Glomerular and extraglomerular immune complex deposits in a bone marrow transplant recipient

Hematological Malignancies and the Kidney

The incidence of hematologic malignancies is on the rise worldwide. Kidney disease is ubiquitous in patients with hematologic malignancies, encompassing a wide spectrum of disorders involving each kidney compartment, including the vasculature, tubules, interstitium, and glomerulus, and there is significant overlap of kidney involvement with each hematologic malignancy. Vascular disorders include both microvascular and macrovascular damage, via thrombotic microangiopathy, hyperleukocytosis, hyperviscosity, and cryoglobulinemia. The tubulointerstitial compartment may be affected by prerenal azotemia and acute tubular injury, but malignant infiltration, tumor lysis syndrome, extramedullary hematopoiesis, cast nephropathy, granulomatous interstitial nephritis, and lysozymuria should be considered in certain populations. Obstructive uropathy may occur due to nephrolithiasis or retroperitoneal fibrosis. Glomerular disorders, including membranoproliferative, membranous, minimal change, and focal segmental glomerulosclerosis, can rarely occur. By understanding how each compartment may be affected, care can best be optimized for these patients. In this review, we summarize the widely varied etiologies of kidney diseases stratified by kidney compartment and hematologic malignancy, focusing on demographics, pathology, pathophysiology, mechanism, and outcomes. We conclude with common electrolyte abnormalities associated with hematologic malignancies.

Antineoplastic agents and thrombotic microangiopathy

Thrombotic microangiopathy is an uncommon but reported adverse effect of a variety of antineoplastic drugs, including chemotherapy agents such as mitomycin C and gemcitabine, and newer targeted agents such as the vascular endothelial growth factor inhibitors. We present a review of thrombotic microangiopathy associated with antineoplastic agents and its implications in current cancer therapy.

Chronic kidney disease after autologous stem cell transplantation: analysis of a single center experience

PURPOSE

Chronic kidney disease (CKD) after allogeneic hematopoietic stem cell transplantation (HSCT) has increasingly been reported. However, CKD after autologous HSCT, especially changes in renal pathology, has rarely been reported. This study aimed to evaluate the frequency of CKD among patients who received autologous HSCT for hematological and nonhematological disorders, and analyze its clinical and pathological features.

METHODS

We performed a retrospective study to evaluate the frequency of CKD after autologous HSCT and analyzed clinical and pathological features of CKD. Clinical records of patients who underwent autologous HSCT at the First Affiliated Hospital of Guangxi Medical University between May 2000 and November 2010 were screened. Clinical data of those with kidney injury on presentation and follow-up were acquired from hospital records.

RESULTS

A total of 41 patients who received autologous HSCT were identified. CKD developed in six patients (14.6%). Among the six patients, all had various degrees of proteinuria and three patients had nephrotic syndrome. Impaired renal function occurred in three patients. Three patients with nephrotic syndrome received only prednisone. Two patients obtained complete remission, and one had partial remission. What is particularly worth mentioning is, in two patients who received renal biopsy in our study, the pathological changes were mesangial proliferative glomerulonephritis.

CONCLUSIONS

Mesangial proliferative glomerulonephritis may not be as uncommon as previously thought in CKD patients after autologous HSCT. Presentation of nephrotic syndrome is common in CKD after HSCT and prednisone alone are effective.

Mesangial Proliferative Glomerulonephritis After Autologous Stem Cell Transplantation

Although glomerulonephritis and renal failure have been observed after allogenic stem cell transplantation, only a few such reports were published about patients undergoing autologous stem cell transplantation. We report a case of mesangial proliferative glomerulonephritis developing 4 months after autologous stem cell transplantation for chronic lymphatic leukemia. Serological test results, together with histological, immunohistochemical, and electronic microscopic findings of a kidney biopsy specimen, confirmed the diagnosis of mesangial proliferative glomerulonephritis in our patient. Complement and immunoglobulin A were not present in the kidney biopsy specimen. An abnormal clone, not previously reported, with the translocation t(5;11)(q31;q13) in blood and bone marrow was observed. The reason for and whether progenitor cells in stem cell transplantations could contribute to the development of glomerulonephritis remain open questions. Kidney biopsy should be performed in patients with microscopic hematuria and/or proteinuria after autologous stem cell transplantation.

