Neoplasia and glomerular injury

Pathological Insights into Non-Neoplastic Renal Parenchyma in Wilms Tumor: Implications for Nephron-Sparing Surgery

INTRODUCTION

 This study aimed to evaluate the non-neoplastic renal parenchyma in Wilms tumor (WT) and investigate its impact on nephron-sparing surgery (NSS).

MATERIALS AND METHODS

 The non-neoplastic renal parenchyma of WT patients was prospectively collected for pathological examination. The histology of non-neoplastic renal parenchyma was assessed from two perspectives: nephrogenic rests (NRs) and nephrons.

RESULTS

 A total of 46 non-neoplastic renal parenchyma specimens were collected from 42 WT patients. The surgeons assessed the median proportion of non-neoplastic renal parenchyma as 30%, whereas using ellipsoid volume, it was calculated to be 27%. The Youden index of surgeons' assessment peaked at a 15% proportion of non-neoplastic renal parenchyma. The bilateral WT (BWT) group and NSS group exhibited significant differences compared with the unilateral WT group and radical nephrectomy group, respectively, with the BWT group showing a tendency toward thickened basement membrane.

CONCLUSION

 The presence of NRs and endogenous nephron alternations should be given due attention in WT. The probability of abnormalities is low when the proportion of non-neoplastic renal parenchyma exceeds 15%, providing pathological support for expanding the adaptation of NSS.

Minimal Change Nephrotic Syndrome Secondary to Methotrexate-associated Hodgkin Lymphoma

The patient was a 64-year-old man who had been receiving methotrexate (MTX) for rheumatoid arthritis for 8 years. Computed tomography (CT) obtained one month prior to admission revealed numerous enlarged lymph nodes. Lower leg edema appeared two weeks prior to admission. Severe proteinuria was confirmed, and the patient was admitted. A renal biopsy revealed minimal changes in glomeruli. CT on day 14 revealed shrinking lymph nodes, and the patient was diagnosed with Hodgkin lymphoma by a neck lymph node biopsy. This is the first report of secondary minimal change nephrotic syndrome caused by an MTX-associated lymphoproliferative disorder.

Clinical covariates influencing clinical outcomes in primary membranous nephropathy

BACKGROUND

Primary membranous nephropathy (PMN) frequently causes nephrotic syndrome and declining kidney function. Disease progression is likely modulated by patient-specific and therapy-associated factors awaiting characterization. These cofactors may facilitate identification of risk groups and could result in more individualized therapy recommendations.

METHODS

In this single-center retrospective observational study, we analyze the effect of patient-specific and therapy-associated covariates on proteinuria, hypoalbuminemia, and estimated glomerular filtration rate (eGFR) in 74 patients diagnosed with antibody positive PMN and nephrotic-range proteinuria (urine-protein-creatinine-ratio [UPCR] ≥ 3.5 g/g), treated at the University of Freiburg Medical Center between January 2000 - November 2022. The primary endpoint was defined as time to proteinuria / serum-albumin response (UPCR ≤ 0.5 g/g or serum-albumin ≥ 3.5 g/dl), the secondary endpoint as time to permanent eGFR decline (≥ 40% relative to baseline).

RESULTS

The primary endpoint was reached after 167 days. The secondary endpoint was reached after 2413 days. Multivariate time-to-event analyses showed significantly faster proteinuria / serum-albumin response for higher serum-albumin levels (HR 2.7 [95% CI: 1.5 - 4.8]) and cyclophosphamide treatment (HR 3.6 [95% CI: 1.3 - 10.3]). eGFR decline was significantly faster in subjects with old age at baseline (HR 1.04 [95% CI: 1 - 1.1]).

CONCLUSION

High serum-albumin levels, and treatment with cyclophosphamide are associated with faster proteinuria reduction and/or serum-albumin normalization. Old age constitutes a risk factor for eGFR decline in subjects with PMN.

A Rare Case of Immunotactoid Glomerulopathy Associated with Hodgkin Lymphoma

Immunotactoid glomerulopathy (ITG) is characterized by Congo red-negative microtubular deposits, and it has been reported as a rare paraneoplastic syndrome due to hematologic malignancies, viral infections, or autoimmune diseases. In hematologic malignancies, multiple myeloma and other mature B-cell malignancies are the most common hematologic malignancies, and Hodgkin lymphoma (HL) is extremely rare. A 59-year-old woman was admitted to our hospital because of a pulmonary mass and proteinuria. Computed tomography-guided lung biopsy confirmed the presence of HL stage IIA. Immunofixation of peripheral blood was positive for immunoglobulin G (IgG) kappa. Renal biopsy showed mesangial proliferation with deposits in the subendothelial lesion and no invasion of the HL. These deposits were positive for IgG3, C3, and kappa light chain but negative for C1q and lambda light chain. Electron microscopy showed randomly aligned tubular structures with a diameter of approximately 50 nm. We diagnosed the patient with immunotactoid nephropathy and HL. After systemic chemotherapy, the patient achieved a complete response and loss of proteinuria. On the contrary, her serum monoclonal gammopathy was observed after chemotherapy. The existence of a monoclonal antibody itself might not be a sufficient factor for ITG in some cases, and an additive trigger is necessary for development.

