Acute renal insufficiency due to lymphomatous infiltration of the kidneys: report of six cases

Acute tubulo-interstitiel nephritis associated with diffuse large B-cell lymphoma presenting as acute renal failure

Renal infiltration in malignant lymphomas may involve the interstitium but rarely causes acute renal failure. In this report, we describe a 59-year-old woman presenting with an acute renal failure due to bilateral diffuse large B-cell non-Hodgkin's infiltration of the kidneys.

Bilateral nephromegaly simulating wilms tumor: a rare initial manifestation of acute lymphoblastic leukemia

A 7-year-old boy was referred with a provisional diagnosis of bilateral Wilms tumor. Peripheral smear revealed elevated leukocyte count with 90% blasts. Bone marrow aspiration and biopsy were hypercellular with sheets of blasts. Immunohistochemistry on paraffin sections showed a pre-B phenotype of acute lymphoblastic leukemia. Computerized tomographic scan of the abdomen showed moderate bilateral renal enlargement. Ultrasound-guided fine needle aspiration cytology of both kidneys showed blasts similar to those seen in the bone marrow. Finally, a diagnosis of pre-B acute lymphoblastic leukemia infiltrating both the kidneys was made. This case is being presented because of its rarity.

Renal disease in patients with cancer

Kidney disease is very common in patients with cancer. Nephrologists are vital members of the multidisciplinary care team for these patients. Given the high prevalence of comorbidities in patients treated for active malignancy, it is not surprising that these individuals frequently develop renal diseases that are common among other hospitalized patients, such as those arising from sepsis, hypotension or use of nephrotoxic agents (e.g. radiocontrast or antimicrobial agents). The role of the nephrologist in these cases differs little with respect to the presence or absence of cancer. On the other hand, there are several renal syndromes that are unique to patients with cancer, being caused either by the cancer itself or by its treatment. These syndromes are reviewed here. In addition, patients who are receiving chemotherapy often require dialysis for either acute or chronic kidney disease. Unfortunately, there is very little information on the clearance characteristics of most chemotherapeutic agents. In cancer patients with renal disease, both the timing of administration and the dose-adjustment of chemotherapy must rely on clinical experience and close clinical observation.

Renal cell carcinoma with non-Hodgkin's lymphoma infiltration: a case report

The coexistence of renal cell carcinoma and non-Hodgkin's lymphoma is more common than expected in the general population; however, renal cell carcinoma with infiltration by non-Hodgkin's lymphoma has rarely been reported. Here we report on a 77-year-old patient who presented with small lymphocytic lymphoma in the jugulodigastric lymph node. He underwent nephrectomy for a renal mass 5 months later. On histopathological examination, the mass was diagnosed as a grade III renal cell carcinoma with infiltrated small lymphocytic lymphoma that was positive for B-cells (CD20). This case is discussed in terms of the coexistence of these tumors and tumor to tumor metastasis.

[Metastatic renal failure]

A 52-year-old man, treated 15 months earlier for a poorly differentiated bronchial adenosquamous carcinoma, was admitted for oligoanuric renal failure preceded by macroscopic hematuria. Clinical and paraclinical investigations were unremarkable except ++proteinuria and mild echographic enlargement of both kidneys. Bilateral renal biopsy disclosed replacement of normal renal tissue by an adenocarcinomatous proliferation. Despite transient improvement and cessation of hemodialysis, the patient died one month later. Analysis of literature reveals that secondary kidney tumours -especially of bronchial origin- are more frequent than primary ones, but that cases of renal failure are uncommonly reported, probably because of underdiagnosis, poor prognosis and limited therapeutic issues. Features of previously published cases are listed in a synthetic table.

