Haemostatic problems in acute leukaemia.

Disseminated intravascular coagulation (DIC) is a frequent complication of acute leukaemia, in particular acute promyelocytic leukaemia. Although procoagulant substances released from leukaemic blast cells may induce DIC by activating conventional coagulation pathways, there is increasing evidence to suggest that direct activation of fibrinogen by proteases released from blast cells may be the predominant mechanism by which DIC is initiated. Primary fibrinolysis has also been proposed as the cause of the haemorrhagic diathesis in some cases of acute leukaemia. Although plasminogen activators have been demonstrated in leukaemic blast cells supporting this view, cases of primary fibrinolysis would appear to be rare. A bleeding tendency attributed to primary fibrinolysis may more often be the result of an exaggerated fibrinolytic response secondary to DIC. The main strategies of treatment for leukaemia associated DIC are rapid initiation of chemotherapy and vigorous blood product support until the DIC resolves once the blast cells have been eradicated. The role of heparin in the management of leukaemia associated DIC remains controversial. There is recent evidence to suggest that heparin therapy does reduce the incidence of haemorrhagic death although it has been recommended that relatively low intravenous doses should be administered initially to reduce the risk of heparin induced haemorrhage.