IgA Nephropathy with Dominant IgA2 Deposition Accompanied by Mantle Cell Lymphoma

Malignant lymphoma is rarely complicated by secondary IgA nephropathy. We encountered a 74-year-old man with rapidly progressive glomerulonephritis due to IgA nephropathy with predominant deposition of IgA2, instead of IgA1, in the glomerulus that was eventually diagnosed as secondary IgA nephropathy due to mantle cell lymphoma. Renal impairment was improved by chemotherapy for the mantle cell lymphoma. IgA came from the colonic mucosa that was stimulated by the infiltrated lymphoma cells, instead of the tumor itself. We should consider mantle cell lymphoma as a cause of secondary IgA nephropathy, although its prevalence may not be very high.

Secondary Membranous Nephropathy. A Narrative Review

Membranous nephropathy (MN) is a common cause of proteinuria and nephrotic syndrome all over the world. It can be subdivided into primary and secondary forms. Primary form is an autoimmune disease clinically characterized by nephrotic syndrome and slow progression. It accounts for ~70% cases of MN. In the remaining cases MN may be secondary to well-defined causes, including infections, drugs, cancer, or autoimmune diseases, such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), urticarial vasculitis, sarcoidosis, thyroiditis, Sjogren syndrome, systemic sclerosis, or ankylosing spondylitis. The clinical presentation is similar in primary and secondary MN. However, the outcome may be different, being often related to that of the original disease in secondary MN. Also, the treatment may be different, being targeted to the etiologic cause in secondary MN. Thus, the differential diagnosis between primary and secondary MN is critical and should be based not only on history and clinical features of the patient but also on immunofluorescence and electron microscopy analysis of renal biopsy as well as on the research of circulating antibodies. The identification of the pathologic events underlying a secondary MN is of paramount importance, since the eradication of the etiologic factors may be followed by remission or definitive cure of MN. In this review we report the main diseases and drugs responsible of secondary MN, the outcome and the pathogenesis of renal disease in different settings and the possible treatments.

Dipstick proteinuria and cancer incidence: a nationwide population-based study

BACKGROUND

The association between proteinuria and malignancy has been frequently reported, but the issue is matter of controversy. Thus, in order to shed light on the association, we evaluated proteinuria as a risk factor for malignancy using the dataset from the Korean National Health Insurance System (NHIS).

METHODS

The subjects had undergone a medical examination in 2009 (index year) among the entire Korean adult population. From a pool of 10,505,818 participants, we excluded subjects who were younger than 19 years (15,327), had a previous diagnosis of cancer (152,095), had missing data for at least one variable (544,508), and were diagnosed with cancer within 1 year from the index year (79,501). Proteinuria was examined by a single dipstick urinalysis.

RESULTS

A total of 9,714,387 subjects were included in this study and tracked until December 31, 2017. The participants were divided into three groups; no (95.2%), trace (2.3%), and overt (2.5%) proteinuria. Over the duration of this study, we observed that overt proteinuria was associated with an increased risk of cancer development (all cancers) (adjusted HR 1.154, 95% CI 1.134-1.173) and the long-term risk of cancer incidence increased proportionally according to the changes in proteinuria over a four-year period.

LIMITATIONS

Our study population consisted of Korean adults. Therefore, the results of this study may not be generalized to other ethnicities.

CONCLUSIONS

We found a significant relationship between proteinuria and the risk of overall and site-specific cancer development. Further studies are needed to find an explanation of these findings.

Clinicopathological features in membranous nephropathy with cancer: A retrospective single-center study and literature review

BACKGROUND

Membranous nephropathy is the most common glomerular disease related to malignancy. However, it is difficult to distinguish between true malignancy-related membranous nephropathy and idiopathic membranous nephropathy coincident with cancer. It has been reported that phospholipase A2 receptor (PLA2R) is the first autoantigen involved in idiopathic membranous nephropathy and thrombospondin type-1 domain-containing 7A (THSD7A) may have a close relationship with malignancy-related membranous nephropathy. Therefore, the aim of this study was to compare the clinicopathological characteristics between membranous nephropathy patients with cancer and idiopathic membranous nephropathy patients without cancer to better detect malignancy-related membranous nephropathy, including glomerular PLA2R and THSD7A depositions and their circulating antibodies, together with glomerular IgG4 deposition.

METHODS

Twelve membranous nephropathy patients with cancer and 257 idiopathic membranous nephropathy patients without cancer were included in this study and had been followed up for more than 1 year. The glomerular expression of PLA2R, THSD7A, and IgG4 was analyzed by immunohistochemistry. Circulating anti-PLA2R and anti-THSD7A antibodies were assessed by enzyme-linked immunosorbent assay and indirect immunofluorescence testing, respectively.

RESULTS

Membranous nephropathy patients with cancer were significantly older and had higher serum creatinine and a lower estimated glomerular filtration rate than idiopathic membranous nephropathy patients (P<0.05). The positive rates of glomerular PLA2R and IgG4 depositions and circulating anti-PLA2R antibodies in membranous nephropathy patients with cancer were significantly lower than those in idiopathic membranous nephropathy patients without cancer (P<0.01).

CONCLUSION

The absence of glomerular PLA2R deposition and negative circulating anti-PLA2R antibodies, along with negative glomerular IgG4 staining, may be useful clues to more accurately screen underlying malignancies in membranous nephropathy patients.

