³

et al. 2017

J Blood Lymph

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A 61 year old man was admitted to the hospital due to low hemoglobin levels and altered renal function found on a follow up test. He was on the 8 cycle of chemotherapy and had received gemcitabine two weeks prior to hospitalization. He did not report any fevers, diarrhea or weight loss. He is a nonsmoker and his family history is of no interest. On presentation, the patient was mildly tachycardic (heart rate 95 beats/min) with a blood pressure reading of 100/70 mmHg, but he was otherwise stable. Heart auscultation was normal and lung sounds were clear. He had no axillary, cervical or inguinal adenopathy. Abdominal examination was negative with no tenderness or mass. The rest of the physical exam was irrelevant. Laboratory tests a progressive macrocytic anemia was noted, with a drop in hemoglobin level from 12.1 g/dL to 7.1 g/dL (normal 13 to 18 g/dL). The reticulocyte count was at112 giga/L. The leukocyte count was normal but platelets were slightly diminished at 147 giga/L (normal range from 150 to 400 giga/L). Haptoglobin was inferior to 0.04 g/ (normal range from 0.4 to 2.68) and 2% of schistocytes were found on peripheral smear. Coombs test came back negative. Metabolic panel findings showed acute renal failure (creatinine raised up to 181 ummol/L and glomerular filtration dropped from 98 mL/min to 34 mL/min). Proteinuria raised from 2.93 to 3.25 g/L. Liver function tests were within the normal range but for a LDH at 539 UI/L and total bilirrubin (13.70 mmol/L). Workup for infection, including serology for hepatitis B and C, HIV, CMV and EBV returned negative. Folate and vitamin B12 levels were normal. The immunologic panel came back negative for antinuclear antibody titer and antineutrophil cytoplasmic antibodies. Protein electrophoresis showed marked hypoalbuminemia and hypogammaglobulinemia. Bone marrow examination was normal. DiscussionHemolytic uremic syndrome (UHS) is a clinical entity characterized by the presence of acute renal failure, thrombopenia and hemolytic anemia [1,2]. In this regard, increase levels of LDH are consistent not only with hemolysis but also with tissue ischemia. Other important markers of hemolysis include elevated bilirrubin, reticulocytes count and low levels of haptoglobin. The diagnosis will be made in the presence negative Coombs test and schistocytes. Thrombopenia could also be severe and it reflects their peripheral destruction and acute renal failure result from the formation of microthrombi in the vascular lumen of arterioles and glomeruli [3]. This entity has been related to some infectious diseases, autoimmune conditions like systemic lupus and sclerodermia and in the setting of some drugs intake. The incidence of UHS in the context of cancer or chemotherapy varies from 2,6 to 13% according to the literature [4]. Uremic hemolytic syndrome in the setting of gemcitabine is a very uncommon clinical situation and its incidence varies from 0,015 à 2,2% [5]. This syndrome may appear from some days to some months after the administration of the drug or even once it has been ...

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Section: Discussionmentioning

confidence: 99%

Gemcitabine and Hemolytic Uremic Syndrome: a Case Report

Nl¹,

Merzouki²,

Ns³

et al. 2017

J Blood Lymph

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“…En este paciente las alteraciones hematológicas aparecieron después de la quinta dosis de GEM (1.600 mg por vez). La administración de GEM simultáneamente con otras drogas oncológicas y el uso previo de otros esquemas de quimioterapia predisponen a esta complicación 10,11,19,20 . Este paciente, que no había sido tratado previamente con ningún medicamento oncológico, había recibido una dosis acumulada de GEM de 16.400 mg (9.318 mg/m 2 ) hasta la aparición del síndrome nefrítico.…”

Section: Discussionunclassified

“…En ocasiones esta sola medida revierte el trastorno, en otras, el SHU secundario no se detiene, dañándose irreversiblemente el riñón dejando al enfermo en diálisis crónica o provocando su muerte 24 . Entre los agentes empleados en la terapia destacan los hipotensores, diuréticos, corticoides, vincristina, azatioprina, plasmaféresis, recambios sanguíneos, transfusiones, plasma fresco congelado, prostaciclina, inmunoglobulinas, antiplaquetarios y rituximab 3,5,[10][11][12]17,20,22 . Con esta última droga hay escasa experiencia pero los resultados parecen promisorios 10 .…”

Section: Discussionunclassified

“…En los últimos años se han comunicado en forma creciente casos de SHU asociados al uso de gemcitabina (GEM), droga introducida en 1996 para el tratamiento del cáncer pancreático irresecable o metastásico y que ha tenido un amplio uso [3][4][5][6][7][8][9][10][11][16][17][18][19][20][21][22][23][24] . Se ha utilizado también en cáncer pulmonar de células no pequeñas, linfoma, cáncer de ovario, mama, hígado, vía biliar y vejiga [3][4][5]14,19 .…”

Section: Gemcitabine Is a Widely Used Drug In The Treatment Of Advancunclassified

