Successful management of transformed chronic myelomonocytic leukemia in a background of CKD in a resource poor setting

Chronic myelomonocytic leukemia (CMML), a myeloid neoplasm with features of both myelo-proliferative neoplasm (MPN) and myelodys-plastic syndrome (MDS), presents with peripheral blood (PB) monocytosis and has an inherent risk for transformation to acute myeloid leukemia (AML)1,2. Clonal cytogenetic changes are seen in around 30% of patients, while gene mutations are seen in >90% of patients4. Transformed AML shows a poor median overall survival (OS) and a modest survival advantage only with curative allogenic haemopoietic stem cell transplant (HSCT) [4]. We report here a patient with CMML, transformed to AML who achieved a good response with a hypomethylating agent (HMA). A 76-year-old man with multiple co-morbidities including stage 3B chronic kidney disease (CKD), was diagnosed with CMML with subdivision categories of myelopro-liferative-CMML, CMML-1 and managed with hydroxyurea and supportive care. Three years after the initial diagnosis of CMML, he presented with acute blast transformation (BT) along with further deranged renal functions, compromised cardiac functions and early features of tumor lysis. He was successfully managed with subcutaneous (SC) azacitidine and achieved a good response even though he didn’t reach true complete remission.