Hodgkin's lymphoma, nephrotic syndrome, and echinococcosis cysts: an unusual association and literature review

We present a 5-year-old female with minimal change nephrotic syndrome (MCNS). Within several months, she became steroid-dependent with progression of edema and ascites. Imaging studies revealed abnormal solid mass and liver cysts and she was diagnosed with both abdominal Hodgkin's lymphoma (cHD) and large hepatic cystic echinococcosis (CE). Association between MCNS and cHL or with CE has been described in the literature in adults and rarely in the pediatric population. We report, for the first time, a simultaneous occurrence of all three: MCNS, cHL, and CE. Literature review and suggested pathophysiologic mechanisms underlying this phenomenon are presented.

Renal toxicities associated with pembrolizumab

Objective

Expanded clinical experience with patients treated by pembrolizumab has accumulated. However, renal toxicities associated with this anti-programmed cell death 1 agent are poorly described because kidney histology is rarely sought. As a nephrology referral centre, we aimed to describe the clinic-biological and histopathological characteristics of pembrolizumab-related nephropathy and its response to treatment.

Methods

We conducted a monocentric large case series study, including all pembrolizumab-treated cancer patients presenting a renal toxicity addressed to our centre from 2015 to 2017.

Results

A total of 12 patients (7 men) out of 676 pembrolizumab-treated patients (incidence 1.77%) were included (median age 69.75 years). Patients were referred for acute kidney injury (n = 10) and/or proteinuria (n = 2). A kidney biopsy was performed in all patients, with a median duration of use of 9 months (range 1–24 months) after the beginning of treatment. Biopsy showed that four patients had acute interstitial nephritis (AIN), whereas five had acute tubular injury (ATI) alone, one had minimal change disease (MCD) and ATI, and one had MCD alone. Pembrolizumab withdrawal coupled with corticosteroid therapy was the most effective treatment for kidney function recovery. Drug reintroduction resulted in a more severe recurrence of AIN in one patient who required maintenance of pembrolizumab. Two patients died of cancer progression with one of them developing severe renal failure requiring dialysis.

Conclusion

In our series, ATI, AIN and MCD are the most frequent forms of kidney involvement under pembrolizumab therapy. Kidney dysfunction is usually isolated but can be severe. Use of corticosteroids in case of AIN improves the glomerular filtration rate.

Nephrotic Syndrome With Cancer Immunotherapies: A Report of 2 Cases

Oncologic immunotherapies use a patient's immune response to eliminate tumor cells by modulation of immune checkpoints, including programmed cell death 1 (PD-1) and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) proteins. Immune-mediated sequelae, including interstitial nephritis, have been reported; however, glomerular disease appears rare. We describe 2 cases of nephrotic syndrome in patients treated with these agents. Patient 1 received the anti-PD-1 antibody pembrolizumab for Hodgkin lymphoma. Following his second dose, he developed nephrotic syndrome and acute kidney injury. Biopsy showed diffuse foot-process effacement consistent with minimal change disease and findings of acute tubular injury. Pembrolizumab therapy cessation and corticosteroid treatment yielded improvement in proteinuria and acute kidney injury. Patient 2 received the CTLA-4 antibody ipilimumab for melanoma. He developed nephrotic syndrome with biopsy changes consistent with minimal change disease. Ipilimumab therapy was stopped and proteinuria resolved following corticosteroid treatment. Ipilimumab rechallenge caused relapse of nephrotic-range proteinuria. These cases suggest an association between therapeutic immune activation and the development of nephrotic syndrome. Given the increasing prevalence of oncologic immunotherapies, monitoring patients for renal sequelae is warranted.

An association between membranoproliferative glomerulonephritis and metastatic colorectal carcinoma: a case report

BACKGROUND

Membranoproliferative glomerulonephritis is a common pattern of glomerular injury in monoclonal gammopathy, but has only rarely been associated with solid organ tumors, mainly lung, renal, gastric, breast, and prostate. There have been two reported cases of membranoproliferative glomerulonephritis associated with adenocarcinoma of the colon and rectum, although the association may be coincidental. We report a case where nephrotic syndrome due to membranoproliferative glomerulonephritis developed in a patient with colorectal carcinoma and elucidate some of the pathophysiological mechanisms underpinning this presentation.

CASE PRESENTATION

A 54-year-old white man with a history of adenocarcinoma of the colon with metastasis to the liver and ureter presented with a 1-week history of bilateral pedal edema, and worsening hypertension and renal function. A renal biopsy confirmed membranoproliferative glomerulonephritis type I. Curative therapy for the malignancy was not possible, so treatment was commenced with prednisolone with consequential biochemical improvement in renal function and proteinuria, although his serum albumin remained low.

CONCLUSIONS

This case report illustrates an association between membranoproliferative glomerulonephritis and metastatic colorectal carcinoma and adds to the evidence to consider malignancy to be an underlying pathology among newly diagnosed cases of nephrotic syndrome. In the clinical setting, treatment of the underlying malignancy should be first considered in patients with a tumor presenting with kidney disease which is suspected to be paraneoplastic in etiology.

An unusual case of glomerulonephritis in a patient with non-Hodgkin mucosal associated lymphoid tissue (MALT) B-cell lymphoma

Background

Kidney involvement in non-Hodgkin lymphoma is well recognized and glomerulonephritis, when present, has been commonly reported to be associated with a membranoproliferative pattern.

