Case Report:Chronic Myeloid Leukemia Treatment in a Hemodialysis Patient

INTRODUCTION:Chronic myeloid leukemia is a rare hematologic malignancy. The incidence and prevalence of the disease vary between countries. However, the treatment success rate is over 90%, and the first choice for treatment is tyrosine kinase inhibitors. The most important factor in the success of treatment is the compliance of the medicine treatment and using effective dosage of the TKI.The incidence of patients with chronic renal disease (CKD) and hemodialysis (HD) treatment is much higher than that of CML. Although there is no data about the incidence of CKD in CML patients.The rate of CKD in CML patients is stated as % 2.6 by Hoffman et al. at a review about EUTOS population based registry of CML.The frequency of hemodialysis patients in CML patients is unknown.There is no data on the use of TKI in CML patients undergoing hemodialysis both drug approval procedure and during the post marketing period. In this case report, we want to share our experience about CML therapy in a patient with hemodialysis treatment who applied to our clinic.This is the fifth patient case report in the literature.

CASE REPORT:A 53-year-old female patient was referred to our hematology clinic after detection of leukocytosis in a whole blood test. Patient is followed up due to renal atrophy and treated with hemodialysis in our nephrology department.When the hemogram values of the last ten years were examined, it was determined that neutrophilic leukocytosis started on February 2017 and progressed gradually. Following the exclusion of possible causes of leukocytosis during the evaluation, peripheral blood smear test ,bone marrow biopsy and aspiration ,genetic tests was done from bone marrow blood examples.She was diagnosed with chronic phase CML according to the results of genetic tests and bone marrow biopsy pathology evaluation .After diagnosis confirmed, imatinib was began at a dose of 100 mg /day. Third month of treatment,the molecular response evaluation was found to be consistent with the complete molecular response (MR:4.5), and it was seen that this response was also preserved in the 6-month. In the course of this 6-month period, imatinib was first increased to 200 mg / day and then to 300 mg / day without any side effect or response loss.

DISCUSSION: In the literature, the relationship between CML and renal disease has been studied under the headings of tumor lysis syndrome, cancer related membranous glomerulopathy, imatinib after renal transplantation, acute renal damage with imanitinib.Due to the rarity of CML, data on CML therapy in CKD and especially in hemodialysis patients are scarce. A total of 4 cases together with our case were identified in the literature. (3 cases Onaka et al., American Journal of Hematology, 2012 and 1 case Özdemir et al., American Journal of Hematology, 2006).Due to the very rare association, and the complex nature of CKD including altered drug metabolism, accompanying diseases, hemodialysis-specific conditions, treatment decisions are even more difficult to obtain.There is insufficient data on the use of imatinib mesylate in hemodialysis patient.There is no data on the safety and efficacy of imatinib mesylate in hemodialysis patients.The imatinib dose used in reported cases is between 100 mg and 400 mg and is given between 1 and 4 hours after hemodialysis. The response status of the treatment is changing from case to case. For this reason, it is not possible to make a definite recommendation. In our case,we started with 100 mg / day dose, and we gradually increased dose 300 mg/day dose and response is major molecular response.Data from this group of patients during multicentre clinical trials must be shared.