Evaluation of Mortality during Treatement of Acute Myeloid Leukemia in Patients According to Morocco National AML-MA-2011 Protocol in Casablanca

Introduction : The treatment of Acute Myeloid Leukemia (AML), in developing countries is characterized by high rate of death during induction cycles. In 2011, the Morocco National AML-MA-2011 Protocol was initiated to treat AML patients according to international standards and was focused on the improvement of supportive care with particular the prevention and management of infection, transfusion support, and, the hand hygiene education of patients, families, and health care providers. One of the objectives of the new protocol was to reduce the induction mortality rate to 10%. This report evaluates the etiology of mortality during AML treatement from 2011 to 2015 in Casablanca Hematology Departement and the impact of improvement of supportive care on the outcome of AML patients.

Patients and methods : Were reviewed the data ofpatients (aged 18-60yrs) treated according to AML-MA-2011 protocol from 1st january 2011 to 31th december 2015. Patients with APL or secondary AML were excluded. In 2011 and 2012 patients were hospitalized in conventional rooms without any precautions. At the begining of 2013 to 2015 patients were hospitalized in protected unit, in single rooms with filtered and controlled air. Access to the protected unit is only reserved for medical staff with strict isolation precautions. A group of specialists in hospital hygien and microbiology was established to control, to conduct periodic evaluations, and publish new recommendations hand for washing and hygien. This group also educated patients families and health care providers.

Platelet support was provided in the case of bleeding, or whenever the platelet count was less than 10 × 10⁹/L. For infections, Ceftazidime was the first line of antibiotic used. Amikacin was added for persistent fever beyomd 48-h or clinical deterioration. Imipenem was used for persistent fever. Additional antibiotic or antifungal or antiviral was dictated by clinical and biological findings.

The Early Death (ED) was defined as death within the first 6 weeks (42 days) of treatment. Early Death was subdivided into two types : ED1 death within the first 15 days of induction 1 and reflects lethal envents due to leukastasis and bleeding. ED2 death within in the period between days 16 and 42 of induction I and reflects deaths caused by complications from infections and bleeding during aplasia after induction I therapy. The treatement-related mortality (TRM) was evaluated based on all patients with complete remission who died after day 28. The analysis of data was done by SPSS 18.0

Résultats : In all323 patients with de novo AML treated betwen 2011-2015, there were 115 (35.60%) deaths. In death group median age was 41 (18-60years) ; sex ratio H/F was 1.16 ; median hemoglobin was 7.38 g/dl (3.1-14.9) ; median platelet was 63.42 G/L (2.25-165) ; median leucocyte was 39.02 G/L (0.97-245) ; 33(28.69%) had hyperleukocytosis ≥50G/L ; for cytology, according to FAB the dominants types was M1 : 42 (36.5%), M2 : 30 (26.08%) , M4 : 17(14.78%) ; according to karyotype 13 (11.3%) had good prognosis ; 86(74.77%) was in intermediate group, 16(13.91%) had adverse prognosis. The death rate after two inductions was 30.34% and the treatement-related mortality was 17.39%.The death rate wich was 27 / year during 2011-2013 decreased to 17 / year between 2014-2015. The analysis of differents deaths is summarized in the table.

Conclusion : Comparing the two periodsthe treatement-related mortality decreased but could be reduced by continue hygien education and improvement of supportive care therapy.