Case presentation

We report a case of a 58-year-old lady with a recurrence of non-Hodgkin MALT B-cell lymphoma, presenting with acute kidney injury, nephrotic range proteinuria and a cellular urinalysis. She underwent a renal biopsy that showed a severe diffuse proliferative and exudative lupus-like glomerulonephritis, which is likely paraneoplastic in nature. We discuss the differential diagnosis and possible pathogenesis of glomerular injury in lymphoma-related proliferative glomerulonephritis.

Conclusion

Differentiating between true lupus nephritis and a paraneoplastic glomerulonephritis is important, as it would have significant implications on treatment and clinical course.

EBV-positive diffuse large B-cell lymphoma in a patient with primary Sjögren's syndrome and membranous glomerulonephritis

BACKGROUND

Sjögren's syndrome is a systemic autoimmune disease in which lymphatic cells destroy the salivary and lacrimal glands. Glomerulonephritis is thought to be a rare occurrence in primary Sjögren's syndrome. Furthermore, concurrent glomerular involvement and lymphoma in patients with Sjögren's syndrome has seldom been reported.

CASE PRESENTATION

A 52-year-old woman with primary Sjögren's syndrome developed membranous glomerulonephritis and Epstein-Barr virus-positive diffuse large B-cell lymphoma (DLBCL). She was diagnosed with Sjögren's syndrome based on the dry eyes, dry mouth, positive anti-nuclear antibody test, anti-Ro (SS-A) antibody, salivary gland biopsy, and salivary scintigraphy. Moreover, renal biopsy confirmed the diagnosis of membranous glomerulonephritis. Three months later, her small bowel was perforated with pneumoperitoneum, and the biopsy revealed Epstein-Barr virus-positive DLBCL.

CONCLUSIONS

We observed the first case of primary Sjögren's syndrome associated with Epstein-Barr Virus-positive DLBCL and membranous glomerulonephritis. Because of the possibility of malignancy-associated membranous glomerulonephritis in patients with primary Sjögren's syndrome, we should be careful and examine such patients for hidden malignancy.

Minimal change disease associated with MALT lymphoma

Low-grade Extranodal Marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue, a subtype of non-Hodgkin's Lymphoma, involving the kidney is a rare clinical entity. Association of Minimal change disease nephrotic range proteinuria with Hodgkin's lymphoma is well described, however is extremely uncommon with non-Hodgkin's lymphoma. We describe a patient who presented with nephrotic syndrome and a kidney biopsy revealed marginal zone lymphoma and diffuse epithelial foot process effacement. He showed dramatic response to a combination therapy with cyclophosphamide, corticosteroids, and Rituximab.

Membranous nephropathy and malignancy

An association between the glomerular disease membranous nephropathy (MN) and malignancy has long been appreciated, but evidence supporting this relationship remains limited, speculative, and, at times, controversial. Reports that the two disease processes often evolve in parallel, as well as the occasional findings of tumor antigens or tumor-reactive antibodies within glomerular immune deposits, are all supportive of an association. However, the diagnosis of both MN and malignancy in the same individual also may be coincidental, especially in an older demographic group in which both diseases tend to occur. This article briefly reviews the proposed pathogenetic mechanisms of idiopathic and secondary forms of MN, as well as the arguments for and against the contention that malignancy-associated MN is itself a distinct clinical entity. In addition, the recent identification of the M-type phospholipase A₂ receptor as a major glomerular antigen in idiopathic MN has the potential to offer fresh tools that might help resolve some of the controversy, and ultimately aid in the decision of how aggressively to screen for malignancy in an individual diagnosed with MN.

Hodgkin lymphoma and nephrotic syndrome in childhood

An association between nephrotic syndrome and extrarenal neoplasia was described for the first time in 1922. Since then a large number of cases have been published, few of them describing the link between Hodgkin disease (HD) and nephrotic syndrome (NS). It shows that the incidence of nephrotic syndrome in Hodgkin lymphoma is less than 1%. Till date, to the best of author's knowledge, there are about 50 pediatric cases published, no one among Italian children. In the present paper, the authors report 2 cases observed in their department in the 7 yrs period.

Treatment of a nephrotic syndrome by endoscopic removal of a villous adenoma of the duodenum

We report the case of a patient diagnosed with a villous adenoma of the duodenum showing high degree dysplasia who developed a nephrotic syndrome (NS) due to a membranous nephropathy (MN), demonstrated by renal biopsy. Only the endoscopic resection of the duodenal adenoma could control the NS. The first manifestation of a MN is often the development of a NS. Up to 20% of patients older than 65 years who develop a MN have cancer. Tumours most often identified are those of lung, prostate and digestive tract. A renal biopsy is required to identify this type of nephropathy. If a diagnosis of MN is made, an associated tumour should be looked for.

The spectrum of kidney involvement in lymphoma: a case report and review of the literature

Kidney involvement is an under-recognized complication of both Hodgkin and non-Hodgkin lymphoma. The diversity of lymphoma-related renal manifestations makes diagnosis difficult. Although abrupt worsening of kidney function may be the first sign of malignant disease, renal effects can be subtle or even silent. The causes of renal involvement similarly are varied. We discuss a case of non-Hodgkin lymphoma and associated kidney failure from several distinct malignancy-related mechanisms and review the spectrum of lymphoma-related kidney involvement.

