Background: Acute promyelocytic leukemia (APL) is a rare, aggressive subtype of acute myeloid leukemia with distinct molecular features and highly effective targeted treatments. While survival has dramatically improved, the impact of comorbid chronic kidney disease (CKD) on inpatient outcomes remains unclear. CKD may alter drug pharmacokinetics—especially for agents like arsenic trioxide (ATO)—and increase risks of toxicity, fluid overload, and cardiovascular complications. It is also a known predictor of worse inpatient outcomes across cancer populations. However, patients with advanced CKD are underrepresented in APL trials, leaving a critical evidence gap. This study aimed to evaluate the impact of CKD on hospitalization outcomes among patients with APL using a large, nationally representative dataset.

Methods: We performed a retrospective cohort study using the National Inpatient Sample (2016–2022). Adult patients admitted with a primary diagnosis of APL not in remission or relapsed were included. Of 17,774 admissions, 2,295 (13%) had CKD. Discharge weights provided by the NIS were applied to generate nationally representative estimates. The primary outcome was in-hospital mortality; secondary outcomes included need for mechanical ventilation, packed red blood cell (pRBC) transfusion, and continuous renal replacement therapy (CRRT). Multivariable logistic and linear regression models were used to assess outcomes, adjusting for demographics, hospital characteristics, Charlson Comorbidity Index, mechanical ventilation, septic shock, and ICU admission.

Results: Patients with APL and CKD were older (mean age 64.5 vs 51.5 years, p < 0.0001) and more often male (51% vs 48%, p = 0.0002). Racial distribution was: White (63%), Black (12%), Asian (15%), American Indian/Alaska Native (3%), Native Hawaiian/Pacific Islander (0.3%), and multiracial (4%) (p < 0.0001). Most CKD admissions occurred in urban teaching hospitals (68%, p = 0.56). Unadjusted in-hospital mortality was higher in patients with CKD (13% vs 0.09%, p = 0.03), but not significant after adjustment (aOR 0.71, p = 0.14). Native Hawaiian/Pacific Islander and multiracial patients had significantly higher adjusted odds of mortality (aOR 6.8, p = 0.014; aOR 1.7, p = 0.044, respectively). Mean length of stay (LOS) was similar overall, but among CKD patients, those admitted to urban teaching hospitals had 9 days longer LOS than rural hospitals, and those in larger hospitals (>500 beds) had LOS 8 days longer than in smaller hospitals. Differences in hospitalization costs were not statistically significant.

Regarding secondary outcomes CKD was associated with lower odds of mechanical ventilation (aOR 0.72, p = 0.05) among patient with APL, possibly reflecting treatment limitations or goals-of-care considerations. Asian patients had higher odds of mechanical ventilation than White patients (aOR 2.05, p = 0.014). Patients with CKD were also less likely to receive pRBC transfusions (aOR 0.74, p = 0.041), potentially due to fluid overload concerns or more conservative strategies. Transfusion odds were higher among American Indian/Alaska Native (aOR 1.28, p = 0.02) and Asian patients (aOR 2.03, p = 0.002) compared to White patients. CRRT use was higher in CKD patients (aOR 1.2, p = 0.6), though not statistically significant. Among Asian patients, CRRT use was significantly more likely (aOR 3.9, p = 0.017) compared to White patients.

Conclusion: In this national cohort of hospitalized patients with active APL, CKD was not independently associated with increased mortality. However, it was linked to lower use of mechanical ventilation and pRBC transfusions, suggesting potential differences in treatment intensity or decision-making. Racial disparities were observed across several outcomes, particularly among Asian and multiracial populations. These findings highlight the need for individualized management strategies and further research into how CKD and race influence APL-related outcomes.

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2025
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