Lactic acidosis and renal enlargement at diagnosis and relapse of acute lymphoblastic leukemia

Warburg effect mimicking inborn errors of metabolism in childhood hematologic malignancies: A case-based systematic review

BACKGROUND

Type B lactic acidosis and hypoglycemia can occur in various pediatric conditions. In young children with a history of fasting preceding these metabolic derangements, inborn errors of metabolism should be primarily considered. However, the Warburg effect, a rare metabolic complication, can also manifest in children with hematologic malignancies. Only a few reports of this condition in children have been published in the literature.

AIM

To identify the clinical course, treatment strategies, and outcomes of childhood hematologic malignancies with type B lactic acidosis.

METHODS

We performed a comprehensive search of the PubMed, Scopus, and Cochrane databases without any time restriction but limited to English language articles. The databases were last accessed on July 1st, 2023.

RESULTS

A total of 20 publications were included in the analysis, all of which were case reports or case series. No higher quality evidence was available. Among children with hematologic malignancies and Warburg effect, there were 14 cases of acute lymphoblastic leukemia and 6 cases of non-Hodgkin's lymphoma including our illustrative case. Lactic acidosis occurred in 55% of newly diagnosed cases and 45% of relapsed cases. The mean age was 10.3 ± 4.5 years, and 80% of cases were male. The mean serum lactate was 16.9 ± 12.6 mmol/L, and 43.8% of the cases had concomitant hypoglycemia. Lactic acidosis initially subsided in 80% of patients receiving chemotherapy compared to 60% in the contrast group. The mortality rate of newly diagnosed cases was 45.5%, while the relapsed cases represented a 100% mortality rate. All 8 patients reported before 2001 died from disease-related complications. However, patients described in reports published between 2003 and 2023 had a 54.5% rate of complete remission.

CONCLUSION

This complication has historically led to fatal outcome; however, patients who received chemotherapy showed a more favorable response. Therefore, it is crucial to promptly initiate specific treatment in this context.

Accurate detection of renal leukemic involvement in children using 3-D computed tomography modeling

BACKGROUND

The rate of renal involvement in pediatric acute lymphoblastic leukemia (ALL) at diagnosis varies between reports because renal involvement is diagnosed on renal size larger than aged-matched standards on conventional modalities. We propose a new method for precise renal involvement detection using 3-D enhanced computed tomography (CT) reconstruction.

METHODS

Twenty-five children with ALL were evaluated utilizing 3-D enhanced CT reconstruction to measure renal volume before and after induction therapy, renal mass lesions and renal axis at diagnosis. Renal involvement was defined as a marked decrease of renal volume or the presence of mass lesions.

RESULTS

According to the 3D-CT criteria, nine of 25 patients (36%) had renal involvement. All of them had bilateral mass lesions except for one who had diffuse nephromegaly alone. This method detected renal involvement more accurately than ultrasonography. When using conventional criteria based on the length of the renal axis, 19 of 25 (76%) had renal involvement, including many cases of false-positive nephromegaly. Patients with renal involvement had significantly more extramedullary involvement according to the 3D-CT-based criteria.

CONCLUSIONS

The use of 3D-CT reconstruction was accurate in detecting renal involvement in childhood ALL, most of which consisted of piled up mass lesions. Patients with renal involvement should be worked up for the detection of other extramedullary lesions.

Kidney and pancreatic extramedullary relapse in adult acute lymphoblastic leukemia: a case report and review of the literature

Extramedullary relapse of acute lymphoblastic leukemia (ALL) is rare and has been primarily reported in pediatric patients or hematopoietic stem cell transplant recipients. We report a case of a 62-year-old woman who presented with relapsed ALL involving her kidneys, pancreas, and bone marrow 2 years after completing chemotherapy with a standard ALL protocol. Unfortunately, her extramedullary disease progressed despite treatment. To the best of our knowledge, this is the first reported case of extramedullary relapse of B-cell ALL to the kidneys and pancreas occurring in an adult patient who had not previously undergone a hematopoietic stem cell transplant. A literature review of kidney and pancreatic extramedullary relapse in ALL is also included.