Acute kidney injury requiring dialysis: a very unusual presentation of non-Hodgkin's lymphoma

Acute kidney injury due to lymphomatous infiltration of the kidneys is uncommon, and it is rarely the initial manifestation of the lymphoma. Here, we present a case of lymphomatous infiltration of the kidneys resulting in acute kidney injury requiring dialysis, as the initial presentation of non-Hodgkin’s lymphoma. Renal biopsy established the diagnosis, and renal function completely recovered after chemotherapy.

Nonneoplastic kidney diseases in adult tumor nephrectomy and nephroureterectomy specimens: common, harmful, yet underappreciated

CONTEXT

Nonneoplastic kidney diseases, such as arterionephrosclerosis and/or diabetic nephropathy, are commonly encountered in tumor nephrectomy and nephroureterectomy specimens. Although any nonneoplastic kidney disease may be encountered in these resection specimens by chance, additional diseases that may be related to the underlying neoplasm or its treatment regimen include thrombotic microangiopathy, Amyloid A amyloidosis, membranous nephropathy, immunoglobulin A nephropathy, membranoproliferative glomerulonephritis, pauci-immune crescentic glomerulonephritis, focal segmental glomerulosclerosis, minimal-change disease, acute interstitial nephritis, and xanthogranulomatous pyelonephritis. Given the morbidity of chronic kidney disease and the relatively favorable 5-year survival rates for urothelial and renal cell carcinomas, accurate evaluation of the nonneoplastic kidney parenchyma is important.

OBJECTIVES

We will discuss our approach for evaluating the nonneoplastic kidney parenchyma in tumor nephrectomy and nephroureterectomy specimens. The pathologic features of the aforementioned kidney diseases as well as pertinent references will be reviewed. The identification of glomerular abnormalities, including mesangial sclerosis or hypercellularity, segmental sclerosis, crescent formation, glomerulitis, or glomerular basement membrane alterations, should lead to additional immunofluorescence and electron microscopic studies. Safeguards to ensure that the nonneoplastic parenchyma is not overlooked include adding this important parameter to synoptic reports and obtaining periodic acid-Schiff and/or Jones methenamine silver stains prior to microscopic evaluation of the neoplasm.

DATA SOURCES

Relevant literature and University of Chicago Medical Center pathology archives.

CONCLUSIONS

The practicing surgical pathologist should be aware of the importance of both correctly classifying the resected renal or urothelial neoplasm and the concomitant nonneoplastic kidney disease that may be present in these specimens.

Membranoproliferative glomerulonephritis associated with a mutation in Wilms' tumour suppressor gene 1

Wilms' tumour suppressor gene 1 (WT1) encodes a transcription factor required for normal development of the genitourinary system. In the kidney, mutations in WT1 can cause diffuse mesangial sclerosis or focal segmental glomerulosclerosis. Here, we report on a girl with a mutation in WT1, who developed membranoproliferative glomerulonephritis (MPGN) 3 years after completion of treatment for Wilms' tumour. This finding extends the spectrum of glomerular disease seen with WT1 mutations and could have implications for the screening of children with MPGN.

Long-term risk of cancer in membranous nephropathy patients

BACKGROUND

There is a well-known association between membranous nephropathy (MN) and cancer, and patients with MN usually are examined for cancer at the time of diagnosis. The long-term risk of cancer after MN is not well studied.

STUDY DESIGN

Cohort study with record linkage between the Norwegian Kidney Biopsy Registry and Norwegian Cancer Registry.

SETTING & PARTICIPANTS

161 patients with MN from 1988 to 2003.

PREDICTOR

Patients with MN compared with the age- and sex-adjusted general Norwegian population.

OUTCOMES

Cancer diagnosis reported through 2003.

RESULTS

Mean duration of follow-up was 6.2 years (range, 0.1 to 15 years). 33 patients developed cancer; including 24 patients with cancer after the diagnosis of MN. Median time from diagnosis of MN to diagnosis of cancer was 60 months (range, 0 to 157 months). Mean annual incidence ratio of cancer was 2.4/100 person-years (2.1/100 person-years in the 0- to 5-year period and 2.8/100 person-years for the 5 to 15 years after kidney biopsy). During the 0 to 15 years after the diagnosis of MN, the expected number of cancers was 10.7, resulting in a standardized incidence ratio of cancer of 2.25 (95% confidence interval, 1.44 to 3.35). In the 5 to 15 years after diagnosis, standardized incidence ratio was 2.30 (95% confidence interval, 1.19 to 4.02). Patients with MN who developed cancer were older (65 versus 52 years; P < 0.001). Patients with cancer and MN had a greater mortality rate than patients without cancer (67% versus 26%; P < 0.001).

LIMITATIONS

Follow-up treatment after MN with cytotoxic and immunosuppressive medications is not known.

CONCLUSIONS

An increased risk of developing cancer is observed after the diagnosis of MN, which persists for many years.