Thrombotic microangiopathy associated with alpha-interferon therapy for chronic myeloid leukaemia (Case Report)

The association of interferon (IFN) therapy with haemolytic uraemic syndrome in patients with chronic myeloid leukaemia (CML) has been reported infrequently. The pathogenesis of the renal lesion in such cases remains unclear. We report the case of a patient with chronic myeloid leukaemia who developed nephrotic syndrome and renal failure while being treated with hydroxyurea and IFN-alpha. Renal biopsy showed features of chronic thrombotic microangiopathy. The discontinuation of IFN-alpha, and a prompt institution of plasmapheresis and steroids resulted in improvement of the nephrotic syndrome and renal function. These findings suggest that long-term IFN-alpha therapy can induce thrombotic microangiopathy and haemolytic uraemic syndrome in patients with chronic myeloid leukaemia.

Antineutrophil Cytoplasmic Antibody–Associated Glomerulonephritis in Chronic Graft-Versus-Host Disease After Allogenic Hematopoietic Stem Cell Transplantation

Graft-versus-host disease (GVHD) is one of the most frequent complications that occur after hematopoietic stem cell transplantation (HSCT). Recently, renal involvement, including membranous nephropathy, focal segmental glomerulosclerosis, and minimal change disease, has been described as a manifestation of chronic GVHD. This case report describes a patient who developed antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis after HSCT. Following preparation with chemotherapy, a 29-year-old man with chronic myeloid leukemia underwent allogenic peripheral blood stem cell (PBSC) transplantation, after which first acute and then chronic GVHD developed. Treatment with prednisone resulted in improvement in the patient's GVHD. After the termination of steroid therapy and about 10 months after PBSC transplantation, nephritic syndrome appeared and the patient's serum creatinine value increased to 1.7 mg/dL. Laboratory evaluation revealed perinuclear antineutrophilic cytoplasmic antibody (p-ANCA) in the serum. Histological examination of renal biopsy tissue showed focal segmental proliferative glomerulonephritis with glomerulosclerosis in 20% of available glomeruli, large cellular crescents in 6% of glomeruli, and no staining of immunoglobulins or complement along the capillary walls. Electron microscopy revealed no immune deposits. After treatment with prednisone 60 mg/d, diltiazem 120 mg/d, and enalapril 10 mg/d, the proteinuria gradually decreased, and p-ANCA was undetectable. These findings suggest that in this patient the ANCA-associated glomerulonephritis was associated with renal involvement that occurred during the course of chronic GVHD.

Von Willebrand factor-cleaving protease activity remains at the intermediate level in thrombotic thrombocytopenic purpura

A 59-year-old woman, diagnosed with chronic myelogenous leukemia (chronic phase) and treated with interferon-alpha for 13 years, developed renal failure. Renal biopsy showed thrombotic thrombocytopenic purpura, but intensive therapy including plasma exchange and steroid administration was not effective. The activity of von Willebrand factor-cleaving protease was detectable at the intermediate level (15-46%) during the clinical course, suggesting that this case was not compatible with the previously reported pattern of idiopathic or drug-induced thrombotic thrombocytopenic purpura, but with the pattern associated with malignant disease or immunological disorders. Further studies to determine the effects of interferon-alpha on endothelial cells in chronic myelogenous leukemia patients are needed.

Withdrawal of interferon-alpha results in prompt resolution of thrombocytopenia and hemolysis but not renal failure in hemolytic uremic syndrome caused by interferon-alpha

This case report describes 2 patients with chronic myeloid leukemia in whom hemolytic uremic syndrome developed while being treated with interferon-alpha and hydroxycarbamide. Hemolytic uremic syndrome was recognized by progressive renal dysfunction, thrombocytopenia, microangiopathic hemolytic anemia, and histologic features of thrombotic microangiopathy in the kidney. Although renal dysfunction progressed to dialysis-dependent renal failure in one patient despite treatment with prednisolone and plasmapheresis but not in other, withdrawal of the treatment resulted in a prompt resolution of thrombocytopenia and microangiopathic hemolytic anemia in both patients.