Common and less-common renal masses and masslike conditions

As an increasing number of imaging examinations are performed, a greater number of incidental renal lesions are detected. Apart from the usual cysts and solid renal cell carcinomas, a variety of unusual benign and malignant renal lesions exist. Imaging is invaluable in characterizing these lesions and is confirmatory in some benign lesions. Renal cell carcinoma remains the diagnosis of exclusion; however, assessment of the imaging pattern in the appropriate clinical context can improve diagnostic accuracy. The objective of this article is to familiarize the radiologist with the imaging appearance of unusual non-neoplastic and neoplastic lesions and correlate with histopathologic studies when available.

A case report of acute lymphoblastic leukemia complicated by lactic acidosis

Type B lactic acidosis (LA) is a distinct form of metabolic acidosis characterized by low blood pH (≤ 7.35) accompanied by accumulation of lactate (blood concentration ≥ 5 mmol/L) (Luft et al. in Am J Clin Pathol 80:484-489, 1983). There are two types of LA that are caused by different mechanisms. Type A is more common, and is caused by the lack of oxygen (tissue hypoxia or hypoperfusion). In this case, impaired cellular respiration leads to lower pH level and at the same time the cells are forced to metabolize glucose anaerobically, which leads to increased production of lactate. The other type, Type B, is relatively rare, and is occasionally found in patients with hematological malignancies, such as leukemia or lymphoma. The molecular mechanism of Type B LA is not fully understood. Here, we report a case of precursor B cell acute lymphoblastic leukemia who initially shows manifestations of Type B LA and bilateral renal enlargement.

Lactic acidosis and hypoglycemia with ALL relapse following engrafted bone marrow transplant

Lactic acidosis together with hypoglycemia in the face of hematologic malignancy is a grave development. A 7-year-old male with pre-B-cell ALL following hematopoietic cell transplant was admitted to our hospital in his second relapse. On hospital days 4 and 5, he developed refractory hypoglycemia, lactic acidosis, central respiratory failure, and acute renal failure. Bicarbonate infusion, B vitamins, and hemodialysis were not effective. Care was withdrawn on hospital day 9. Further understanding of the mechanisms that cause the combined onset of lactic acidosis and hypoglycemia will help clinicians in implementing timely therapies that may reduce mortality.

Pediatric renal leukemia: spectrum of CT imaging findings

BACKGROUND

The kidneys are a site of extramedullary leukemic disease that can be readily detected by CT.

OBJECTIVE

To demonstrate the spectrum of CT findings in children with renal leukemic involvement.

MATERIALS AND METHODS

Twelve children were identified retrospectively as having renal leukemic involvement by contrast-enhanced CT of the abdomen. Contrast-enhanced CT images through the kidneys of each patient were reviewed by two pediatric radiologists. Pertinent imaging findings and renal lengths were documented. The electronic medical record was accessed to obtain relevant clinical and pathologic information.

RESULTS

Five patients with renal leukemic involvement presented with multiple bilateral low-attenuation masses, while three patients demonstrated large areas of wedge-shaped and geographic low attenuation. Four other patients presented with unique imaging findings, including a solitary unilateral low-attenuation mass, solitary bilateral low-attenuation masses, multiple bilateral low-attenuation masses including unilateral large conglomerate masses, and bilateral areas of ill-defined parenchymal low attenuation. Two patients showed unilateral nephromegaly, while eight other patients showed bilateral nephromegaly. Two patients had normal size kidneys. Two patients had elevated serum creatinine concentrations at the time of imaging.

CONCLUSION

Renal leukemic involvement in children can present with a variety of CT imaging findings. Focal renal abnormalities as well as nephromegaly are frequently observed. Most commonly, renal leukemic involvement does not appear to impair renal function.

