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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 634-636

Tranexamic acid-induced acute renal failure in a pediatric patient with acute myeloid leukemia: A cautionary note


Department of Medical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India

Date of Submission26-Apr-2020
Date of Decision09-Jun-2020
Date of Acceptance11-Jun-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Venkatraman Radhakrishnan
Department of Medical Oncology, Cancer Institute (WIA), 36, Sardar Patel Road, Guindy, Chennai - 600 036, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_158_20

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How to cite this article:
Mehra N, Radhakrishnan V. Tranexamic acid-induced acute renal failure in a pediatric patient with acute myeloid leukemia: A cautionary note. Cancer Res Stat Treat 2020;3:634-6

How to cite this URL:
Mehra N, Radhakrishnan V. Tranexamic acid-induced acute renal failure in a pediatric patient with acute myeloid leukemia: A cautionary note. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Oct 25];3:634-6. Available from: https://www.crstonline.com/text.asp?2020/3/3/634/295534



Tranexamic acid is an antifibrinolytic drug used as a prophylactic and therapeutic agent in the setting of bleeding.[1] It acts by reversibly binding to plasminogen or plasmin, thereby preventing it from degrading the fibrin. However, the antifibrinolytic action of tranexamic acid can lead to abnormal clot formation, thus predisposing an individual to thromboembolism. Here, we report a case of tranexamic acid-induced acute renal failure, secondary to obstructive uropathy caused by clots.

A 5-year-old boy was diagnosed with acute myeloid leukemia (AML) M2-subtype at our hospital. His disease was in remission after the first cycle of daunorubicin and cytarabine arabinoside (3 + 7) induction. Post the second 3 + 7 induction, on day 15, he developed gross hematuria. His platelet count was 20 × 109/L, and he showed no clinical or laboratory features of sepsis or disseminated intravascular coagulation (DIC). The patient had no history of thrombotic disorders or inherited thrombosis predisposition syndromes. A routine urine test revealed the presence of red blood cells, casts and pus cells were absent, and the urine culture was sterile. His coagulation parameters were within the normal limits. As the hematuria could not be controlled with random and single-donor platelet transfusions, the patient was prescribed intravenous tranexamic acid (10 mg/kg every 8 hours). After the third dose of tranexamic acid, he developed severe lower abdominal pain and anuria. His serum creatinine level increased from 0.5 mg/dL to 2.4 mg/dL after the onset of symptoms. An ultrasound of the abdomen revealed a sub-urothelial right renal pelvic hematoma and bilateral hydroureteronephrosis with diffuse urothelial thickening on both sides; a noncontrast computed tomographic scan of the abdomen revealed a hematoma in the right proximal ureter [Figure 1]. He was, therefore, diagnosed with tranexamic acid-induced acute renal failure secondary to ureteropelvic obstruction due to a blood clot. The patient underwent four cycles of hemodialysis and required oral nifedipine to control his hypertension. On day 5, he resumed normal urine output with the passage of blood clots, and his renal parameters normalized thereafter. He did not present with similar issues during his subsequent consolidation chemotherapy cycles. No evaluation of thrombotic disorders in the patient was performed. The timeline of the patient's clinical events is shown in [Figure 2].
Figure 1: Computed tomography scan showing a clot in the right ureteropelvic junction (arrow)

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Figure 2: Timeline of the clinical events