A rare case of enteropathy-associated T-cell lymphoma presenting as acute renal failure

Enteropathy-associated T-cell lymphoma (EATCL) is a high grade, pleomorphic peripheral T-cell lymphoma usually with cytotoxic phenotypes. We describe a first case of patient with EATCL that is remarkable for its fulminant course and invasion of both kidneys manifested as acute renal failure. The patient was a 23 year old woman with a long history of celiac disease. She was presented with acute renal failure and enlarged mononuclear infiltrated kidneys. Diagnosis of tubuloi-nterstitial nephritis and polyserositis was confirmed with consecutive pulse doses of steroid therapy. After reco-very, she had disseminated disease two months later. Magnetic resonance imaging showed thickened intestine wall, extremely augmented kidneys, enlarged intra-abdominal lymph nodes with extra-luminal compression of common bile duct. Laparotomy with mesenterial adipous tissue and lymph glands biopsy was done. Consecutive pathophysiological and immunohistochemical analyses confirmed the diagnosis of EATCL: CD45RO+, CD43+, CD3+. The revision of renal pathophysiology sub-stantiated the diagnosis. The patient received chemotherapy, but unfortunately she died manifesting signs of pulmonary embolism caused by tumor cells.

Acute renal failure in African children with Burkitt's lymphoma: a comparison of two treatment regimens

BACKGROUND

The outcome for patients presenting with acute renal failure and Burkitt lymphoma (BLARF) without dialysis is poor. This was a retrospective non-randomized comparative study designed to determine the outcome of two different treatment protocols.

METHODS

One group of patients (TPA) received oral allopurinol, intravenous (IV) cyclophosphamide, vincristine, methotrexate, furosemide, 8.4% sodium bicarbonate, and intrathecal (IT) methotrexate; the other (TPB) alternate day IV infusion of low dose cyclosphosphamide (125 mg/m(2) x 4 doses), IT methotrexate (Days 1 and 5) and aggressive pre-emptive anti-tumor lysis syndrome therapy including oral allopurinol and calcium lactate, IV calcium gluconate, salbutamol, insulin and infusions of furosemide, sodium bicarbonate and glucose.

RESULTS

Nine of 16 received TPA, 7 received TPB. Post chemotherapy anemia was more severe with TPA (P < 0.05). TPB patients received significantly more chemotherapy than those in TPA (P = 0.04). All 16 had tumor lysis syndrome (TLS). Six of nine patients with TPA died from this (three from other causes), two deaths in TPB were due to causes other than tumor lysis. Other evaluated outcome indices were similar in both groups.

CONCLUSION

Slow IV infusion of low dose cyclophosphamide given on alternate days in addition to pre-emptive anti-TLS measures (TPB) were associated with better outcome in BLARF patients compared to a high dose multiple chemotherapy regimen (TPA).

Precursor B-cell lymphoblastic leukemia as a cause of a bilateral nephromegaly

Nephromegaly and non-oliguric acute renal failure is an unusual manifestation of lymphoblastic infiltration of the kidneys. We report the clinical history of a female child where a precursor B-cell lymphoblastic proliferation was diagnosed at the age of 21 months by a surgical renal biopsy for an unexplained bilateral nephromegaly. Lymphoblastic infiltration should be suspected in any patient presenting with unexplained renal failure and enlarged kidneys. The importance of renal biopsy to identify the etiology of renal failure and nephromegaly is emphasized.

Oliguric acute renal failure in mycosis fungoides with lymphomatous infiltrates in the kidneys

OBJECTIVE

To present the clinical picture of acute renal failure in patients with mycosis fungoides (MF) and renal lymphomatous infiltrates. To analyze the pathogenesis of renal failure.

METHODS

Correlation of clinical picture, urinary findings, imaging reports and autopsy findings in two patients with long-standing MF who died with renal failure.

CASE SUMMARIES

Both subjects had sustained oliguria in the last 2 weeks. One patient had persistent hypotension, normal urinalysis, normal renal sonogram, and scarce interstitial lymphomatous infiltrates with preservation of renal parenchymal architecture. He was thought to have ischemic acute renal failure not directly linked to the lymphomatous infiltrates. The second patient developed hypertension one month prior to death, and had moderate proteinuria, hematuria, pyuria, grossly enlarged kidneys with hypoechoic masses, and extensive replacement of the renal parenchyma by lymphomatous infiltrates. This picture is typical of renal failure secondary to lymphomatous replacement of the kidneys.

