Early Treatment-Related Mortality in Acute Leukemia: A Real-World, Single-Center Study From a Resource-Limited Setting.

Background and objectives Treatment-related mortality (TRM) remains a significant barrier to successful outcomes in acute leukemia despite therapeutic advances. This study aimed to evaluate the frequency, clinical features, and risk factors associated with early TRM in a real-world cohort from a resource-limited setting, defined as death occurring within 30 days of treatment initiation. The primary aims of this study were to evaluate the incidence and timing of early death (ED) and TRM across different blood cancer classifications. The secondary aim was to identify the specific clinical causes, such as infectious complications, hemorrhagic events, or refractory disease, that drive these fatalities. Methods We retrospectively analyzed 155 patients aged 14 to 100 years diagnosed with acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), acute promyelocytic leukemia (APL), or acute undifferentiated leukemia (AUL) between 2016 and 2025 at a single tertiary center in Iraq. Patients received standard treatment protocols, including the 3+7 regimen, UKALL XC, ATRA/ATO (all-trans retinoic acid and arsenic trioxide), hyper-CVAD (hyper-fractionated cyclophosphamide, vincristine, adriamycin, and dexamethasone), azacitidine, ATRA/idarubicin, and others. Results The overall TRM rate was 9.0% (14/155). APL patients demonstrated the highest mortality at 28.6% (8/28), followed by ALL at 5.1% (3/59), and AML at 4.5% (3/66). Female patients accounted for 78.6% of deaths. The principal causes were sepsis (42.9%), differentiation syndrome (28.6%), intracranial hemorrhage (21.4%), and alveolar hemorrhage (7.1%). No statistically significant differences in clinical parameters were observed between patients with ED and those without ED. Conclusions TRM rates remain substantial, particularly among APL patients, with infection representing the predominant cause. These real-world findings highlight the need for early risk recognition, rapid supportive care, and improved treatment pathways for acute leukemia in resource-limited settings.