AML-174 Dilemma of Treating Acute Myeloid Leukemia Patient After Kidney Transplant in the COVID-19 Era

Context: The incidence of malignancy increases after solid organ transplantation, which might be related to recipients' age and immunosuppressive drugs; this is accounted as the 3rd leading cause of death. Therefore, understanding cancer facts after transplantation is mandatory for transplant recipients' long-term care. Objective: A case study of a secondary acute myeloid leukemia (AML) patient after renal transplant complicated by COVID-19 infection. Design: A case report. Setting: Hematology Unit/Oncology Center, Mansoura University, Egypt. Patient: A 53-year-old male patient with a history of renal transplant due to end-stage renal failure since 2001. He was on steroids, cyclosporine (CSA), and mycophenolate mofetil since then. On December 31st, 2019, AML diagnosis (FAB-M4 AML) was confirmed by bone marrow aspiration (BMA), biopsy, and immunophenotyping (IPT). Cytogenetic and molecular analyses were negative for t(8;21), t(15;17), t(16;16), and FLT3 mutation. Interventions: He received induction chemotherapy with dose-adjusted 7+3, and immunosuppressant doses were reduced to steroids 10 mg and CSA 75 mg. BMA at D+28 showed complete remission (CR). The response was consolidated by 2 cycles of 5+2. On May 4th, 2020, CBC showed leukocytosis and anemia; BMA showed normocellular marrow with 5% blasts. Thus, he received 5 days of mitoxantrone with etoposide, and BMA reassessment was in CR. The patient's performance (PS) worsens after chemotherapy, so he continued subcutaneous cytarabine. On June 30th, 2020, the patient presented with fever and dyspnea. Relapse was confirmed by IPT and FLT-3 positivity. Chest high-resolution computed tomography (HRCT) showed bilateral mild pleural effusion and cardiomegaly. COVID-19 PCR was positive. Main Outcome Measures: The challenge was how to deal with relapse, COVID-19, and poor PS and kidney condition. He received dose-adjusted hydroxyurea with supportive measures, anticoagulant, and continued steroids. Results: Unfortunately, on August 4th, 2020, the patient was admitted to the ICU with disturbed consciousness and hyperleukocytosis with progression of HRCT and died. Conclusions: Our case had a unique presentation as the diagnosis of AML was very late after renal transplant. Managing the case was challenging as there is no consensus for this category of patients with the dilemma associated with their disease and the additional COVID-19 burden. Further studies are needed to validate a chemotherapy protocol for these patients.