CONCLUSIONS

The development of oliguric renal failure in MF with renal lymphomatous infiltrates may have varying clinical and imaging manifestations and pathogeneses. Potentially reversible pathogenic mechanisms should be systematically investigated, particularly if the overall clinical picture is not characteristic of renal failure secondary to lymphomatous replacement of the parenchyma.

Primary renal lymphoma and hypercalcemia in a child

Renal lymphoma is most frequently due to secondary lymphomatous infiltration of the kidneys in advanced stage disease. Rarely, are the kidneys the tissue of origin. We describe a 15-year-old male presenting with hypercalcemia and acute renal failure, due to a bilateral "primary B-cell lymphoma of the kidneys". The diagnosis was established by percutaneous needle biopsy of the right kidney. His disease was metastatic to multiple bones. His presenting features radiological findings and biopsy results are unique. We report his case, and review the pediatric literature.

Acute renal failure as presentation of a Burkitt's lymphoma

Acute renal failure due to diffuse renal infiltration is rarely the presenting manifestation of non-Hodgkin's lymphoma. We report a patient with acute renal failure secondary to diffuse bilateral renal infiltration by a Burkitt's lymphoma. The presence of bilateral renal enlargement, an elevated serum lactate dehydrogenase (LDH), and lymphopenia should suggest the diagnosis, which can be confirmed by renal biopsy.

Acute renal failure with hyperuricemia as initial presentation of leukemia in children

PURPOSE

We report on two children who presented with hyperuricemia and acute renal failure (admission uric acid levels 57.4 and 59.2 mg/dl).

RESULTS

Both were subsequently diagnosed to have acute lymphoblastic leukemia, despite normal initial complete blood counts and peripheral smear. Neither patient had nephromegaly on renal ultrasound.

CONCLUSIONS

Hyperuricemia and acute renal failure, particularly if recurrent, may be an early presentation of childhood leukemia and should lead to a bone marrow aspirate/biopsy.

Acute renal failure secondary to solid tumor renal metastases: case report and review of the literature

Renal metastases from solid tumors to both kidneys rarely result in acute renal failure (ARF). We present a case of squamous cell pulmonary carcinoma responsible for ARF due to (1) extensive (50% to 75%) bilateral parenchymal infiltration and replacement accompanied by tissue destruction, (2) widespread vascular invasion and thrombosis resulting in ischemia, and (3) histological evidence for foci of distal intratubular obstruction and pyelonephritis. Five additional cases, including one pulmonary cancer, causing ARF from extensive tissue replacement and destruction are reviewed. In a separate case, ARF resulted from lymphatic metastases rather than from parenchymal destruction or obstruction. Common findings in all six reported cases include bilaterally enlarged kidneys and progressive oligoanuria despite correction of prerenal or postrenal conditions. In our patient and in one other prior reported case, extrarenal obstruction was not considered important because invasive therapeutic procedures were unsuccessful in reversing ARF. In one case, irradiation of kidney tumor resulted in reversal of ARF. These cases emphasize the rare potential for solid tumors to metastasize to both kidneys and result in irreversible oligoanuric ARF. A high level of suspicion is required, and an early diagnosis may result in reversible ARF if the tumor is amenable to chemotherapy or irradiation.

A case of non-Hodgkin's lymphoma presenting with polyuria and acute renal insufficiency

A case of non-Hodgkin's lymphoma presenting with polyuria, enlarged kidneys, and renal insufficiency is reported. The diagnosis was made by percutaneous needle biopsy of the kidney. Renal failure reversed and the kidneys regressed in size on exhibition of the first cycle of chemotherapy. The rarity of polyuria at presentation, the role of renal biopsy in the diagnosis, and the response of renal failure to specific chemotherapy are discussed.

Primary bilateral B-cell renal lymphoma: a case report and review of the literature

Renal lymphoma is commonly secondary to lymphomatous infiltration of the kidneys in disseminated lymphoma and advanced stage IV disease. We describe a 57-year-old white woman presenting with an acute renal failure due to a bilateral "primary" B-cell lymphoma infiltration of the kidneys. The diagnosis of the lymphoma was made by renal biopsy. The striking feature observed was a destructive infiltration of the kidney by a malignant B-cell lymphoma that left the renal capsule intact, without any sign of secondary localization on the hilar regions. Physical examination did not reveal any peripheral lymphadenopathy or hepatosplenomegaly. A bilateral infiltration of both kidneys was the only feature shown by computed tomography and renal angiography. This case raises the question of the occurrence of a primary B-cell lymphoma in a nonlymphoid organ, which was diagnosed by renal biopsy at a time when the development was exclusively renal in origin.

