Kidney involvement in leukemia and lymphoma

Prevalence of kidney disease in patients with different types of cancer or hematological malignancies: a cross-sectional study

PURPOSE

This study investigated the prevalence and risk factors of acute kidney injury (AKI) and chronic kidney disease (CKD) in cancer patients with the aim of providing guidance for clinical treatment of cancer patients.

METHODS

A retrospective study was conducted on all cancer and hematological malignancy patients admitted to Xuanwu Hospital, Capital Medical University, from January 2018 to July 2023. The study population included patients aged 18-80 years with a confirmed cancer or malignancy diagnosis. Chi-square tests, Spearman's correlation, and logistic regression were used to evaluate the relationships between demographic factors, comorbidities, cancer types, antitumor drugs and the prevalence of AKI/CKD.

RESULTS

Among the 2438 participants, the prevalence rates of AKI and CKD were 3.69% and 7.88%, respectively. Patients with diabetes had higher prevalence of AKI/CKD than those without diabetes (OR = 1.66, 95% CI 1.01-2.68, p = 0.040; OR = 1.60, 95% CI 1.10-2.31, p = 0.012, respectively). In addition, a higher prevalence of CKD was observed in patients with hypertension (OR = 3.49, 95% CI 2.43-5.06, p < 0.001). Underweight patients were more likely to develop AKI (OR = 2.66, 95% CI 1.03-6.08, p = 0.029). Anthracyclines may contribute to a higher risk of AKI, and antimetabolites and immunomodulators may be associated with the development of CKD. Overall, patients with hematological malignancies had significantly higher rates of AKI/CKD than those with solid tumors. Among solid tumor patients, the prevalence of AKI/CKD was low in patients with lung and breast cancer.

CONCLUSIONS

AKI and CKD prevalence varies across cancer types, influenced by factors, such as diabetes, hypertension, body weight, and antitumor drugs. Tailored treatment plans are essential for improving cancer patient outcomes.

Predominantly multiple focal non-cystic renal lesions: an imaging approach

Multiple non-cystic renal lesions are occasionally discovered during imaging for various reasons and poses a diagnostic challenge to the practicing radiologist. These lesions may appear as a primary or dominant imaging finding or may be an additional abnormality in the setting of multiorgan involvement. Awareness of the imaging appearance of the various entities presenting as renal lesions integrated with associated extrarenal imaging findings along with clinical information is crucial for a proper diagnostic approach and patient work-up. This review summarizes the most relevant causes of infectious, inflammatory, vascular, and neoplastic disorders presenting as predominantly multiple focal non-cystic lesions.

Unmasking the Rarity: A Case Report on Type B Lactic Acidosis in Pediatric Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia (ALL) is the most prevalent pediatric malignancy, accounting for approximately 25% of childhood cancers. Despite significant advancements in treatment protocols, ALL remains a complex disease, often presenting with various complications, including the rare metabolic disturbance of type B lactic acidosis. This case report details the clinical journey of a 14-year-old female with ALL who developed type B lactic acidosis during treatment. The patient presented with intermittent fever, abdominal pain, jaundice, and hepatosplenomegaly, accompanied by severe anemia and thrombocytopenia. Initial management included supportive care and chemotherapy initiation. Despite aggressive interventions, the patient's condition deteriorated, with escalating lactic acidosis and respiratory distress, leading to a critical need for tailored management strategies. This report underscores the importance of early recognition and comprehensive management of type B lactic acidosis in pediatric ALL, highlighting its multifactorial etiology and potentially life-threatening consequences. Enhanced clinical awareness and a multidisciplinary approach are crucial for improving outcomes in such complex cases.

Kidney and Urinary Tract Involvement in Chronic Myelomonocytic Leukemia

Chronic myelomonocytic leukemia (CMML) is a hematologic malignancy affecting the bone marrow and resulting in peripheral blood monocytosis. Kidney and urinary tract involvement is common and can present dramatically with life-threatening consequences. Kidney involvement can be the result of direct or indirect mechanisms, including prerenal azotemia, glomerular disease, tubulointerstitial involvement, and renovascular disorders. Urinary tract involvement, electrolyte and acid-base disorders, as well as nephrotoxicity from treatment of the disorder can also occur. Given this multifactorial pathogenesis involving several mechanisms concomitantly, nephrologists must exercise heightened awareness and maintain a low threshold for kidney biopsy. There is a pressing need for future research endeavors to elucidate and target the manifestations of CMML that involve the kidneys with the ultimate goal of augmenting overall prognosis and therapeutic outcomes.

A rare cause of posterior reversible encephalopathy syndrome: Acute lymphoblastic leukemia

Key Clinical Message

The presentation of posterior reversible encephalopathy syndrome (PRES) as the initial presenting sign of acute lymphoblastic leukemia is unusual, as PRES is more often a complication of therapy. This case highlights the importance of maintaining a broad differential diagnosis for pediatric hypertension and its complications.

Abstract

A 6-year-old male presented with a seizure-like episode. Evaluation revealed hypertension and brain imaging showed findings consistent with posterior reversible encephalopathy syndrome. Complete blood count showed lymphoblasts, and the cause of his hypertension was determined to be renal infiltration of leukemia cells due to B-cell acute lymphoblastic leukemia.

The normal reference values and estimation formulae of renal structural parameters in Chinese children based on large-sample CT data

Purpose

Our aim was to investigate the normal reference value and to establish an estimation formulae for renal structural parameters (RSPs) based on large-sample CT data of Chinese children, which can provide a data reference for the clinical assessment of kidney development and diseases in Chinese children.

Materials and Methods

A total of 438 children aged 0-17 years with normal renal CT images and basic indices were continuously collected. The bilateral RSP, including renal length (RL), renal width (RW), renal thickness (RT), renal volume (RV), renal cortical thickness (RCT), renal artery diameter (RAD) and renal CT value, were measured. Kendall's rank correlation was used to analyze the correlation between RSP and sex. Pearson's correlation was used to analyze the correlation between RSP and age, height and weight. Differences in the RSP of bilateral kidneys were analyzed via a paired samples t-test. Multiple linear regression was used to analyze the multivariate relationships between RSP and basic indices and establish the estimation formula of RSP.

Results

The RSP of normal kidneys showed a dynamic increasing trend with age, except for the CT values. The reference value ranges (95% confidence interval) of normal RSP for each age group were determined. Pearson correlation analysis demonstrated strong correlations between RSP (RL, RW, RT, RV, RCT and, RAD) and basic indices (age, height and, weight), with height exhibiting the greatest correlation coefficient, followed by age or weight. Kendall's analysis showed that none of the RSPs were correlated with sex. The RL, RW, RV and RAD of the left kidney were larger than those of the right kidney, and the RT and RCT of the right kidney exhibited opposite results. Multiple linear regression analysis demonstrated a significant linear relationship between the RSP (RL, RW, RT, RV and, RCT) and the variables of the basic indices. The estimation formulae for calculating the RSP were established.

