AML-M5 and DIC Morning Report

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AML-M5 and DICMorning Report

• Tuesday, July 24, 2007
• Dave Rometo

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Acute Myelogenous Leukemia

• M1 myeloblastic
• M2 myeloblastic with maturation
• M3 promyelocytic
• M4 myelomonocytic
• M5 monocytic
• M6 erythroleukemia
• M7 megakaryoblastic

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AML-M5 Acute Monocytic Leukemia

• 7-15 of adult ANLL
• gt20 blasts in marrow
• gt80 of blasts of monocytic lineage
• M5a monocytic cells gt80 monoblasts
• M5b lt80 (mixture with promonocytes)
• Monocytic markers CD11b, CD11c

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DIC

• Disseminated intravascular coagulation
• i.e. Consumption coagulopathy, Defibrination
  syndrome
• Systemic, /- thrombosis, /- hemorrhage

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Components

• Exposure of blood to procoagulants
• Formation of fibrin in the circulation
• Fibrinolysis
• Depletion of clotting factors
• End-organ damage

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Pathogenesis

• Generation of thrombin overwhelms the
  antithrombotic pathways
• Thrombin circulates-gt widespread deposition of
  fibrin
• Tissue ischemia
• Consumption of platelets, fibrinogen,
  prothrombin, factor V and VIII

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Acute (decompensated)

• Bleeding diathesis predominates
• Liver and bone marrow cannot compensate for
  consumption
• Unlike chronic, where thrombosis predominates

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Etiology

• Sepsis
• Trauma
• Malignancy
• Obstetrical complications (i.e. amniotic fluid
  embolism and abruptio placenctae)

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DIC in Malignancy

• 7 of clin. sig. DIC
• Usually chronic, thrombotic (Trousseaus)
• Acute in AML-M3, promyelocytic
• Pulmonary or cerebrovascular hemorrhage
• In M3, tx w/ all-trans-retinoic acid induces cell
  differentiation

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Diagnosis labs

• Platelets lt 100K
• High FDP, D-dimer (accelerated fibrinolysis)
• High PT (factors II, V, VII, X)
• High aPTT (8,9,11,12)
• Low fibrinogen, but may be elevated as acute
  phase reactant
• Low AT (sensitive for poor prognosis)

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Factor replacement

• FFP, thawed plasma, and 24 hour frozen plasma
  (one unit) All soluble plasma proteins from one
  unit of whole blood. Correction of bleeding due
  to excess warfarin, vitamin K deficiency, or
  deficiency of multiple coagulation factors (eg,
  DIC, liver disease, dilutional coagulopathy).
  Initial dose 15 mL/kg. Treatment of TTP-HUS
• Cryo-precipitate (one bag) 10-15 mL of cold
  insoluble protein from one unit of FFP
  Pasteurized contains vWF, factors VIII, XIII,
  fibrinogen, fibrinonectin. Source of fibrinogen
  (200 mg/bag). For bleeding in vWD 1 bag/10 kg q
  6-12 hrFactor XIII deficiency 1 bag/10 kg
  usually onceFactor VIII deficiency 100
  units/bag. This use is outmoded recombinant
  factor VIII should be used

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Acknowledgements

• UpToDate.com (e-mail yourself an article from
  work to get a 1 month free access from
  home/anywhere)
• Dr. Thomas Stinchcombe