A case of Hodgkin’s lymphoma with severely impaired liver function treated successfully with gemcitabine followed by ABVD

Figures & data

Table 1 Laboratory data (infectious and autoimmune workup)

Variable	Reference range	Value	Interpretation	Day
Hepatitis B surface Ab		Reactive	Positive	1
Hepatitis B surface Ag		Non-reactive	Negative	1
Hepatitis B core Ab		Non-reactive	Negative	1
Hepatitis C Ab		Non-reactive	Negative	1
CMV Ab (IgM)	<0.91	0.39	Negative	2
EBV capsid Ab IgG	<0.91	1.41	Positive	2
EBV capsid Ab IgM	<0.91	0.00	Negative	2
EBNA Ab IgG	<0.91	4.10	Positive	2
CMV Ab (IgG)	<0.9	1.12	Positive	2
Parvovirus B19 Ab (IgG)	<0.9	4.1	Positive	2
Parvovirus B19 Ab (IgM)	<0.9	0.3	Negative	2
Mono heterophile Ab		Negative	Negative	2
Haptoglobin	16–200 mg/dL	203	Elevated	2
Urine histoplasma Ag			Negative	6
Serum histoplasma Ab			Negative	6
JAK 2 mutation			Negative	8
HIV-1 RNA, quantitative	<48 copies/mL	<48 copies/mL	Negative	11
Dengue IgG Ab	<0.9	0.23	Negative	12
Dengue IgM Ab	<0.9	0.24	Negative	12
Syphilis IgG		Negative	Negative	12
ANA		Negative	Negative	21
Anti-SM Ab	<1:20	1:80	Positive	21
Anti-mitochondrial Ab		Negative	Negative	21
CMV DNA quantitative	<200 copies/mL	<200 copies/mL	Negative	25

Abbreviations: ANA, anti-nuclear antibody; Anti-SM, anti-smith antibody; CMV, cytomegalovirus; EBNA, Epstein–Barr nuclear antigen; EBV, Epstein–Barr virus.

Table 2 Laboratory data

Variable	Reference range	Hospital Day (D)
		D 1	D 10	D 12	D 20	D 30	D 33	2 months	6 months	2 years
Hemoglobin (g/dL)	13.5–17.5	6.6	9.3	8.6	8.7	9.4	8.9	13	14.4	15.7
Hematocrit (%)	41–53	20	26.9	25.1	25.3	27.3	25.8	38.2	43.1	46.5
White cell count (k/mm^3)	4.5–11	3.1	1.7	1.6	1.9	3.5	3.4	4.1	2.9	8.2
Neutrophils (%)	40–70	58.3	60.1	63	72.2	70.1	59.6	48.9	21.4	69.7
Lymphocytes (%)	22.2–43.6	19.9	19.7	19.5	17.8	25.7	36.8	47.7	63.7	22.7
Monocytes (%)	2–11	21.2	19.9	17.5	9.8	3.7	3.2	1.5	13.3	5.6
Eosinophils (%)	0–7.5	0.4	0.5	0.0	0.1	0.2	0.3	0.2	1.6	0.3
Basophils (%)	0–2	0.2	0.1	0.0	0.1	0.3	0.1	1.7	0	1.7
Platelets (k/mm^3)	130–400	76	57	38	41	10	52	223	247	175
Alkaline phosphatase (u/L)	30–115	611	546	666	821	597	597	107	77	74
Aspartate aminotransferase (u/L)	5–40	42	75	107	106	34	34	27	30	22
Alanine aminotransferase (u/L)	5–50	28	37	60	190	125	125	42	41	25
Gamma glutamyl transpeptidase (u/L)	3–40	68	126	128	253	178	178	122	122	27
Lactate dehydrogenase (u/L)	90–225	581	510	553	412	125	125	149	126	141
Albumin (g/dL)	3.5–5	2.2	1.7	1.5	1.5	2.7	2.7	4.2	4.4	4.4
Total bilirubin (mg/dL)	0–1.5	2.67	2.62	5.39	9.22	2.39	2.39	1.02	0.66	0.63
Conjugated bilirubin (mg/dL)	0–0.3	1.25	1.51	3.64	5.76	1.05	1.05	0.20	0.05	0.15
Serum creatinine (mg/dL)	0.4–1.6	0.9	0.8	0.8	0.8	0.5	0.5	0.5	0.8	0.9

Table 3 Manufacturer recommended dose reduction of chemotherapeutic agents used in Hodgkin’s lymphoma

Drug	Moderate hepatic impairment	Severe hepatic impairment	Renal impairment
Doxorubicin	50% dose reduction for bilirubin 1.2–3.0 mg/dL^Citation1	75% dose reduction for bilirubin 3.1–5.0 mg/dL^Citation1	No dose adjustment needed
Bleomycin	No dose adjustment needed	No dose adjustment needed	CrCl 40 to 50 mL/min (70% dose); CrCl 30 to 40 mL/min (60% dose); CrCl 20 to 30 mL/min (55% dose); CrCl 10 to 20 (45% dose); CrCl 5 to 10 mL/min (40% dose)^Citation2
Vinblastine	No dose adjustment needed	50% dose reduction for direct bilirubin greater than 3 mg/dL^Citation3	No dose adjustment needed
Dacarbazine	Precaution recommended	Precaution recommended	Precaution recommended
Mechlorethamine	No dose adjustment needed	No dose adjustment needed	No dose adjustment needed
Vincristine	No dose adjustment needed	50% dose reduction if direct serum bilirubin greater than 3 mg/dL^Citation4	No dose adjustment needed
Procarbazine	No dose adjustment needed	No dose adjustment needed	No dose adjustment needed
Etoposide	Dose reduction by 50% for bilirubin 1.5–3.0 mg/dL^Citation5	Not recommended for bilirubin greater than 3.0 mg/dL^Citation5	25% dose reduction recommended for CrCl 15–50 mL/min
Methylprednisolone	No dose adjustment needed	No dose adjustment needed	No dose adjustment needed
Cytarabine	Dose may need to be reduced, exact data not available	Dose may need to be reduced, exact data not available	Dose may need to be reduced, increased neurotoxicity associated with CrCl less than 60 mL/min
Cisplatin	Data not available	Data not available	Repeat courses not recommended until serum creatinine less than 1.5 mg/dL and/or BUN is less than 25 mg/dL^Citation6
Cyclophosphamide	No dose adjustment needed	No dose adjustment needed	No dose adjustment needed

Abbreviations: BUN, blood urea nitrogen; CrCl, creatinine clearance rate.

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