IgA nephropathy associated with Hodgkin's disease in children: a case report, literature review and urinary proteome analysis

We report herein a rare case of IgAN associated with Hodgkin's disease in a 14-year-old boy. Clinical manifestations and laboratory parameters were improved after treatment with CHOP chemotherapy and enalapril. Urinary proteins were isolated and examined using state-of-the-art proteomic technology, before and during the treatment course. Two-dimensional gel electrophoresis showed obvious alterations in the urinary proteome profile in response to such therapy. Quantitative intensity analysis and gel mapping revealed 14 altered proteins with reduced excretion levels during the treatment course, including albumin, albumin complexed with decanoic acid, alpha-1 antitrypsin, cadherin-11 precursor, collagen alpha 1 (VI) chain precursor, complement C1q tumor necrosis factor-related protein, Ig heavy chain, Ig light chain, kininogen, inter-alpha-trypsin inhibitor (alpha-1 microglobulin), inter-alpha-trypsin inhibitor heavy chain, leucine-rich alpha-2 glycoprotein, beta-2 microglobulin, and transferrin precursor. Their potential roles in the pathogenesis and pathophysiology of IgAN are discussed.

Minimal change nephrotic syndrome and classical Hodgkin's lymphoma: Report of 21 cases and review of the literature

Minimal change nephrotic syndrome (MCNS) is described as a paraneoplastic manifestation of classical Hodgkin's lymphoma (cHL). We reassessed the pathophysiological and clinical significance of this association. A retrospective study was performed to evaluate a cohort of adult patients who developed MCNS and cHL. Twenty-one patients recruited in 15 French centers were analyzed. cHL was associated with inflammatory and general symptoms in most cases. The morphological subtype was predominantly nodular sclerosis (71.4%). MCNS appeared before the diagnosis of lymphoma in eight patients (38.1%) and in this case, it was characterized by a nephrotic syndrome (NS) frequently resistant (50%) or dependent (12.5%) to steroid treatment. Interestingly, diagnosis (3-120 months after MCNS) and effective treatment of the hemopathy were associated with the disappearance of the MCNS. cHL was diagnosed before MCNS in nine patients (42.9%), and in this case, glomerulopathy was associated with cHL relapse in 55.5% of cases. In four patients (19%), the two diseases occurred simultaneously. Extensive immunohistochemical study of lymph nodes was performed in eight patients and did not reveal particular features. In conclusion, MCNS associated with cHL is frequently dependent or resistant to steroid regimen, but remission of NS is obtained with the cure of lymphoma.

Nephrotic syndrome after hematopoietic cell transplantation: do glomerular lesions represent renal graft-versus-host disease?

Glomerular disease associated with nephrotic syndrome has rarely been recognized as a distinct complication of allogeneic hematopoietic cell transplantation. Case reports in the English and Japanese literature since 1988 have described variable glomerular histology, comprising mainly membranous glomerulonephritis (MGN) in almost two thirds and minimal change disease (MCD) in nearly one quarter of patients. Review of the literature reveals a close temporal relationship between the development of nephrotic syndrome shortly after cessation of immunosuppression and the diagnosis of chronic graft-versus-host disease (GVHD). An association of glomerular disease with simultaneous GVHD was seen in 47% of patients overall. Nephrotic syndrome followed GVHD within 5 months in 60% of the combined MCD and MGN reports. A decrease in immunosuppressive medication use was linked to nephrotic syndrome occurrence within 9 months in 63% of patients with MCD and MGN. MCD occurred earlier after hematopoietic cell transplantation, was diagnosed sooner after medication change, and exhibited a better prognosis in comparison with MGN. Glomerular lesions after hematopoietic cell transplantation may therefore represent the renal manifestation of GVHD. Further studies are warranted to delineate the pathogenesis of this complication.

Focal segmental glomerulosclerosis in kidney resected for renal cell carcinoma

A diagnosis of renal dysfunction is usually made on the basis of clinical, biochemical, radiologic, and renal tissue analysis. Accurate diagnosis often requires a renal biopsy, but that procedure is contraindicated in certain clinical circumstances, particularly in patients who have only one kidney. We describe a patient who previously had undergone left nephrectomy for a renal clear cell carcinoma, in whom the diagnosis of focal segmental glomerulosclerosis was made on retrospective analysis of remnant renal tissue from the patient's nephrectomy specimen.

Incidence of renal insufficiency in cancer patients

The frequency of chronic renal insufficiency among cancer patients is unclear. The aim of this study was to determine the frequency of impaired renal function within a population of cancer patients. One thousand two hundred seventeen patients (563 women, 654 men) with cancer underwent serum creatinine concentration and glomerular filtration rate (GFR) evaluations. The Cockcroft-Gault formula was used to estimate the GFR from the creatinine clearance (Cl(cr)). Renal insufficiency was defined as a GFR <or=90 mL/min. Among this population, 72 (5.9%) demonstrated an abnormal serum creatinine concentration (>1.2 mg/dL). According to the Cockcroft-Gault formula evaluations, however, 330 (27.1%) of the patients had an estimated GFR <90 mL/min. Among these, the Clcr was between 60 and 89 mL/min in 241 patients (19.8%); 30 and 59 mL/min in 75 patients (6.2%); and 15 and 29 mL/min in 7 patients (0.6%); 7 patients (6%) had a Cl(cr) <15 mL/min. As a result, 21.2% of patients demonstrating a normal serum creatinine level had abnormal renal function. Renal function should be evaluated in all cancer patients, regardless of their serum creatinine level, before any drug regimen is administered. The Cockcroft-Gault formula appears to be more accurate than serum creatinine concentration for diagnosing renal insufficiency in patients with cancer, but more prospective studies in this population will be necessary to confirm this finding.

