MAJOR CASE STUDY: ACUTE LYMPHOBLASTIC LEUKEMIA Jenni Wolf, DI Illinois State University UnityPoint Health – Methodist March 2018
OUTLINE: I. Patient Introduction II. Review of PMH III. HPI IV. Acute Lymphoblastic Leukemia V. Antineoplastsic Chemotherapy + Methotrexate VI. Timeline of Care a. Medical Treatment b. Medical Nutrition Therapy – ADIME VII.Prognosis VIII.Review and Reflection IX. References X. Questions
Meet N.S. Patie tient: t: N.S. Dx Dx: : IT chemotherapy tx r/t acute lymphoblastic leukemia (ALL) – Age: e: 75 y.o. F relapsed/transformed disease Heig ight: t: 5’1” Weig ight: t: 210 lb (95.3 kg) BMI: : 40 PMH: : CHF, afib, HTN Admit: mit: 01.30.18 Unit: t: Oncology/ICU LOS: S: 18 days Care e team am: : ICU, Oncology, Hematology, Nephrology, Nutrition, SLP, PT, OT, Wound, IV Pharm, Chaplain
CA Hx Augus ust t 2017 Nov. . 201 016 PET scan. f/u bone Dec. c. 2016 6 – Apr. . 2017 Stage IVB DLBCL marrow biopsy (marrow only). R-CHOP, 8 cycles consistent w/ ALL. Began HyperCVAD/IT chemo
ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)
Acute Lymphoblastic Leukemia (ALL) ■ Acute e – rapid onset and progression ■ Lympho hoblas astic ic – immature white blood cells ■ Leukem kemia ia – bone marrow or blood ■ Rapid creation and proliferation of immature white blood cells (leukemic lymphoblasts) in the blood and bone marrow. ■ Etiology unknown – acquired vs. genetic Begins in bone marrow – ■ Childhood vs. adult onset ■ Incidence: 6,000 new cases x 1 year ■ Anemia, neutropenia, thrombocytopenia ---> pancytopenia
https://www.cancer.gov/types/leukemia/patient/adult-all-treatment-pdq
https://orthoinfo.aaos.org/en/diseases--conditions/leukemia
ALL Symptoms + Treatment ■ Symptoms ■ Treatment – 4 phases – Fatigue 1. Induction therapy 2. Consolidation therapy – Weakness o Post-remission – Dizziness 3. Maintenance therapy – Fever 4. Preventative therapy – Chronic infections ■ Chemotherapy or radiation – Bruising easily ■ PRBC, platelets – Bleeding at the gums or nose – Night sweats ■ MNT – Wt loss; decreased appetite – Neutropenic diet – High-energy, high protein
TIMELINE
LOS 1 – 2 (1/30 – 1-31) ■ Admitted for final chemo cycle ---> C6 HyperCVAD/IT tx HyperCVAD: Cyclophophamide Vincristine Sulfate Adriamycin Dexamethasone Methotrexate (MTX) also given intrathecally ■ Thrombocytopenia, hypomagnesemia r/t ALL + chemo ■ Lasix r/t chronic edema ■ Afib controlled with Beta-blocker; no anticoagulation therapy ■ MST 0; tolerating tx well; no new concerns
INTRATHECAL CHEMO https://www.cancer.gov/publications/dictionaries/cancer- terms/def/intrathecal-chemotherapy
LOS 3 – 7 (2/1 – 2/5) Fever; er; Declining lining PO AKI; ; MTX toxicit icity PNA A w/ abx intake ake RRT r/t ment ntal al Alter ered mental al Cardia iac + R Renal al status, seizure re- status; Consult lted ed like e activity; ivity; ICU CT unrem remarkab arkable le trans ansfer er
METHOTREXATE- ASSOCIATED AKI
