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BACKGROUND: The purpose of our study was to determine whether spontaneousand post-initial therapy apoptosis indexes (AI) and the intracellular pH of blasts have prognostic valuein the treatment of children with acute leukemia.MATERIAL/METHODS: Blasts from 38 children with acuteleukemia (31 with ALL and 7 with AML) were tested for apoptotic index (Annexin V) and intracellular pH(SNARF). Of the ALL patients, 9 were low risk, 7 medium risk, and 15 high risk. Among the AML patients,1 was low risk and 6 were high risk. Follow-up ranged from 6 to 120 weeks (median 60 weeks).RESULTS:The mean spontaneous AI was 19 +/-16%. The pH of leukemic blasts before treatment varied between 6.6and 7.9 (mean 7.2 +/- 0.5). For patients < 10 years old, the markers for good prognosis were a WBC countbelow 50 x 10(3)/microml, good response to prednisone therapy at day 8, and remission at or before day33. Univariate analysis showed that pH < 7 had favorable prognostic significance. Overall, the probabilityof EFS for patients with pH < 7 was 1.0, as opposed to 0.49 for those with pH > 7 (p=0.049, n=36). Theprobability of EFS for patients with AI below the median was not significantly different from those withAI above the median (0.4 vs 1.0, NS).CONCLUSIONS: The assessment of intracellular pH in blasts may bean important prognosticator for ALL patients. Children with low spontaneous AI or high pH of leukemicblasts appear to have an unfavorable prognosis.