Conclusion

This is the first Chinese study to report of the trends, normal reference values and estimation formulae of normal RSP based on large-sample CT data. These results can provide data references for assessing adequate kidney growth or disease damage in Chinese children.

Onco-Nephrology: Kidney Disease in the Cancer Patient

Patients with cancer may develop kidney disease with a variety of different clinical manifestations including acute kidney injury, chronic kidney disease, hypertension, proteinuria and electrolyte disturbances. Onco-nephrology is the subspecialty of nephrology that diagnoses and manages kidney disease in patients with cancer. In this article, we review major topics in Onco-Nephrology that may be encountered by the general internist.

Role of Vitamin D in the diagnosis of acute Myeloid Leukemia

A range of hematological and biochemical markers have been investigated in Acute Myeloid Leukemia (AML) patients to determine the relationship between cancer growth and metabolic problems. This study aimed to determine the effects of vitamin D deficiency in Iraqi patients with acute myeloid leukemia who had recently been diagnosed. There was a significant inverse correlation between the total serum cholesterol (TC) level of acute myeloid leukemia (AML) patients group [(148.77±12.2) for males, (165.29±9.64) for females] and the control group [(164.50±7.26) for males, (180.05±7.31) for females], also an inverse correlation between high-density lipoprotein (HDL) level of acute myeloid leukemia (AML) patients group [(46.00±2.04) for males, (46.18±1.08) for females] and control group [(54.25±1.86) for males,(51.94±1.37) for females]. A significant difference was between the serum triglyceride (TG) level of acute myeloid leukemia (AML) patients group [(128.71±13.07) for males, (152.48±10.6) for females] and control group [85.12±11.30) for male, (90.50±10.90) for females], also between vitamin D level of acute myeloid leukemia (AML) patients group [(17.23±1.18) for males, (12.96±0.74) for females] and control group [(42.62±1.43) for males, (40.76±0.82) for females]. A statistically significant difference was between the serum calcium levels of individuals with acute myeloid leukemia [(8.99±0.32) for males, (8.91±0.23) for females] and the control group [(13.13±1.16) for males, (10.73±0.28) for females]. AML patients can benefit from vitamin D treatment, according to a pairwise analysis of receiver operating characteristic (ROC) curves. The above results are related to concluding that Vitamin D can be utilized as a diagnostic test for AML patients. Keywords; acute myeloid leukemia (AML), Hypereosinophilia, ROC curve, hypocholesterolemia, vitamin D.

Intravoxel incoherent motion diffusion-weighted MRI of renal parenchyma and its clinical significance in patients with untreated acute leukemia: a pilot study

PURPOSE

To evaluate quantitative parameters derived from intravoxel incoherent motion diffusion-weighted MRI (IVIM) of renal parenchyma in patients with untreated acute leukemia (AL) and analyze its prognostic significance and probable pathological mechanism.

METHODS

From March 2019 to November 2021, 67 newly diagnosed AL patients and 67 healthy controls matched in age and sex were recruited. All participants underwent IVIM in the kidneys, and D, D*, f, standard ADC values were measured. The differences of all parameters between AL and controls were analyzed. The relationship between imaging parameters and estimated glomerular filtration rate (eGFR) was studied. Univariable and multivariable analyses were performed to investigate prognostic significance of possible indicators.

RESULTS

The f and D value of renal medulla and D value of renal cortex in AL patients were lower than those in the healthy control group (t = - 2.173, t = - 3.463, t = - 2.030, respectively, all P < 0.05). The cortical f, cortical standard ADC, medullary f, and medullary standard ADC were correlated with the eGFR (r = 0.524, r = 0.401, r = 0.415, r = 0.325, respectively, all P < 0.05) in patients with AL. A medullary f value ≤ 9.51% (hazard ratio: 0.282; 95% confidence interval: 0.110, 0.719; P = 0.008) was associated with overall survival in a multivariable analysis.

CONCLUSION

The f and standard ADC values in renal parenchyma were the probable imaging markers of renal function in patients with newly diagnosed de novo AL. Lower renal medullary f value was a potential independent predictor for overall survival.

Lysozyme-Induced Nephropathy: A Diagnosis Not to Forget

Kidney injury in hematologic malignancies can manifest in many ways. We present a case report of a 44-year-old female with de novo acute myeloid leukemia (AML) and acute kidney injury. Following the etiological investigation, lysozyme-induced nephropathy was believed to be the most probable cause of renal injury. Intensive cytoreduction and chemotherapy were started and the patient's cytopenias and kidney injury have improved. This case highlights the importance of recognizing lysozyme-induced nephropathy as a form of kidney injury in AML. Despite being frequently underrecognized, a precocious diagnosis may impact the patient's prognosis.

Human Umbilical Cord MSC Delivered-Soluble TRAIL Inhibits the Proliferation and Promotes Apoptosis of B-ALL Cell In Vitro and In Vivo

The TNF-related apoptosis-inducing ligand (TRAIL) could induce apoptosis of leukemic cells, while showed no cytotoxic effect on normal cells. One of the limitations for application of recombinant TRAIL (rhTRAIL) in leukemia treatment is that the serum half-life of this protein is short. Gene delivery is a good strategy to prolong the half-life of TRAIL. In this study, we genetically engineered umbilical cord-MSCs to continuously express and secrete soluble TRAIL (MSC-sTRAIL), to investigate the effects of MSC-sTRAIL on B-cell acute lymphocytic leukemia (B-ALL) cells. In vitro, MSC-sTRAIL significantly inhibited the proliferation of B-ALL cells by suppressing PI3K/AKT and MEK/ERK signaling pathways, and induced apoptosis of B-ALL cells via the caspase cascade-mediated pathway and mitochondrial-mediated pathway. In vivo, MSC-sTRAIL dramatically inhibited B-ALL cell growth. Meanwhile, B-ALL-induced splenic and renal injuries were significantly alleviated after MSC-sTRAIL treatment. Moreover, the serum levels of MSC-secreted sTRAIL were still high in MSC-sTRAIL treated mice, indicating an extended half-life of sTRAIL. Our study suggests that MSC delivered-TRAIL secretion is a potential therapeutic strategy for B-ALL treatment.