MTX Toxicity - AKI ■ MTX = essential component of chemo; used to treat a wide range of cancers ■ Interferes with folic acid metabolism – competitive inhibitor ■ Prevents synthesis of thymidine + purines, DNA ---> stops cell division ■ Risk for renal toxicity ■ Pathophysiology : MTX metabolite crystallization Blockage of renal tubules – Decreased renal flow, GFR – Reduced ability to clear MTX – ■ MTX also associated with hepatotoxicity, neurotoxicity, mucositis
MTX Toxicity ■ Frequent monitoring is Serum MTX Goals: essential 24 hr: ≤ 5.0 umol/L – Serum creatine, BUN 48 hr ≤ 0.5 umol/L – Serum MTX 72 hr ≤ 0.1 umol/L – Electrolytes – Urine output ■ Cornerstones of care: – Hydration (2.5-3 L/day pre-tx) – Urine alkalinization(pH >7) – Leucovorin “rescue” (@ 24 -36 hr)
MTX TOXICITY ▪ Dose: 12 mg ▪ Hydration: IVFs @ 50 mL/hr ▪ Bicarb infusion 7.61 61 umol/L /L x 24 hr hr ▪ Started on Leucovorin ▪ Elevated BUN, creatine ▪ Low GFR (84 ---> 27) ▪ Nephrology following 2.25 umol ol/L L x 48 hr hr Serum MTX Goals: 24 hr: ≤ 5.0 umol/L 48 hr ≤ 0.5 umol/L 0.59 9 umol/L /L x 5 d 72 hr ≤ 0.1 umol/L
LOS 8 – 9 (2/6-2/7) LOS assessmen ent: : MTX toxic icit ity: NPO r/t Leucovo vorin rin, 0.46 umol/L /L dysphagi agia; a; bicarb arb contin inues es 0.29 umol/L /L TPN consult lt Encep ephalo halopath athy; Thrombo bocytopenia penia Mucositis itis
TPN Consult Considerations: ■ Monitor electrolytes , ■ No NG tube d/t thrombocytopenia weight, plan of care ■ AKI – referred to renal for TPN volume ■ Energy needs: 1350 kcal, 42-48 g pro ■ Risk for refeeding TPN Bag #1: 45/175/0 /0 ■ Electrolytes: elevated na+, low k+ 775 kcal ■ Multiple riders given x 24 hr 12.9 kcal/k al/kg, g, 0.75 g/kg pro – 100 mEq KCL – 1 g mg++ – 1 g ca++ Nutrit ritio ion n dx: Inadequate energy intake r/t ALL, chemo , dysphagia, encephalopathy as evidenced by NPO status, lab values.
LOS 10 – 12 (2/8-2/10) TPN continues inues; ; Encep ephalo halopath athy Pureed reed + MTX levels els @ goal impro roved ved at times es nectar ar-thick ick
TPN Trends ■ Increased volume per Nephrology – 730 mL --> 1030 mL --> 2000 mL ■ na+ remains elevated, despite minimum na+ given ■ k+, mg++, phos WNL ■ CMP, mg++, phos labs ordered TPN Bag #2: 45/175/50 TPN Bag #3 -#5: 45/180/100 875 kcal 992 kcal 14.6 kcal/kg, 0.75 g/kg pro 16.5 kcal/kg, 0.75 g/kg pro
LOS 13 – 16 (2/11-2/14) RRT r/t BiPAP; NPO; hypoxemia, emia, PRBC C + P PLT TPN bags #5-#7 #7 lethar hargy gy trans ansfusio ion Pleural al effusio ion n Fever; er; D5 @ 50 mL/hr hr via CXR encephalop halopath athy
TPN Trends TPN Bag #6: 45/180/100 1086 kcal 18.1 kcal/kg, 0.83 g/kg pro ■ Increased protein needs – GFR improving ■ No riders given x 24 hr ■ Electrolyte trends: TPN Bag #7: 55/190/150 – Na+ & phos trending towards high 1166 kcal Minimum amount given via Freeamine o 19.4 kcal/kg, 0.92 g/kg pro – K+ high 2/11, low 2/14 ■ D5 providing 204 kcal/d ■ TG lab ordered TPN Bag #8: 55/205/180 1277 kcal 21.3 kcal/kg, 0.92 g/kg pro
LOS 17 – 18 (2/15-2/16) Comfo fort rt care re Trans nsfer fer to 7H TPN d/c measures res Oncology gy
