Day 30 Mortality in Patients with AML: A Single Center Analysis Based on 1036 Patients

Introduction: Early death mortality influences the outcome of patients with AML. This study aims to analyze clinical, hematological, and cytogenetic characteristics as well as patterns of therapy in patients with AML with regard to the frequency of day 30 mortality.

Methods: Day 30 mortality was assessed in all patients diagnosed and treated between 2007 and 2023 at our institution (n=1036). Causes and time of death were assessed in detail including death certificates and medical reports. 59 patients (5.7%) had best supportive care (BSC) only, 158 (15.3%) received HMA, 465 (44.9%) were treated with induction chemotherapy, 334 patients (32.2%) were treated with low dose cytoreduction, and 20 (1.9%) underwent allogeneic stem cell transplantation as first line therapy.

Results: 10.2% of the entire patient population died within 30 days. 58% of the patients who received BSC therapy only died within 30 days. 15% of patients who received low dose cytoreduction died within 30 days. 7.1% of patients treated with HMA as first line therapy died within 30 days. 2.2% of patients who underwent induction chemotherapy as first line therapy died within 30 days, and no patient died within 30 days who received allogeneic stem cell transplantation.

We then analyzed parameters that may be associated with day 30 mortality. In the entire patient cohort age >64 years, ECOG status of >3, Karnofsky status of <50, HCTCI of >2, coronary heart disease, ELN risk category of intermediate or high, aberrant karyotype, WBC >100.000/µl, platelet count <50.000/µl, elevated LDH, blasts in peripheral blood <10%, and type of firstline therapy were associated with an increased risk of day 30 mortality. In patients who were treated with induction chemotherapy, ECOG status of >3, Karnofsky status of <50, high MDS-CI, ELN risk category of intermediate or high, the presence of coronary heart disease, WBC >100.000/µl, peripheral blasts of >10%, platelet count <50.000/µl, elevated LDH, as well as PT<70 were risk parameters. In patients receiving HMA only and in patients who underwent allogeneic stem cell transplantation we could not find predicting parameters. In patients who received best supportive care only, ECOG status of 3 or more, WBC >12.000/µl, and elevated LDH were risk parameters. In patients who received low dose cytoreduction, ECOG status of >3, Karnofsky status of <50, HCTCI of >2, ELN risk category intermediate or high, aberrant karyotype, and WBC >100.000/µl could be identified as risk parameters for day 30 mortality.

In a multivariate analysis for the entire patient group choice of firstline therapy (BSC versus low dose cytoreduction versus HMA or induction or allogeneic stem cell transplantation) (p<0.001), ECOG performance status of >3 (p<0.001), blasts in peripheral blood >10% (p=0.008), aberrant karyotype (p=0.01), and WBC >100.000/µl (p<0.02) were identified to be independently associated with an increased risk for day 30 mortality. When then tested by multivariate analyses the group of patients who received induction chemotherapy, HMA, or allogeneic stem cell transplantation as first line therapy, WBC>100.000/µl (p<0.001), platelet count <50.000/µl (p=0.006), and blasts in peripheral blood >10% (p=0.02) were the only parameters associated with increased risk of day 30 mortality.

Conclusion: Day 30 mortality in AML must be expected in about 10% of patients. The majority of patients in our department (80%) died without receiving AML treatment besides cytoreduction, whereas day 30 mortality was significantly lower in patients receiving HMA, induction chemotherapy, or first line allogeneic stem cell transplantation and was mainly dependent on performance status and choice of treatment. In view of these data, treatment should be offered whenever possible.