Acute kidney injury and childhood acute myeloid leukemia

BACKGROUND

Acute kidney injury (AKI) appears to be particularly common in children with acute myeloid leukemia (AML), although the epidemiology data on this patient population is sparse. The objective of this study was to assess the prevalence and factors associated with AKI in childhood AML during chemotherapy treatment.

METHODS

The medical records of 112 children aged under 15 years diagnosed with AML who received chemotherapy in a major tertiary-care referral center in southern Thailand were reviewed. Logistic regression was used to identify factors associated with AKI.

RESULTS

Fifty-six (50%) children had AKI events. The median time from AML diagnosis to the first AKI was 29.5 days (interquartile range: 11.0-92.8) and the median follow-up time was 10.9 months (interquartile range: 3.6-31.1). Age at diagnosis ≥ 10 years (OR 2.75, 95% CI 1.09-6.93), glomerular filtration rate < 90 mL/min/1.73 m² at AML diagnosis (OR 7.58, 95% CI 1.89-30.5), and septic shock (OR 22.0, 95% CI 4.63-104.3) were independently associated with AKI.

CONCLUSIONS

Childhood AML has a high rate of kidney injury with 50% having AKI. Age ≥ 10 years at diagnosis, impaired kidney function before treatment, and septic shock were strongly associated with AKI. A higher resolution version of the Graphical abstract is available as Supplementary information.

An Unusual Case of High-Grade Non-Hodgkin Lymphoma Masquerading as Acute Pyelonephritis with Acute Kidney Injury

Renal involvement in non-Hodgkin lymphoma (NHL) has myriad of morphological features. We discuss an unusual case who presented as acute pyelonephritis (leucocytosis and acute kidney injury), ovarian mass and compressive myelopathy finally diagnosed as Non Hodgkins Lymphoma.

Isolated Renal Relapse in a Post-Allogenic Transplant Adult Patient With Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia (ALL) is an aggressive hematological neoplasm typically more common in children than adults. More prolonged remissions and a potential cure can be achieved if allogeneic hematopoietic stem cell transplantation (allo-HSCT) is performed. Outcomes after allo-HSCT vary significantly among patients, and multiple factors contribute to these outcomes. Isolated extramedullary relapse (iEMR) after allo-HSCT is rare. We present the case of a 43-year-old man who was diagnosed with Philadelphia chromosome-negative (Ph-neg), B-cell ALL and underwent haploidentical allo-HSCT because of high-risk features at diagnosis. One year later, he was admitted to the hospital with facial and peripheral edema, proteinuria, elevated serum creatinine levels, and hypertension. Renal biopsy was performed immediately. Renal infiltration of TdT+ leukemic cells was detected by immunohistochemistry. Bone marrow aspiration, lumbar puncture, and computed tomography (CT) scans were performed to identify other sites of possible relapse. No other sites were identified, and an extramedullary isolated renal relapse was diagnosed. Intensive re-induction with chemotherapy was not possible because of the coronavirus disease 2019 (COVID-19) infection. Six weeks later, a medullary relapse was noted. Medullary infiltration of B-cell ALL after allo-HSCT has a historically poor prognosis; however, iEMR appears to have a better overall prognosis. The optimal treatment for renal iEMR is still a matter of debate.

Defining kidney outcomes in children with acute lymphoblastic leukemia in the modern era

BACKGROUND

To define the incidence of acute kidney injury (AKI), chronic kidney disease (CKD), and hypertension (HTN) in pediatric patients diagnosed with acute lymphoblastic leukemia (ALL) over a recent 9-year period.

METHODS

This study is a retrospective cohort study of all pediatric patients diagnosed with ALL at Nationwide Children's Hospital from January 1, 2008, to December 31, 2016. Patient demographic and clinical data including serum creatinine and blood pressure were collected at diagnosis up to 9 years post diagnosis.

RESULTS

A total of 222 patients were identified for this study. The overall incidence of AKI in our cohort was high, with 101 subjects (45.5%, CI 38.8-52.3%) developing AKI at least once. CKD status could only be determined in 214 patients due to limited later GFR data. The incidence of CKD was low with only 5 of 214 patients developing CKD (2.3%, CI: 0.8-5.4%). The overall incidence of HTN at diagnosis was 45.6% (95% CI: 59.1-72%), and at 1 month post diagnosis was 65.8% (95% CI: 59.1-72.0%). Chronic HTN could only be determined in 216 patients due to limited blood pressure data. Chronic HTN was noted in 34.3% of patients (74/216, 95% CI: 28-41%).

CONCLUSIONS

Among children with ALL, the incidence of AKI is relatively high at the time of diagnosis. However, development of CKD is relatively rare, suggesting good mid-term kidney prognosis. There is a high incidence of HTN at the time of diagnosis, 1 month post diagnosis, and chronic HTN that often goes untreated. A higher resolution version of the Graphical abstract is available as Supplementary information.

Extent of hypertension and renal injury in children surviving acute lymphoblastic leukemia

BACKGROUND

Childhood acute lymphoblastic leukemia (ALL) fortunately has high survival rates, and understanding longer term implications of therapy is critical. In this study, we aimed to investigate kidney health outcomes by assessing the prevalence of renal dysfunction and hypertension (HTN) in children with ALL at 1-5 years after ALL diagnosis.

METHODS

This was a single-center, cross-sectional study of children with ALL who were 1-5 years post diagnosis. Glomerular filtration rate (GFR) measurements were calculated, and urine samples were collected to assess for protein/creatinine and albumin/creatinine. Blood pressure (BP) was determined by standard oscillometric technique, and children ≥6 years of age were eligible for ambulatory blood pressure monitoring (ABPM).

RESULTS

Forty-five patients enrolled in the study, and 21 completed ABPMs. Fifteen patients (33%, 95% CI: 20%-49%) developed acute kidney injury (AKI) at least once. Thirteen (29%, 95% CI: 16%-44%) had hyperfiltration, and 11 (24%) had abnormal proteinuria and/or albuminuria. Prevalence of HTN based on clinic measurements was 42%. In the 21 ABPM patients, 14 had abnormal results (67%, 95% CI: 43%-85%), with the majority (11/21) demonstrating abnormal nocturnal dipping pattern.

CONCLUSIONS

Among children with ALL, there is a high prevalence of past AKI. The presence of hyperfiltration, proteinuria, and/or albuminuria at 1-5 years after ALL diagnosis suggests real risk of developing chronic kidney disease (CKD) over time. There is a high prevalence of HTN on casual BP readings and even higher prevalence of abnormal ABPM in this group. The high prevalence of impaired nocturnal dipping by ABPM indicates an increased risk for future cardiovascular or cerebral ischemic events.