High blood pressure and hypertension in children with newly diagnosed acute leukemia and lymphoma

Little has been published on the rate of prehypertension (HBP) and hypertension (HTN) in children with hematologic malignancies. This study was preformed to determine the prevalence and predictors of HBP and HTN in newly diagnosed acute leukemia and lymphoma patients. Retrospectively, blood pressure (BP) values were followed from admission until normalization in 102 children. HBP and HTN were defined as either a systolic or diastolic value > or = the 90th and 95th percentile BP measurement, respectively. HBP and HTN were identified in 68.6% and 52.9% of children prior to chemotherapy and 78.4% and 67.3% postchemotherapy, respectively. Mean time to BP normalization was 54 days. Only ten children (15% of HTN patients) received antihypertensive therapy. Logistic regression determined that the only predictor for HBP and HTN was the estimated glomerular filtration rate (eGFR) at the time of admission -- every 10 ml/min per 1.73 m(2) increase led to a 16% and 14% decrease in the odds of postchemotherapy HBP (p = 0.02) and HTN (p = 0.03), respectively. A surprisingly high prevalence of BP abnormalities was identified and lower eGFR predicted HBP and HTN in children with newly diagnosed hematologic malignancies. Better recognition and serious consideration for treatment should be given to this cardiovascular abnormality.

Lactic acidosis: from sour milk to septic shock

Lactic acidosis is frequently encountered in the intensive care unit. It occurs when there is an imbalance between production and clearance of lactate. Although lactic acidosis is often associated with a high anion gap and is generally defined as a lactate level >5 mmol/L and a serum pH <7.35, the presence of hypoalbuminemia may mask the anion gap and concomitant alkalosis may raise the pH. The causes of lactic acidosis are traditionally divided into impaired tissue oxygenation (Type A) and disorders in which tissue oxygenation is maintained (Type B). Lactate level is often used as a prognostic indicator and may be predictive of a favorable outcome if it normalizes within 48 hours. The routine measurement of serum lactate, however, should not determine therapeutic interventions. Unfortunately, treatment options remain limited and should be aimed at discontinuation of any offending drugs, treatment of the underlying pathology, and maintenance of organ perfusion. The mainstay of therapy of lactic acidosis remains prevention.

Severe lactic acidosis due to thiamine deficiency in a patient with B-cell leukemia/lymphoma on total parenteral nutrition during high-dose methotrexate therapy

An 11-month-old girl with B-cell leukemia/lymphoma developed profound lethargy due to severe lactic acidosis during chemotherapy and total parenteral nutrition (TPN). Initial treatment with NaHCO3 was ineffective. Treatment with a vitamin cocktail (OH-cobalamin, pyridoxine, thiamine, riboflavine, biotin, carnitine) at pharmacologic doses rapidly improved the child's clinical and laboratory status. Lactic acidosis was caused by an impairment of pyruvate dehydrogenase complex, which was due to lack of its necessary cofactor thiamine in the TPN. This case report indicates that lactic acidosis may be a front-line diagnosis in patients on TPN with lethargy and outlines the need for monitoring thiamine supply in TPN.

Acute lymphoblastic leukemia presenting with lactic acidosis and renal tubular dysfunction

Acute lymphoblastic leukemia (ALL) in children can rarely present with severe lactic acidosis in the absence of a high white blood cell count or other complications. Renal tubular dysfunction with hypercalciuria and hypocalcemia in the absence of pre-existing renal disease or concurrent medications has not been described at presentation in childhood ALL. The authors describe a 7-year-old boy with ALL presenting with severe lactic acidosis and renal tubular dysfunction, both of which were refractory to conventional management and resolved rapidly with appropriate chemotherapy.

Multiple myeloma associated with lactic acidosis

Type B lactic acidosis is rare among patients with malignant diseases. To date only one case report has documented lactic acidosis occurring in a patient with multiple myeloma (MM). Our patient, a 55-year-old black man, was diagnosed with stage IIIA immunoglobulin G-kappa (IgG-kappa) MM in September 1995. He was found to have severe lactic acidosis at the time of second relapse. During the terminal phase of his disease, he required multiple hospitalizations for management of lactic acidosis and other complications of his MM. No other cause of his elevated lactate levels was identified. Although type B lactic acidosis may more commonly occur in patients with leukemia or lymphoma, it may rarely present in patients with rapidly progressive and refractory MM.