Amyloidosis associated with chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL), the most common form of leukemia in Western countries, rarely induces glomerular disease, but membranoproliferative glomerulonephritis or immunotactoid glomerulopathy has been reported. The proliferating cells in CLL are of mature B-cell origin and produce monoclonal immunoglobulin (Ig), thus leading to various kinds of autoimmune disorders or immunotactoid glomerulopathy. Although there have been a few reported cases of amyloidosis accompanying CLL, the type of amyloid fibrils has not been demonstrated nor described in detail, particularly regarding monoclonal Ig productivity. We report a rare case of amyloidosis associated with CLL, in which we detected ?-light chain type monoclonal Ig in the sera, urine, and on the surface membrane of lymphocytes, and discuss an association between monoclonal Ig-related disease and non-Hodgkin's lymphoma.

Nephrotic syndrome as a result of membranous nephropathy caused by renal cell carcinoma

A 77-year-old woman was admitted for a renal biopsy to evaluate a case of nephrotic syndrome. In the course of the examination, a right renal tumor was incidentally found. We performed a right radical nephrectomy in advance of the renal biopsy. Histologically, the tumor was diagnosed as a renal cell carcinoma (clear cell carcinoma) and the non-neoplastic renal cell tissue showed membranous nephropathy (MN). After surgery, the nephrotic syndrome remitted without any further medical treatment and the MN was considered to be a malignancy associated syndrome. There have been few case reports in the literature regarding this association and we wish to describe another case.

Malignant gastrointestinal stromal tumor originating in the lesser omentum, complicated by rapidly progressive glomerulonephritis and gastric carcinoma

A 69-year-old man was admitted with a large elastic mass in the upper abdomen. Computed tomography revealed a massive tumor in contact with the liver and gastrointestinal endoscopy revealed a gastric adenocarcinoma. He developed acute renal failure with massive proteinuria and died with a marked enlargement of the tumor. Autopsy revealed a tumor located in the lesser omentum. The tumor was considered to be a Gastrointestinal Stromal Tumor (GIST) because it was positive for c-kit. In addition, crescent formations and immune complexes in glomeruli were observed. We report the first case of GIST complicated by rapidly progressive glomerulonephritis and gastric carcinoma.

Prognostic significance of albuminuria in patients with renal cell cancer

PURPOSE

A relationship between the urinary albumin excretion rate (UAE) and different types of tumors has been previously described but little is known about UAE and renal cell cancer (RCC). We evaluated the prognostic significance of UAE and its correlation with tumor clinicopathological findings in patients with RCC treated with recombinant interleukin-2 (rIL-2) and recombinant interferon-alpha (rIFN-alpha). Because rIL-2 and rIFN-alpha increase glomerular permeability, we also determined whether the first immunotherapy cycle induced a significant increase in UAE and whether it was related to tumor parameters.

MATERIALS AND METHODS

A total of 51 consecutive patients with RCC were enrolled. Inclusion criteria were patient age at diagnosis younger than 70 years and serum creatinine less than 1.8 mg/dl. Patients with central nervous system metastases and diabetes mellitus were excluded. Nephrectomy was followed by systemic treatment with 1-month cycles of low dose rIL-2 and rIFN-alpha, which were repeated every 4 months, UAE was determined before and after the first treatment cycle.

RESULTS

Univariate analysis showed that pre-cycle and post-cycle UAE greater than 30 mg/24 hours significantly influenced survival (p = 0.006 and 0.007, respectively). A multivariate model adjusted for age at onset, performance status, post-cycle UAE, tumor stage and grade, and metastases showed that pre-cycle UAE greater than 30 mg/24 hours had an independent prognostic role (p = 0.011). The first treatment cycle increased UAE 81.8% vs baseline (p = 0.002). The post-cycle vs pre-cycle increase was significant in patients with stages III-IV (p = 0.003) and grades 3-4 (p = 0.028) tumors. Pre-cycle and post-cycle UAE were significantly higher in stages III-IV than in stages I-II cases (p = 0.030 and 0.007, respectively).

CONCLUSIONS

UAE is an independent prognostic factor that is related to disease stage in patients with RCC.

Glomerulonephritis and malignancy: a population-based analysis

BACKGROUND

An association between glomerulonephritis and malignant tumors has previously both been found and discarded in clinical series, but to our knowledge never has been tested in a population-based setting.

METHODS

The Danish Kidney Biopsy Registry includes all kidney biopsies performed from 1985. Using a unique personal identification number, each person in the registry to the National Population Registry and the Danish Cancer Registry were linked. Cancer occurrence after the biopsy was compared in patients with morphological, glomerular diseases with that of the general Danish population, taking into account sex, age, calendar period and time since biopsy, and the 95% confidence interval (95% CI) for the observed-to-expected rates was calculated, assuming a Poisson distribution. Cancer occurrence was stratified to <1 year, 1 to 4, and >or=5 years after a biopsy.

RESULTS

A total of 102 de novo cancers were found in 1958 patients. These cancers represent a two- to threefold excess of the expected number at <1 and 1 to 4, but not >or=5 years after a biopsy. Non-Hodgkin's lymphomas were observed six to eight times more than expected. Cancer excess was seen in glomerulonephritides with a known or suspected virus etiology.