Aggressive lymphomas with renal involvement: a study of 48 patients treated with the LNH-84 and LNH-87 regimens. Groupe d'Etude des Lymphomes de l'Adulte

In order to describe renal involvement in aggressive non-Hodgkin's lymphomas (NHLs) and its prognostic significance, we reviewed the outcome of 48 patients with renal involvement treated with the LNH-84 or LNH-87 regimen. Histology was diffuse large cell in 29 (60%) patients; immunoblastic, diffuse mixed cell and lymphoblastic in four each; follicular large cell, diffuse small cleaved cell and diffuse small non-cleaved cell in one each; and unclassified in four. Ann Arbor stage was IV in 44 patients, and IE or IIE in four. Tumour mass > or = 10 cm, performance status (ECOG scale) > 2 and increased LDH level were present in 69%, 20% and 76% of patients respectively. Fifteen patients (31%) had multiple intraparenchymal nodules, 14 (29%) had direct spread into the kidney from a perirenal mass, ten (21%) had a single intraparenchymal nodule and nine (19%) had diffuse infiltration. Twenty-one patients (43%) presented with bilateral lesions. Three patients (6%) presented with acute renal failure. Ten other patients (21%) had serum creatinine > 120 mumol l-1. In 12 of these 13 patients renal function was restored with chemotherapy. Twenty-eight patients (57%) achieved complete remission. Estimated 4 year disease-free survival was 39%. Disease-free survival and actuarial survival at 4 years were estimated to be 58% respectively. Two renal parameters had adverse prognostic significance for survival: renal hilum involvement (P = 0.02) and diffuse renal infiltration (P = 0.01). A Cox model identified only two independent prognostic factors for survival, namely performance status > or = 2 and tumour size > or = 10 cm. We conclude that alteration in renal function occurs in 27% of patients with renal involvement. Systemic chemotherapy improves renal function rapidly. Long-term outcome is similar to that expected in NHL patients presenting with the same prognostic factors.

Acute renal failure secondary to carcinomatous lymphatic metastases to kidneys

We report a rare case of acute renal failure secondary to bilateral renal parenchymal metastases from carcinoma. Despite clinical investigation the cause of the renal failure remained undiagnosed and was discovered only upon microscopy at autopsy, which revealed metastatic gastric adenocarcinoma. The pattern of tumor infiltration was predominantly lymphatic involvement limited to the vascular bundles at the corticomedullary junction, and the lymphatics adjacent to the calices and pelves. The significance of lymphatic obstruction in the pathogenesis of renal failure is discussed. Renal parenchymal metastases should be considered in the differential diagnosis of acute renal failure in patients with carcinoma.

Primary extranodal non-Hodgkin's lymphoma

A total of 52 of 238 patients (22%) with non-Hodgkin's lymphoma presented with disease in a primary extranodal site. The gastrointestinal tract was the commonest site involved (50%) and diffuse large cell was the commonest histological sub-type of the lymphoma (64%). Survivorship analysis of these patients, treated predominantly with chemotherapy, suggests that long-term survival is associated with: low-grade malignancy--median survival greater than 120 months; localized disease or spread of disease confined to the regional lymph nodes--median survival 65.5 months; and the use of aggressive combination chemotherapy for intermediate grade malignancy when the disease is localized or spread is confined to the regional lymph nodes--median survival greater than 110 months.

Renal failure due to lymphomatous infiltration of the kidneys. Report of three new cases and review of the literature

Three new cases of renal failure due to lymphomatous infiltration of the kidneys are described and the clinical features of 14 similar patients in the literature are reviewed. The diagnosis of renal failure secondary to lymphomatous infiltration was made by ruling out other causes of renal failure and demonstrating prompt improvement in renal function after systemic chemotherapy or local irradiation of one or both kidneys. Histiocytic lymphoma was the most common underlying disease. In the setting of diffuse lymphoma with other causes of renal failure reasonably excluded, radiographic demonstration of enlarged kidneys without obstruction suggests the need for intensive combination chemotherapy in most cases.