The association between symmetric dimethylarginine concentrations and various neoplasms in dogs and cats

Following the introduction of the symmetric dimethylarginine (SDMA) immunoassay, cases were reported where the SDMA concentration was markedly increased above the reference interval (RI) with neither concurrent increases in serum creatinine (Cr) concentrations nor clinical signs of kidney disease. Many of these animals were also concurrently diagnosed with cancer, most commonly lymphoma. The purpose of the study was to evaluate the association of increased SDMA in dogs and cats with lymphoma and other cancers as compared with age- and breed-matched non-tumour controls. In this retrospective case-control study, serum chemistry results from 1804 tumour cases, and age- and breed-matched non-tumour control animals were used. Matched-pair odds ratios between animals diagnosed with neoplasms and non-tumour controls for dichotomized SDMA values were determined by tumour type. SDMA concentrations were significantly higher in dogs and cats with lymphoma (p < .0001) compared with non-tumour controls. The odds ratio for increased SDMA concentrations in dogs with lymphoma was 10.0 (95% CI, 5.98-16.72) and for cats with lymphoma was 3.04 (95% CI 1.95-4.73). A significant number of canine and feline lymphoma cases had an increased SDMA concentration not associated with an increased Cr concentration (p < .001). Canine and feline lymphoma patients have an increased odds of having a SDMA concentration above the RI at diagnosis. Further characterization and evaluation of dogs and cats with lymphoma is required to help understand the mechanism(s) and the clinical significance of these alterations.

Diagnostic Value of 1H NMR-Based Metabolomics in Acute Lymphoblastic Leukemia, Acute Myeloid Leukemia, and Breast Cancer

Cancer refers to a massive number of diseases distinguished by the development of abnormal cells that divide uncontrollably and have the capability of infiltration and destroying the normal body tissue. It is critical to detect biomarkers that are early detectable and noninvasive to save millions of lives. The aim of the present work is to use NMR as a noninvasive diagnostic tool for cancer diseases. This study included 30 plasma and 21 urine samples of patients diagnosed with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML), 25 plasma and 17 urine samples of patients diagnosed with breast cancer (BC), and 9 plasma and urine samples obtained from healthy individuals as controls. They were prepared for NMR measurements; then, the metabolites were identified and the data were analyzed using multivariate statistical procedures. The OPLS-DA score plots clearly discriminated ALL, AML, and BC from healthy controls. Plots of the PLS-DA loadings and S-line plots showed that all metabolites in plasma were greater in BC than in the healthy controls, whereas lactate, O-acetylcarnitine, pyruvate, trimethylamine-N-oxide (TMAO), and glucose were higher in healthy controls than in ALL and AML. On the other hand, urine samples showed lower amounts of lactate, melatonin, pyruvate, and succinate in all of the studied types of cancer when compared to those of healthy controls. ¹H NMR can be a successful and noninvasive tool for the diagnosis of different types of cancer.

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.

OUP accepted manuscript

Podocytopathies are glomerular disorders in which podocyte injury drives proteinuria and progressive kidney disease. They encompass a broad spectrum of aetiologies, resulting in pathological pictures of minimal-changes, focal segmental glomerulosclerosis, diffuse mesangial sclerosis or collapsing glomerulopathy. Despite improvement in classifying podocytopathies as a distinct group of disorders, the histological definition fails to capture the relevant biological heterogeneity underlying each case, manifesting as extensive variability in disease progression and response to therapies. Increasing evidence suggests that podocytopathies can result from a single causative factor or a combination of multiple genetic and/or environmental risk factors with different relative contributions, identifying complex physiopathological mechanisms. Consequently, the diagnosis can still be challenging. In recent years, significant advances in genetic, microscopy and biological techniques revolutionized our understanding of the molecular mechanisms underlying podocytopathies, pushing nephrologists to integrate innovative information with more conventional data obtained from kidney biopsy in the diagnostic workflow. In this review, we will summarize current approaches in the diagnosis of podocytopathies, focusing on strategies aimed at elucidating the aetiology underlying the histological picture. We will provide several examples of an integrative view of traditional concepts and new data in patients with suspected podocytopathies, along with a perspective on how a reclassification could help to improve not only diagnostic pathways and therapeutic strategies, but also the management of disease recurrence after kidney transplantation. In the future, the advantages of precision medicine will probably allow diagnostic trajectories to be increasingly focused, maximizing therapeutic results and long-term prognosis.

Renal lymphoma diagnosed on kidney biopsy presenting as acute kidney injury

Introduction:

Renal manifestations associated with hematolymphoid malignancies are known. Primary or secondary involvement of the kidney by lymphomatous infiltration has various clinical presentations. Acute kidney injury is not an uncommon finding in relation to lymphomatous interstitial infiltration proven on kidney biopsy. However, diagnosing it solely on renal biopsy remains a challenge and needs expertise and aid of immunohistochemistry as the prognosis is dismal.

Methods:

This is a retrospective study of kidney biopsy-proven cases of renal lymphoma presenting with acute kidney injury.

Results:

The study included 12 patients with ages ranging from 4 to 50 years who presented with serum creatinine ranging 2.1–9.6 mg%. Renal biopsy findings showed interstitial lymphomatous infiltrate. Two cases were diagnosed as primary lymphoma and the other 10 as secondary lymphomas. Among the 12 cases, nine were B-cell non-Hodgkin lymphoma, of which diffuse large B-cell lymphoma was diagnosed in six (50%), low-grade B-cell type in two (16.6%), chronic lymphocytic leukemia in one (8.3%), and three were T-cell-type. Two were acute T-cell lymphoblastic lymphoma and one other was a high-grade T-cell lymphoma. Four patients succumbed. The other four patients are alive; one is on chemotherapy, while two of them are on hemodialysis.

Conclusion:

Acute kidney injury as a presenting feature with lymphomatous infiltration of renal parenchyma is not uncommon. The patchy involvement makes it challenging on kidney biopsy with definitive diagnosis being made with the help of immunohistochemistry. Appropriate multidisciplinary involvement improves patient outcome.

An update of proliferative glomerulonephritis with monoclonal immunoglobulin deposits

As aging increases, monoclonal gammopathy is becoming more common, and monoclonal gammopathy of renal significance (MGRS) is gaining attention due to frequent renal involvement. Among MGRS, proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a special category. The disease was first described in 2004, and the research history on it is relatively short. Compared with other MGRS, the detection rate of circulating clones is lower in patients with PGNMID, which is easy to be missed and misdiagnosed in clinical work. In this review, the etiology and clinical features of PGNMID are discussed. It is noted that PGNMID is not only associated with MGRS, but also with malignancy, infection, and other factors. PGNMID is not a disease exclusive to the elderly, young people can also develop this disease. Due to the low detection rate of circulating clones in most patients, confirmation of the disease needs to be combined with renal pathology, which emphasizes the importance of completing light and heavy chain subtype staining. Treatment options for patients with PGNMID differ by etiology. For MGRS-associated PGNMID, the current treatment is primarily empirical and more research evidence is needed to fill the treatment gap.