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Tranexamic acid can cause clotting of blood in the kidneys, ureters, or bladder in patients with hematuria because of its antifibrinolytic action. It has been used for treating life-threatening hematuria, especially in patients with polycystic kidney disease.[2] However, patients with polycystic kidney disease have been shown to develop bilateral ureteric obstruction due to the formation of blood clots after the administration of tranexamic acid.[3] Routine use of tranexamic acid in urological surgery is not recommended, unless the bleeding is problematic.[1] A randomized controlled trial has reported the benefit of the prophylactic use of tranexamic acid in bringing down the number of platelet transfusions during induction and consolidation in patients with AML; however, this study did not include patients with symptomatic hematuria.[4] In another randomized trial for the use of tranexamic acid in patients with hematological malignancies and thrombocytopenia, patients with visible hematuria were excluded from the study.[5] Tranexamic acid has been used for bladder irrigation to control bleeding from the bladder.[6] Schultz and van der Leliereported three patients, one with aplastic anemia, one with idiopathic thrombocytopenia, and one with chronic myeloid leukemia, who developed obstructive uropathy due to ureteric or urethral clots after the administration of tranexamic acid to control bleeding secondary to thrombocytopenia.[7] All three patients had microscopic hematuria at the time of presentation. Therefore, it is essential to rule out microscopic hematuria in patients before the administration of tranexamic acid. There are reports of tranexamic acid-induced renal cortical necrosis in patients who did not have hematuria.[8] A study by Ben-Bassat etal. showed that the use of tranexamic acid leads to a reduced need for platelet transfusions in patients with AML who have mucosal bleeds.[9] However, it is not known whether the patients in this study had hematuria. Tranexamic acid is contraindicated in patients with hemophilia who develop hematuria, as it can lead to mechanical obstruction due to ureteral clots.[10] Tranexamic acid may be administered during the early fibrinolytic phase of DIC to control bleeding.[11] The role of tranexamic acid in the treatment of hematuria is debatable. Studies suggest that the systemic use of tranexamic acid in patients with gross or microscopic hematuria is more harmful than beneficial. Through this case report, we want to sensitize the oncologists to the complications associated with the use of tranexamic acid in patients with hematuria. In conclusion, tranexamic acid should be used with caution, and its use should be reserved for life-threatening hematuria rather than mild hematuria.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images, and other clinical information to be reported in the journal. The patient understand that their name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Reed MR, Woolley LT. Uses of tranexamic acid. Contin Educ Anaesth Crit Care Pain 2015;15:32-7.  Back to cited text no. 1
    
2.
Alameel T, West M. Tranexamic acid treatment of life-threatening hematuria in polycystic kidney disease. Int J Nephrol 2011;2011:203579.  Back to cited text no. 2
    
3.
Vujkovac B, Sabovic M. A successful treatment of life-threatening bleeding from polycystic kidneys with antifibrinolytic agent tranexamic acid. Blood Coagul Fibrinolysis 2006;17:589-91.  Back to cited text no. 3
    
4.
Shpilberg O, Blumenthal R, Sofer O, Katz Y, Chetrit A, Ramot B, et al. A controlled trial of tranexamic acid therapy for the reduction of bleeding during treatment of acute myeloid leukemia. Leuk Lymphoma 1995;19:141-4.  Back to cited text no. 4
    
5.
Estcourt LJ, McQuilten Z, Powter G, Dyer C, Curnow E, Wood EM, et al. The TREATT Trial (Trial to evaluate tranexamic acid therapy in thrombocytopenia): Safety and efficacy of tranexamic acid in patients with haematological malignancies with severe thrombocytopenia: Study protocol for a double-blind randomised controlled trial. Trials 2019;20:592.  Back to cited text no. 5
    
6.
Moharamzadeh P, Ojaghihaghighi S, Amjadi M, Rahmani F, Farjamnia A. Effect of tranexamic acid on gross hematuria: A pilot randomized clinical trial study. Am J Emerg Med 2017;35:1922-5.  Back to cited text no. 6
    
7.
Schultz M, van der Lelie H. Microscopic haematuria as a relative contraindication for tranexamic acid. Br J Haematol 1995;89:663-4.  Back to cited text no. 7
    
8.
Odabaş AR, Cetinkaya R, Selçuk Y, Kaya H, Coşkun U. Tranexamic-acid-induced acute renal cortical necrosis in a patient with haemophilia A. Nephrol Dial Transplant 2001;16:189-90.  Back to cited text no. 8
    
9.
Ben-Bassat I, Douer D, Ramot B. Tranexamic acid therapy in acute myeloid leukemia: Possible reduction of platelet transfusions. Eur J Haematol 1990;45:86-9.  Back to cited text no. 9
    
10.
Chaplin S. The use of tranexamic acid in reducing bleeding complications. J Haem Pract 2016;3:1-9.  Back to cited text no. 10
    
11.
Thachil J. Disseminated intravascular coagulation: A practical approach. Anesthesiology 2016;125:230-6. [Figure 1]: Computed tomography scan showing a clot in the right uretero-pelvic junction (arrow)  Back to cited text no. 11
    


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  [Figure 1], [Figure 2]



 

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