TPN LAB TRENDS
Phospho horu rus
Potas assiu ium Phospho horu rus
Magnes nesiu ium Phospho horu rus Potas assiu ium
Phospho horu rus GFR Potas assiu ium
REVIEW + REFLECTION
My Thoughts… ■ Continued need for research AKI common with – chemotherapy tx MTX toxicity o Tumor Lysis o Syndrome ■ Better prevention, prophylaxis
My Thoughts… ■ I feel the appropriate approach to MNT was taken with this patient: NPO ---> TPN ---> Puree + TPN ---> TPN ■ Opportunity to apply field knowledge in context of larger medical picture ■ Was able to gain interdisciplinary and ICU experience ■ Appreciated the opportunity to follow and work on a TPN for a length of time – Improved knowledge + confidence
REFERENCES Academy of Nutrition and Dietetics. (2013). Evidence analysis library: Oncology. Retrieved from https://www.andeal.org/topic.cfm?menu=5291 Dana-Farber Cancer Institute. (2018). Acute lymphoblastic leukemia (ALL). Retrieved from http://www.dana-farber.org/acute- lymphoblastic-leukemia-all/about/ Freeman, T. R. (2017). Leukemia. Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/leukemia Howard, S.C., McCormick, J., Pui, C., Buddington, R.K., & Harvey, R.D. (2016). Preventing and managing toxicities of high-dose methotrexate. The Oncologist. http://dx.doi.org/10.1634/theoncologist.2015-0164 LaCasce, A.S. (2018). Therapeutic use and toxicity of high-dose methotrexate. Retrieved from https://www.uptodate.com/contents/therapeutic-use-and-toxicity-of-high- dose-methotrexate?csi=1bd7b7e6-4f10-4b7b-a7a8-7efb769704dd&source=contentShare May, J., Carlson, K.R., Butler, S., Liu, W., Bartlett, N.L., & Wagner-Johnson, N.D. (2014). High incidence of methotrexate associated renal toxicity in patients with lymphoma: A retrospective analysis. LeukLymphoma, 55, 6, 1345-1349. doi:10.3109/10428194.2013.840780 Mayo Clinic. (2017). Acute lymphocytic leukemia. Retrieved from https://www.mayoclinic.org/diseases-conditions/acute-lymphocytic- leukemia/symptoms-causes/syc- 20369077 PDQ Adult Treatment Editorial Board (2018). PDQ adult acute lymphoblastic leukemia treatment. Retrieved from https://www.cancer.gov/types/leukemia/patient/adult- all-treatment-pdq Raetz, E. (2018). Acute lymphoblastic leukemia. Retrieved from http://www.lls.org/leukemia/acute-lymphoblastic-leukemia The American Cancer Society Medical and Editorial Content Team. (2016). What is acute lymphocytic leukemia? Retrieved from https://www.cancer.org/cancer/acute- lymphocytic-leukemia/about/what-is-all.html The American Cancer Society Medical and Editorial Content Team. (2018). Key statistics for acute lymphocytic leukemia. Retrieved from https://www.cancer.org/cancer/acute- lymphocytic-leukemia/about/key-statistics.html Windpessl, M., Mayrbaeurl, B., Baldinger, C., Tiefenthaller, G., Prischl, F. C., Wallner, M., & Thaler, J. (2017). Refeeding syndrome in oncology: Report of four cases. World J Oncol, 8, 1, 25-29. https://doi.org/10.14740/wjon1007w
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