Acute kidney injury in patients treated with immune checkpoint inhibitors

Background

Immune checkpoint inhibitor-associated acute kidney injury (ICPi-AKI) has emerged as an important toxicity among patients with cancer.

Methods

We collected data on 429 patients with ICPi-AKI and 429 control patients who received ICPis contemporaneously but who did not develop ICPi-AKI from 30 sites in 10 countries. Multivariable logistic regression was used to identify predictors of ICPi-AKI and its recovery. A multivariable Cox model was used to estimate the effect of ICPi rechallenge versus no rechallenge on survival following ICPi-AKI.

Results

ICPi-AKI occurred at a median of 16 weeks (IQR 8–32) following ICPi initiation. Lower baseline estimated glomerular filtration rate, proton pump inhibitor (PPI) use, and extrarenal immune-related adverse events (irAEs) were each associated with a higher risk of ICPi-AKI. Acute tubulointerstitial nephritis was the most common lesion on kidney biopsy (125/151 biopsied patients [82.7%]). Renal recovery occurred in 276 patients (64.3%) at a median of 7 weeks (IQR 3–10) following ICPi-AKI. Treatment with corticosteroids within 14 days following ICPi-AKI diagnosis was associated with higher odds of renal recovery (adjusted OR 2.64; 95% CI 1.58 to 4.41). Among patients treated with corticosteroids, early initiation of corticosteroids (within 3 days of ICPi-AKI) was associated with a higher odds of renal recovery compared with later initiation (more than 3 days following ICPi-AKI) (adjusted OR 2.09; 95% CI 1.16 to 3.79). Of 121 patients rechallenged, 20 (16.5%) developed recurrent ICPi-AKI. There was no difference in survival among patients rechallenged versus those not rechallenged following ICPi-AKI.

Conclusions

Patients who developed ICPi-AKI were more likely to have impaired renal function at baseline, use a PPI, and have extrarenal irAEs. Two-thirds of patients had renal recovery following ICPi-AKI. Treatment with corticosteroids was associated with improved renal recovery.

Renal Diseases Associated with Hematologic Malignancies and Thymoma in the Absence of Renal Monoclonal Immunoglobulin Deposits

In addition to kidney diseases characterized by the precipitation and deposition of overproduced monoclonal immunoglobulin and kidney damage due to chemotherapy agents, a broad spectrum of renal lesions may be found in patients with hematologic malignancies. Glomerular diseases, in the form of paraneoplastic glomerulopathies and acute kidney injury with various degrees of proteinuria due to specific lymphomatous interstitial and/or glomerular infiltration, are two major renal complications observed in the lymphoid disorder setting. However, other hematologic neoplasms, including chronic lymphocytic leukemia, thymoma, myeloproliferative disorders, Castleman disease and hemophagocytic syndrome, have also been associated with the development of kidney lesions. These renal disorders require prompt recognition by the clinician, due to the need to implement specific treatment, depending on the chemotherapy regimen, to decrease the risk of subsequent chronic kidney disease. In the context of renal disease related to hematologic malignancies, renal biopsy remains crucial for accurate pathological diagnosis, with the aim of optimizing medical care for these patients. In this review, we provide an update on the epidemiology, clinical presentation, pathophysiological processes and diagnostic strategy for kidney diseases associated with hematologic malignancies outside the spectrum of monoclonal gammopathy of renal significance.

Hospitalization rates for complications due to systemic therapy in the United States

The aim of this study was to estimate the trends and burdens associated with systemic therapy-related hospitalizations, using nationally representative data. National Inpatient Sample data from 2005 to 2016 was used to identify systemic therapy-related complications using ICD-9 and ICD-10 external causes-of-injury codes. The primary outcome was hospitalization rates, while secondary outcomes were cost and in-hospital mortality. Overall, there were 443,222,223 hospitalizations during the study period, of which 2,419,722 were due to complications of systemic therapy. The average annual percentage change of these hospitalizations was 8.1%, compared to - 0.5% for general hospitalizations. The three most common causes for hospitalization were anemia (12.8%), neutropenia (10.8%), and sepsis (7.8%). Hospitalization rates had the highest relative increases for sepsis (1.9-fold) and acute kidney injury (1.6-fold), and the highest relative decrease for dehydration (0.21-fold) and fever of unknown origin (0.35-fold). Complications with the highest total charges were anemia ($4.6 billion), neutropenia ($3.0 billion), and sepsis ($2.5 billion). The leading causes of in-hospital mortality associated with systemic therapy were sepsis (15.8%), pneumonia (7.6%), and acute kidney injury (7.0%). Promoting initiatives such as rule OP-35, improving access to and providing coordinated care, developing systems leading to early identification and management of symptoms, and expanding urgent care access, can decrease these hospitalizations and the burden they carry on the healthcare system.

Proliferative glomerulonephritis and mantle cell lymphoma: a rare association

Renal involvement in mantle cell lymphoma (MCL) is rare. We present the case of a man followed for MCL presented with acute kidney injury and positive antineutrophil cytoplasmic antibody (ANCA) type anti proteinase 3 (PR3). He was treated as for a rapidly progressing glomerulonephritis with cyclophosphamide and methylprednisolone followed by oral prednisone. Renal biopsy revealed diffuse endocapillary proliferation and segmental extracapillary proliferation in four glomeruli. Immunohistochemistry confirmed the renal invasion of lymphomatous cells. He started improving his renal function shortly after starting treatment. The coexistence of renal MCL infiltration, extracapillary proliferation and ANCA positive is exceptional.

A rare cause of acute kidney injury with chronic myelomonocytic leukemia

An 80-year-old man with myelodysplastic syndrome developed acute kidney injury (AKI) and peripheral blood monocyte-dominant leukocytosis. Glomerular disease was suspected from urinalysis, which showed proteinuria and microscopic hematuria with red cell casts. Eventually, he died of respiratory failure, after which a postmortem was performed. In the glomeruli, the extracapillary space was filled with numerous mononuclear cells and erythrocytes. At first interpretation, the glomerular findings appeared to represent cellular crescents. However, immunostaining revealed that the extracapillary mononuclear cells were in fact leukemic cells. Furthermore, tubular injury due to marked accumulation of lysozyme was also recognized together with infiltration of leukemic cells in the interstitium. The diagnosis of kidney infiltration by chronic myelomonocytic leukemia (CMML) and lysozyme-induced tubular injury was eventually made. Our case is the first report showing extracapillary infiltration of leukemic cells by immunostaining. In addition, lysozyme-induced tubular injury is a forgotten cause of kidney injury in patients with CMML. This case teaches us the rare and forgotten causes of AKI with CMML.