Lactic acidosis: a metabolic complication of hematologic malignancies: case report and review of the literature

BACKGROUND

Lactic acidosis (LA) associated with hematologic malignancies is rare, ominous, and generally occurs in adults. Its pathogenesis is poorly understood.

METHODS

The authors present one case of childhood lymphoma and two cases of childhood leukemia associated with LA, and they review the available literature. Plasma concentrations of insulin-like growth factors (IGFs), IGF binding proteins (IGFBPs), and tumor necrosis factor (TNF)-alpha were retrospectively measured to elucidate the pathogenesis of LA.

RESULTS

Lactic acidosis has been reported to date in 28 cases of lymphoma and 25 cases of leukemia, including the authors' cases. Ongoing rapid cellular proliferation was indicated in all leukemia cases. The liver was involved in 43 of the 53 cases, and hypoglycemia was present in 20. The acidosis improved only if the disease responded to chemotherapy. Remission was achieved in only five of the reported cases. In the authors' three cases, LA was associated with altered concentrations of IGFs, IGFBPs, and TNF-alpha, although causality was not established.

CONCLUSIONS

Lactic acidosis in association with hematologic malignancies carries an extremely poor prognosis. Because cancer cells have a high rate of glycolysis and produce a large quantity of lactate, this condition may result from an imbalance between lactate production and hepatic lactate utilization. The authors speculate that the IGF system is involved in the pathophysiology of LA in these patients. Only chemotherapy so far has been effective in correcting the acute acidosis in a few patients; however, it has not necessarily improved ultimate outcome.

Renal enlargement as presentation of isolated renal relapse in childhood leukemia

Extramedullary relapses in children with acute lymphoblastic leukemia occur most frequently in the central nervous system and in the testis. In this report, the authors describe a 16-year-old girl with an isolated renal relapse of acute lymphoblastic leukemia after a disease-free interval of 2 years and 8 months. This clinically inconspicuous renal relapse was suggested by a routine follow-up renal sonography. No evidence of disease was found in bone marrow or peripheral blood. Renal biopsy was required to establish the diagnosis. Treatment consisted of intensive chemotherapy and autologous bone marrow transplantation. The patient has been in second complete continuous remission for 7 years. The authors recommend the use of an intensive multidrug salvage regimen.

[Severe lactic acidosis and thiamine deficiency during parenteral nutrition in a child]

We report the case of a leukemic child treated with chemotherapy and parenteral nutrition for three weeks, who developed a severe lactic acidosis. Clinical features included both digestive and neurological disorders associated with a moderate cardiovascular collapse. After elimination of a toxic, a neoplastic or a septic cause, a thiamin (or vitamin B1) deficiency was suspected because of the lack of vitamin supply to parenteral nutrition. Intravenous administration of thiamin rapidly controlled lactic and clinical features. The diagnosis was confirmed by a low plasmatic concentration of thiamin. Thiamin deficiency must be suspected in case of severe lactic acidosis during parenteral nutrition and systematically prevented by supply of vitamins.

Acute renal failure associated with the retinoic acid syndrome in acute promyelocytic leukemia

All-trans-retinoic acid is an effective agent to induce remission in patients with acute promyelocytic leukemia (APL). Unlike conventional chemotherapy, this drug exerts its effect by inducing differentiation of immature leukemic cells. A distinctive clinical syndrome characterized by fever, dyspnea, effusions, weight gain, and organ failure (the "retinoic acid syndrome") can occur during treatment with this drug. Postmortem studies have shown extensive organ infiltration by leukemic cells, and the early administration of corticosteroids can result in prompt resolution of symptoms. We describe a patient with APL in whom acute renal failure developed during treatment with all-trans-retinoic acid. Transient renal enlargement during a period of leukocytosis and a beneficial response to treatment with dexamethasone suggest that renal failure in this patient was probably related to the retinoic acid syndrome.