CONCLUSIONS

The excess cancer rate could be the result of underlying undiagnosed tumors whose antigens have initiated glomerulonephritis, or the immunosuppressive therapy that initiated or energized tumor cells. Based on the findings in our study, there is some support for an association to persistent viruses causing first the glomerulonephritides and then the malignancies, perhaps through a common pathogenesis. This calls for other studies to be done that are specifically designed to investigate this issue, with more data on patient characteristics and confounders.

Primary cerebral lymphoma and membranous nephropathy: a still unreported association

Paraneoplastic nephrotic syndrome (NS) in the setting of membranous nephropathy (MN) is a well-known and often prodromal complication of renal and extrarenal malignancy. Primary cerebral lymphoma is a rare neoplasm uncommonly investigated in the setting of NS. We describe for the first time a case of primary cerebral lymphoma in association with MN. An elderly woman presented for renal biopsy because an NS had been diagnosed previously and treated by steroid therapy. Primary membranous glomerulonephritis was diagnosed and immunosuppressive therapy was started. Twenty days later, she was readmitted because of left hemiplegia. Computed tomography and subsequent nuclear magnetic resonance evaluation of the brain documented an extensive cerebral space-occupying lesion. A cerebral malignant lymphoma was diagnosed at intraoperative histologic evaluation, and subsequent light microscopic and immunohistochemical studies allowed the diagnosis of peripheral T-cell lymphoma. Extensive clinical workup, including bone marrow biopsy, documented the lack of any neoplastic involvement outside the brain. Primary cerebral non-Hodgkin's lymphoma of peripheral T-cell derivation consequently was diagnosed. This case suggests that patients with MN, particularly elderly patients, should undergo complete screening for neoplasms. The absence of specific guidelines on this topic may be due partly to the lack of extensive description of all newly identified cases. All cases should be reported to evaluate whether this association is causal or fortuitous.

Lymphatic tumor emboli of perirenal fat in patient with nephrotic syndrome receiving renal biopsy, ultimately revealed gastric adenocarcinoma with membranous glomerulonephritis

The association of malignancy with nephrotic syndrome and renal histopathologic abnormalities is well documented. Paraneoplastic proteinuria caused by membranous glomerulonephritis usually is made simultaneously with the diagnosis of a malignant tumor, or the two conditions are diagnosed within a year of each other. We reported a patient who presented with nephrotic syndrome initially. Incidentally, in kidney specimens, pathologic findings showed perirenal fatty tissue with malignancy tumor emboli in lymphatics. Thereafter, gastric adenocarcinoma was diagnosed by gastrointestinal panendoscopy with gastric biopsy under impression of malignancy associated with glomerulonephritis. Patient died of complications of malignancy-related disseminated intravascular coagulation without chemotherapy after confirming diagnosis was made three months later.

Kidney involvement and renal manifestations in non-Hodgkin's lymphoma and lymphocytic leukemia: a retrospective study in 700 patients

Renal involvement as part of systemic lymphoma (LY) is quite frequent, however, primary extranodal renal non-Hodgkin's lymphoma (NHL) is extremely rare, and only about 65 cases have been reported in the world literature. In a retrospective study of renal manifestations in 700 patients with documented LY and chronic lymphocytic leukemia (CLL) seen at our hospital during 1986-95, 83 patients had signs of acute renal failure. Only five of these had proven renal infiltration, but none of them satisfied the criteria for primary renal LY. Glomerulonephritis (GN) has also rarely been reported in association with LY and CLL, and only 37 glomerular lesions in NHL and 42 in CLL have been documented, respectively. GN may precede, coexist, or follow the diagnosis of LY by several years. Of the 42 cases of CLL reported worldwide, 36 had nephrotic syndrome. Renal failure was seen in about one third. The most common glomerular lesion reported is membranoproliferative GN, followed by membranous GN. In our study, we found only five biopsy-proven cases with GN amongst the 700 patients seen. In this report we also briefly describe some rare interesting associated renal syndromes in CLL and NHL.

Hodgkin's disease complicated by the nephrotic syndrome in a man with Kugelberg-Welander disease

A case of nephrotic syndrome due to minimal change glomerulonephritis complicating Hodgkin's disease in a man with a longstanding neurological disorder is presented. Treatment with combination chemotherapy resulted in a rapid improvement in the nephrotic syndrome, and complete remission of the Hodgkin's disease. Disease relapse occurred less than 12 months later without recurrence of the nephrotic syndrome and was refractory to further treatment. The association of minimal change glomerulonephritis with Hodgkin's disease and the possible pathogenesis of this association are discussed.

Malignancy and renal disease

A variety of renal diseases and electrolyte disorders may be associated with various malignancies or with treatment of malignancy with chemotherapeutic drugs or radiation. This article reviews renal disease in cancer patients, which constitutes a major source of morbidity and mortality.

Crescentic glomerulonephritis associated with renal cell carcinoma

Various glomerular lesions are described in association with malignancy. We report a rare case of crescentic glomerulonephritis occurring in association with renal cell carcinoma. A granular deposition of immune complexes and complement strongly suggests a tumor associated immune complex glomerulonephritis.