Retrospective Study of Acute Kidney Injury Incidence in Patients with Newly Diagnosed Acute Promyelocytic Leukemia

Purpose

Acute promyelocytic leukemia (APL) constitutes 5–10% of all cases of newly diagnosed acute myeloid leukemia. However, data on the epidemiology and risk factors for acute kidney injury (AKI) in patients with newly diagnosed APL are lacking. This study determined the incidence rate of AKI during induction chemotherapy for patients with newly diagnosed APL and the risk factors for AKI.

Patients and Methods

We conducted a retrospective observational study of patients with newly diagnosed APL in the Shonan Kamakura General Hospital between April 2004 and April 2020. Data of 27 patients with newly diagnosed APL were analyzed. The patients were classified as no AKI and AKI stages 1, 2 or 3.

Results

The incidence rate of AKI during induction chemotherapy was 40% (11/27). Among patients who developed AKI, four patients experienced AKI stage 3, and two patients required renal replacement therapy. No significant differences were found in the white blood cell count and baseline renal function between the groups; however, D-dimer and C-reactive protein levels upon admission were significantly higher in patients with AKI than in patients without AKI. Among patients who developed AKI, in hospital mortality at 90 days was 36% (4/11), which was significantly higher than among patients without AKI (p = 0.02). Patients who developed AKI were administered vancomycin more frequently, while almost all blood culture results were negative.

Conclusion

Incidence of AKI development in patients with newly diagnosed APL during induction chemotherapy was approximately 40%. Moreover, patients who developed AKI tended to be administered vancomycin more frequently. Unnecessary use of vancomycin should be avoided in patients with newly diagnosed APL, and using alternative non-nephrotoxic drugs should be considered for patients at risk of AKI.

The Hepatic Microenvironment Uniquely Protects Leukemia Cells through Induction of Growth and Survival Pathways Mediated by LIPG

Due to the disseminated nature of leukemia, malignant cells are exposed to many different tissue microenvironments, including a variety of extramedullary sites. In the present study, we demonstrate that leukemic cells residing in the liver display unique biological properties and also contribute to systemic changes that influence physiologic responses to chemotherapy. Specifically, the liver microenvironment induces metabolic adaptations via upregulating expression of endothelial lipase in leukemia cells, which not only stimulates tumor cell proliferation through polyunsaturated fatty acid-mediated pathways, but also promotes survival by stabilizing antiapoptotic proteins. Additionally, hepatic infiltration and tissue damage caused by malignant cells induces release of liver-derived enzymes capable of degrading chemotherapy drugs, an event that further protects leukemia cells from conventional therapies. Together, these studies demonstrate a unique role for liver in modulating the pathogenesis of leukemic disease and suggest that the hepatic microenvironment may protect leukemia cells from chemotherapeutic challenge. SIGNIFICANCE: The studies presented herein demonstrate that the liver provides a microenvironment in which leukemia cells acquire unique metabolic properties. The adaptations that occur in the liver confer increased resistance to chemotherapy. Therefore, we propose that therapies designed to overcome liver-specific metabolic changes will yield improved outcomes for patients with leukemia.This article is highlighted in the In This Issue feature, p. 211.

Renal Infiltration as a Primary Presentation of Burkitt Lymphoma Secondary to Systemic Lupus Erythematosus: A Rarity Unto a Rarity

Burkitt lymphoma (BL) is a highly aggressive non-Hodgkin B-cell lymphoma characterized by the translocation and deregulation of the MYC (MyeloCytomatosis) gene on chromosome 8. Three distinct clinical forms of BL are recognized: endemic (African), sporadic (non-endemic), and immunodeficiency-associated. Bilateral renal infiltration leading to acute kidney injury (AKI) is a rare initial presentation of BL. Diagnosis is usually made after evaluating the histology and immunophenotyping of the affected tissue.

We report a case of a 46-year-old male who presented with symptoms of AKI resulting from infiltrative disease, a primary presentation of lymphoma. The patient was a known case of systemic lupus erythematosus (SLE) for the last five years and was referred to the nephrology department due to acute elevation in creatinine, from 0.8 mg/dL to 3.57 mg/dL. On physical examination, there was no lymphadenopathy. Nephrology and SLE workup revealed low complement protein levels and absolute neutrophils, lymphocytes, and metamyelocytes. Renal ultrasound (USG) showed both kidneys with symmetric and edematous appearance. Biopsy affirmed high-grade B-cell lymphoma, positive for BCL-6 (B-cell leukemia/lymphoma) and CD-10 (cell surface marker) and negative for BCL-2 (B-cell leukemia/lymphoma). PET (positron emission tomography) scan showed extensive hypermetabolic lymphadenopathy in multiple areas. The patient was started on chemotherapy and on continuous renal replacement therapy. He improved clinically, and his creatinine lowered down to 0.8 mg/dL. Repeat USG showed decreased edematous appearance of both kidneys.

Primary renal infiltration by BL is a rare presentation in adults. Prompt renal biopsy will change the course of treatment and can affect the prognosis. It is thoroughly advised to keep this malignancy in mind when making a diagnosis for AKI.

Lymphoma and the Kidney: A Kidney Biopsy Teaching Case

Lymphomatous infiltration of kidney parenchyma is a frequent complication of systemic hematologic malignancies and often shows subtle clinical presentation. Diffuse large B-cell lymphoma represents the most frequent form involving the kidney, with advanced stage at diagnosis, poor outcome, and risk for central nervous system relapse if not adequately treated. Kidney biopsy can provide specific and early detection of these cases, helping in the differential diagnosis with more frequent entities. Finally, further hematologic workup (bone marrow biopsy, complete blood cell count, and positron emission tomography) can distinguish secondary involvement of the kidney from the rarer kidney-limited forms, especially in patients without a previous diagnosis of lymphoma. Making a prompt and correct diagnosis directs the management of these cases and may improve the outcome, as described in the present report.

Acute Kidney Injury in Patients Receiving Systemic Treatment for Cancer: A Population-Based Cohort Study

BACKGROUND

Patients undergoing treatment for cancer are at increased risk of acute kidney injury (AKI). There are few data on AKI incidence and risk factors in the current era of cancer treatment.

