Acute renal failure, gastrointestinal bleeding, and cardiac arrhythmia after administration of arsenic trioxide for acute promyelocytic leukemia

Abstract

The case of a patient who developed acute renal failure, gastrointestinal bleeding, and cardiac arrhythmia after receiving arsenic trioxide for the treatment of acute promyelocytic leukemia (APL) is described. An 84-year-old Caucasian woman with a history of osteoarthritis sought medical attention for relapse of her APL, which had initially been diagnosed approximately 30 months earlier. Complete remission was accomplished with three cycles of i.v. daunorubicin for 3 days and oral tretinoin for 28 days. After 19 months in remission, she was noted to have increased bruising and blood test values consistent with APL relapse. Two additional trials of oral tretinoin were unsuccessful, and arsenic trioxide was initiated at a daily dosage of 0.15 mg/kg of actual body weight. Less than 24 hours after receiving arsenic trioxide, the patient had "bile-like emesis" and her hemoglobin level decreased. Upper gastrointestinal bleeding was suspected and managed aggressively with transfusions of platelets and fresh frozen plasma and i.v. desmopressin. She became anuric, and her serum creatinine level more than doubled. Hemodialysis was started due to a sudden increase in potassium and fluid overload that did not respond to i.v. furosemide. One hour after hemodialysis, the patient was found pulseless and unresponsive by nursing staff. The cardiac arrest team rapidly responded and noted atrial fibrillation with a fast ventricular rate. Postresuscitation, the patient was transferred to the intensive care unit. Despite aggressive life-support therapy, the patient remained unresponsive. An 84-year-old woman developed acute renal failure, gastrointestinal bleeding, and cardiac arrhythmia after receiving arsenic trioxide for the treatment of APL.