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Síndrome hemolítico-urémico asociado al uso de gemcitabina: Caso clínico

et al. 2013

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Gemcitabine is a widely used drug in the treatment of advanced pancreatic cancer and other malignancies. It is generally well tolerated and exceptionally its use hasE l síndrome hemolítico-urémico (SHU) es una entidad clínica caracterizada por anemia hemolítica microangiopática, trombocitopenia e injuria renal aguda 1,2 . Existen diversas etiologías: infecciones entéricas, formas familiares, enfermedades autoinmunes, trasplante de médula ósea, embarazo, neoplasias diseminadas, infecciones por VIH y drogas 3-10 . De estas últimas se han descrito casos asociados al uso de ciclosporina, tacrolimus, ticlopidina, alfa interferón, quinina y a drogas oncológicas como mitomicina C, cisplatino, bleomicina, 5 fluoracilo, adriamicina, carboplatino y otras [3][4][5][6]10 .En los últimos años se han comunicado en forma creciente casos de SHU asociados al uso de gemcitabina (GEM), droga introducida en 1996 para el tratamiento del cáncer pancreático irresecable o metastásico y que ha tenido un amplio uso [3][4][5][6][7][8][9][10][11][16][17][18][19][20][21][22][23][24] . Se ha utilizado también en cáncer pulmonar de células no pequeñas, linfoma, cáncer de ovario, mama, hígado, vía biliar y vejiga [3][4][5]14,19 .El SHU asociado a GEM tiene una baja incidencia, varía entre 0,008% y 2,2% de los pacientes tratados con la droga 3,[10][11][12][13]22 . Se asocia frecuentemente a falla renal con necesidad de diálisis y tiene elevada mortalidad 11,14,21,22 . La búsqueda rutinaria de las manifestaciones clínicas de este síndrome antes de cada administración de una dosis de GEM permite sospechar oportunamente el trastorno y muchas veces revertirlo al suspender su administración, reduciendo la morbilidad y mortalidad 17 . Comunicamos un caso de SHU por GEM en que el diagnóstico clínico-patológico oportuno permitió obtener una buena evolución, evitando la progresión del daño renal. Caso clínicoPaciente de 60 años, sin antecedentes mór-bidos, a quien en una tomografía computada de abdomen efectuada por dolor abdominal, se le encontró un carcinoma de 2 cm localizado en la cabeza del páncreas. Fue sometido a una operación

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“…The median cumulative gemcitabine dose associated with TMA is >20,000 mg/m 2 (31). However, prior treatment with chemotherapeutic agents known to cause TMA, such as mitomycin-C and cisplatin, has been suggested to increase the likelihood of developing TMA after gemcitabine, and to reduce the indicated cumulative dose of the agent (32)(33)(34)(35). Indeed, patient 2 had been treated with carboplatin and gemcitabine a few months before her presentation.…”

Section: Mitomycin-c-induced Presmentioning

confidence: 99%

Neurological variability in chemotherapy‑induced posterior reversible encephalopathy syndrome associated with thrombotic microangiopathy: Case reports and literature review

et al. 2017

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Abstract. Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome characterized by headaches, seizures, a confusional state and visual disturbances associated with transient predominantly bilateral posterior white mater magnetic resonance imaging lesions. It is primarily reported in the setting of hypertension, acute renal failure, peripartum eclampsia, autoimmune disease, immunosuppression and chemotherapy. Thrombotic microangiopathy (TMA), including hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) has also been reported as potential PRES inducer. The present study reviews two cases of patients with PRES, associated with TMA caused by chemotherapy. Their clinical and imaging data, and the relevant literature were reviewed. Patient 1 presented with TMA-induced PRES following mitomycin-C for metastatic colon adenocarcinoma. Treatment with steroids, plasma exchange, intravenous immuno globulins, aspirin, antihypertensive drugs, and diuretics resulted in resolution of the neurological and imaging deficits. Patient 2 presented with TMA-induced PRES following gemcitabine for metastatic breast carcinoma. Treatment was ineffective and the patient deteriorated despite verapamil, dexamethasone, and plasma exchange. In this report, the relevant literature regarding pathogenesis, treatment and prognosis of chemotherapy-induced PRES associated with TMA was reviewed. We conclude that several chemotherapy agents may cause PRES through various pathogenic mechanisms, leading to clinical variability and divergent response to therapy.

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Hemolytic uremic syndrome following prolonged gemcitabine therapy: report of four cases from a single institution

Cited by 62 publications

References 19 publications

Gemcitabine and Hemolytic Uremic Syndrome: a Case Report

Gemcitabine and Hemolytic Uremic Syndrome: a Case Report

Síndrome hemolítico-urémico asociado al uso de gemcitabina: Caso clínico

Neurological variability in chemotherapy‑induced posterior reversible encephalopathy syndrome associated with thrombotic microangiopathy: Case reports and literature review

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