METHODS

We conducted a population-based study of all patients initiating systemic therapy (chemotherapy or targeted agents) for a new cancer diagnosis in Ontario, Canada (2007-2014). The primary outcome was hospitalization with AKI or acute dialysis. We estimated the cumulative incidence of AKI and fitted Fine and Gray models, adjusting for demographics, cancer characteristics, comorbidities, and coprescriptions. We modeled exposure to systemic therapy (the 90-day period following treatments) as a time-varying covariate. We also assessed temporal trends in annual AKI incidence.

RESULTS

We identified 163 071 patients initiating systemic therapy of whom 10 880 experienced AKI. The rate of AKI was 27 per 1000 person-years, with overall cumulative incidence of 9.3% (95% CI = 9.1% to 9.6%). Malignancies with the highest 5-year AKI incidence were myeloma (26.0%, 95% CI = 24.4% to 27.7%), bladder (19.0%, 95% CI = 17.6% to 20.5%), and leukemia (15.4%, 95% CI = 14.3% to 16.5%). Advanced cancer stage, chronic kidney disease, and diabetes were associated with increased risk of AKI (adjusted hazard ratios [aHR] = 1.41, 95% CI = 1.28 to 1.54; 1.80, 95% CI = 1.67 to 1.93; and 1.43, 95% CI = 1.37 to 1.50, respectively). In patients aged 66 years or older with universal drug benefits, diuretic, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker coprescription was associated with higher AKI risk (aHR = 1.20, 95% CI = 1.14 to 1.28; 1.30, 95% CI = 1.23 to 1.38). AKI risk was further accentuated during the 90-day period following systemic therapy (aHR = 2.34, 95% CI = 2.24 to 2.45). The annual incidence of AKI increased from 18 to 52 per 1000 person-years between 2007 and 2014.

CONCLUSION

Cancer-related AKI is common and associated with advanced stage, chronic kidney disease, diabetes, and concomitant receipt of diuretics or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. Risk is heightened in the 90 days after systemic therapy. Preventive strategies are needed to address the increasing burden of AKI in this population.

Preclinical anticancer studies on the ethyl acetate leaf extracts of Datura stramonium and Datura inoxia

Background

Cancer is a horrific disease relentlessly affecting human population round the globe. Genus Datura encompasses numerous species with reported medicinal uses. However, its potential as a source of natural anticancer agents is yet to be determined. Datura stramonium (DS) and Datura inoxia (DI) are the two species chosen for this study.

Methods

Total phenolic and flavonoid content (TPC and TFC) as well as antioxidant activity were assessed through colorimetric method. Polyphenolic quantification was done by RP-HPLC. Following extract standardization ethyl acetate leaf extracts of both species (DSL-EA and DIL-EA) were chosen for anticancer studies. In vitro cytotoxicity using various models including cancer cell lines was monitored. Following toxicity studies, benzene (0.2 ml) was used to induce leukemia in Sprague-Dawley rats. Extracts were orally administered to preventive (100 and 200 mg/kg) and treatment (200 mg/kg only) groups. The antileukemic potential of extracts was assessed through haematological, biochemical, endogenous antioxidants and histological parameters.

Results

Significant TPC and TFC were estimated in DSL-EA and DIL-EA. RP-HPLC quantified (μg/mg extract) rutin (0.89 ± 0.03), gallic acid (0.35 ± 0.07), catechin (0.24 ± 0.02) and apigenin (0.29 ± 0.09) in DSL-EA while rutin (0.036 ± 0.004) and caffeic acid (0.27 ± 0.03) in DIL-EA. Both extracts exhibited significant brine shrimp cytotoxicity (LC₅₀ < 12.5 μg/ml). DIL-EA exhibited greater cytotoxicity against PC-3, MDA-MB 231 and MCF-7 cell lines (IC₅₀ < 3 μg/ml in each case) as well as higher protein kinase inhibitory action (MIC: 25 μg/disc) compared to DSL-EA. Leukemia induced in rats was affirmed by elevated serum levels of WBCs (7.78 ± 0.012 (× 10³) /μl), bilirubin (7.56 ± 0.97 mg/dl), Thiobarbituric acid reactive substances (TBARs) (133.75 ± 2.61 nM/min/mg protein), decreased RBCs (4.33 ± 0.065 (× 10⁶)/μl), platelets (344 ± 3.19 (× 10³)/μl), total proteins (2.14 ± 0.11 g/dl), Glutathione S-transferases (GST) (81.01 ± 0.44 nM/min/ml), endogenous antioxidant enzymes levels and abnormal liver and kidney functionality in disease control rats. Both species revealed almost identical and significant (p < 0.05) alleviative effects in benzene induced leukemia.

Conclusion

Comprehensive screening divulged the tremendous potential of selected species as potent source of natural anticancer agents in a variety of cancers particularly leukemia. Present study might provide useful finger prints in cancer research and mechanistic studies are prerequisite in logical hunt of this goal.

Refeeding syndrome in hematological cancer patients - current approach

Introduction: According to estimates based on the GLOBOCAN database of the International Agency for Research on Cancer, in 2018 alone, 18 100 000 cancers were globally diagnosed. Importantly, the majority of cancer patients experience unintended weight loss that leads to many adverse clinical consequences, including malnutrition and cancer cachexia. At the same time, each nutritional intervention must be carried out individually, as it can lead to critical complications, resulting in a threat to the health and life of the cachectic patient. An example of this type of risk is refeeding syndrome.Areas covered: Three factors seem to be crucial in this case: early identification of patients at risk of malnutrition, the introduction of an individualized diet regimen and constant monitoring of nutritional intervention. It seems equally important to spread awareness about the possibility of refeeding syndrome and knowledge about its patomechanisms and consequences among medical staff. This should lead to minimizing the risk of refeeding syndrome.Expert opinion: It should be noted that current guidelines on the pathogenesis, risk factors and methods of prevention and treatment of refeeding syndrome require further modifications, that would harmonize the management regimen in both prevention and therapy of refeeding syndrome.

Proteomics-inspired precision medicine for treating and understanding multiple myeloma

Introduction

Remarkable progress in molecular characterization methods has led to significant improvements in how we manage multiple myeloma (MM). The introduction of novel therapies has led to significant improvements in overall survival over the past 10 years. However, MM remains incurable and treatment choice is largely based on outdated risk-adaptive strategies that do not factor in improved treatment outcomes in the context of modern therapies.

Areas covered

This review discusses current risk-adaptive strategies in MM and the clinical application of proteomics in the monitoring of treatment response, disease progression, and minimal residual disease (MRD). We also discuss promising biomarkers of disease progression, treatment response, and chemoresistance. Finally, we will discuss an immunomics-based approach to monoclonal antibody (mAb), vaccine, and CAR-T cell development.

