Management of Acute Myeloid Leukemia in a Dialysis-Dependent Patient: A Case Report, Literature Review, and Therapeutic Considerations

Acute myeloid leukemia (AML) in patients with end-stage renal disease (ESRD) requiring hemodialysis presents numerous challenges to clinicians, including selection of appropriate chemotherapy agents, safe dose adjustment, and supportive care management. Due to the lack of prospective studies in patients undergoing dialysis, it is difficult to determine the optimal therapeutic approach for this population. These patients are commonly excluded from large-scale AML clinical trials, which further complicates the determination of effective management strategies and associated toxicities. We present the case of a 51-year-old man with ESRD on hemodialysis who developed an adverse-risk AML (characterized by a BCL6 corepressor (BCOR) mutation with runt-related transcription factor 1 (RUNX1) and nuclear receptor-binding SET domain protein 1 (NSD1) abnormalities). Initial presentation was notable for profound pancytopenia without circulating blasts, although peripheral blood flow cytometry confirmed AML. Management required a multidisciplinary discussion with leukemia specialists, nephrology, and pharmacy. The patient was treated with azacitidine and venetoclax rather than intensive induction chemotherapy because of dialysis dependence, cardiovascular comorbidities, and anticipated toxicity. Azacitidine was administered after dialysis sessions, while venetoclax dosing was adjusted because of concomitant posaconazole prophylaxis. Repeat molecular testing no longer detected previously identified BCOR and RUNX1 abnormalities, although a persistent NSD1 variant remained detectable, and molecular remission could not be confirmed. Treatment was successfully continued through 12 cycles without clinically significant tumor lysis syndrome. Approximately one year after diagnosis, relapsed AML was identified on peripheral blood flow cytometry. This case highlights the feasibility of venetoclax-based lower-intensity therapy in selected dialysis-dependent AML patients while underscoring the persistent therapeutic limitations and adverse prognosis associated with relapsed disease in this population.