Urinary cytodiagnostic abnormalities in 50 patients with non-Hodgkin's lymphomas

Urinary cytodiagnostic evaluation was performed on 50 consecutive patients with non-Hodgkin's lymphomas. In 14 patients (28%) the urine sediment contained characteristic lymphoma cells. The groups with or without a positive urine cytology were comparable with respect to type of lymphoma, stage and course of disease, and recent treatment with chemotherapy. However, those with a positive urine cytology were more likely to have clinical evidence of kidney disease (43% vs 8%), although this was rarely attributed to disseminated lymphoma. In fact, in three patients, a positive urine cytology was the sole or presenting evidence for disseminated lymphoma. Although the groups with or without a positive cytology were similar with regard to physicochemical urinary findings, there were marked differences in the frequency of microscopic abnormalities. All patients with a positive cytology had evidence of renal parenchymal necrosis, renal tubular injury, or pathologic cast formation as compared with only 56% of those with a negative cytology. Thus, urinary cytodiagnostic evaluation may provide an important adjunct in the staging and evaluation of patients with malignant lymphomas.

Acute oliguric renal failure secondary to lymphomatous infiltration of the kidneys

A case of lymphomatous infiltration of the kidneys presenting as acute oliguric renal failure of unknown cause is described. Renal biopsy was required to establish the diagnosis. Combined chemotherapy (MOPP) produced significant improvement in renal function.

Malignant lymphoma presenting with nonoliguric renal failure

Nonoliguric renal failure was observed as a presenting complaint in a 14-year-old boy with a malignant lymphoma. The diagnosis was made by a renal biopsy, and the renal failure was treated successfully with peritoneal dialysis while the lymphoma was being treated with radiotherapy.

Renal failure due to lymphomatous infiltration of the kidneys

An unusual case of lymphomatous infiltration of the kidneys presenting as uremia of unknown cause is described. The diagnosis was established by renal biopsy. The severe renal impairment in this patient proved to be almost completely reversible by treatment with chemotherapy.

Early renal involvement in acute lymphoblastic leukemia and nonHodgkin's lymphoma in children

Clinical manifestations of kidney disease, particularly renal failure, caused by malignant infiltration in patients with acute lymphoblastic leukemia or nonHodgkin's lymphoma have been described rarely. We report 1 case of acute lymphoblastic leukemia and 3 cases of nonHodgkin's lymphoma in which renal disease was the only or one of the presenting manifestations of malignancy. Of these patients 2 had rapidly progressive renal failure with nephromegaly, 1 presented with bilateral abdominal masses caused by severe nephromegaly and with microscopic hematuria, and 1 had microscopic hematuria without nephromegaly. In all 4 patients kidney biopsy revealed malignant infiltration. In the 2 patients who presented with renal failure kidney function promptly returned to normal after chemotherapy and irradiation of the kidneys. Prompt and correct diagnosis of nephropathy, when it is the only or one of the presenting signs of acute lymphoblastic leukemia or nonHodgkin's lymphoma, is necessary to expedite initiation of specific antitumor therapy.

The abscopal effect: demonstration in lymphomatous involvement of kidneys

A patient with bilateral involvement of the kidneys with diffuse histiocytic lymphoma associated with renal failure is presented. This case report provides an example of the abscopal effect. Although only one kidney received radiation therapy, both kidneys were shown to respond to this treatment.

Lymphocytic lymphoma presenting with peripheral bony manifestations and with massive renal infiltration responsive to BACOP combination therapy

A 26-year-old man with diffuse lymphocytic lymphoma presented with painful peripheral bone involvement and with acute renal failure associated with massive lymphomatous renal infiltration. Renal function returned to near normal following combination chemotherapy with bleomycin, adriamycin, cyclophosphamide, vincristine and prednisolone (BACOP).