Expert opinion

It is an exciting era in oncology with basic scientific knowledge translating in novel therapeutic approaches to improve patient outcomes. With the advent of effective immunotherapies and targeted therapies, it has become crucial to identify biomarkers to aid in the stratification of patients based on anticipated sensitivity to chemotherapy. As a paradigm of diseases highly dependent on protein homeostasis, multiple myeloma provides the perfect opportunity to investigate the use of proteomics to aid in precision medicine.

Primary Tumor Infiltration and Severe Acute Kidney Injury in Patients with Acute Myeloblastic Leukemia

In patients with hematologic malignancies, acute kidney injury (AKI) is the most common kidney complication requiring nephrologist consultation. Although the causes of AKI are multifactorial, primary tumor infiltration is rare in patients with acute myeloblastic leukemia (AML). This makes it challenging to determine the cause of AKI and the optimal chemotherapy regimen for AML. We describe two cases of AML (French-American-British classification: M2, M4) in patients with AKI requiring hemodialysis. We successfully identified the cause of AKI as primary leukemic infiltration and started induction chemotherapy in the setting of hemodialysis. This treatment significantly improved renal function and resulted in AML remission. In this report, we describe several clinical characteristics of AKI due to primary tumor infiltration. In addition, we emphasize the importance of onconephrology, a new subspecialty concerned with the complex relationship between the kidneys and cancer.

The evaluation of monoclonal gammopathy of renal significance: a consensus report of the International Kidney and Monoclonal Gammopathy Research Group

The term monoclonal gammopathy of renal significance (MGRS) was introduced by the International Kidney and Monoclonal Gammopathy Research Group (IKMG) in 2012. The IKMG met in April 2017 to refine the definition of MGRS and to update the diagnostic criteria for MGRS-related diseases. Accordingly, in this Expert Consensus Document, the IKMG redefines MGRS as a clonal proliferative disorder that produces a nephrotoxic monoclonal immunoglobulin and does not meet previously defined haematological criteria for treatment of a specific malignancy. The diagnosis of MGRS-related disease is established by kidney biopsy and immunofluorescence studies to identify the monotypic immunoglobulin deposits (although these deposits are minimal in patients with either C3 glomerulopathy or thrombotic microangiopathy). Accordingly, the IKMG recommends a kidney biopsy in patients suspected of having MGRS to maximize the chance of correct diagnosis. Serum and urine protein electrophoresis and immunofixation, as well as analyses of serum free light chains, should also be performed to identify the monoclonal immunoglobulin, which helps to establish the diagnosis of MGRS and might also be useful for assessing responses to treatment. Finally, bone marrow aspiration and biopsy should be conducted to identify the lymphoproliferative clone. Flow cytometry can be helpful in identifying small clones. Additional genetic tests and fluorescent in situ hybridization studies are helpful for clonal identification and for generating treatment recommendations. Treatment of MGRS was not addressed at the 2017 IKMG meeting; consequently, this Expert Consensus Document does not include any recommendations for the treatment of patients with MGRS.

This Expert Consensus Document from the International Kidney and Monoclonal Gammopathy Research Group includes an updated definition of monoclonal gammopathy of renal significance (MGRS) and recommendations for the use of kidney biopsy and other modalities for evaluating suspected MGRS

Relapsed Acute Lymphoblastic Leukemia Presenting as Acute Renal Failure

Acute lymphoblastic leukemia (ALL) is the second most common acute leukemia in adults. It is an aggressive hematologic neoplasm, with a bimodal age distribution typically presenting in childhood and the 6^th decade of life (Terwilliger and Abdul-Hay, 2017). Renal injury in ALL is common and can occur through many different mechanisms, such as prerenal acute kidney injury, acute tubular necrosis, renovascular disease, obstruction, glomerulonephritis, and parenchymal infiltration of tumor cells (Luciano and Brewster, 2014). Infiltration of kidneys by leukemia cells is common; however a resultant injury only occurs in about 1% of patients, and renal failure is even more rare (Luciano and Brewster, 2014). Renal failure due to bilateral infiltration of tumor cells has been reported in only a few cases and is thought to be a poor prognostic indicator (Luciano and Brewster, 2014; Sherief et al., 2015). Biopsy is essential to the diagnosis of renal infiltration of leukemia. We present a case of acute renal failure secondary to bilateral renal infiltration of ALL presenting as the first sign of relapse in a young man.

Imaging features of immune-mediated genitourinary disease

PURPOSE

Imaging features of immune-mediated genitourinary diseases often overlap, and the same disease may manifest in different ways, so understanding imaging findings in the context of the patient's entire clinical picture is important in providing the correct diagnosis.

METHODS

In this article, diseases mediated by the immune system which affect the genitourinary system are reviewed. Examples of immune-mediated genitourinary disease including IgG4-related disease, post-transplant lymphoproliferative disorder, immunodeficiency-associated lymphoproliferative disorder due to immunosuppressive and immunomodulatory medications, lymphoma, leukemia, myeloma, amyloidosis, and histiocytosis.

RESULTS

Clinical and imaging features will be presented which may help narrow the differential diagnosis for each disease.

CONCLUSION

Recognition of immune-related genitourinary disease is important for appropriate medical management as they may mimic other diseases both by imaging and clinical presentation.

Differential diagnostic ability of 18F-FDG PET/CT radiomics features between renal cell carcinoma and renal lymphoma

BACKGROUND

The aim of this study is to determine the differential diagnostic value of texture parameters of PET/CT on renal cell carcinoma and renal lymphoma.

METHODS

Twenty renal lymphoma and 18 renal cell carcinoma (RCC) patients were analyzed in this study. The pathological information and basic characteristics were extracted from the electronic medical record system of our hospital. We used LIFEx package to extract data from the radiomics images. Receiver operating characteristic analysis and binary logistic regression analysis was applied in determining the diagnostic accuracy of texture parameters as well as the synthetic parameter, of which the sensitivity and specificity was improved.

RESULTS

There were 14 (two in Histogram, two in Grey Level Co-occurrence Matrix, five in Grey-Level Run Length Matrix, five in Grey-Level Zone Length Matrix) out of the texture parameters showing an area under the curve (AUC) >0.7 and P<0.05. Synthesized parameters of each section showed even higher differentiation ability, with AUC varying from 0.725 to 1.000.

CONCLUSIONS

Texture analysis of ¹⁸F-FDG PET/CT could effectively differentiate between RCCs and renal lymphomas.