Acute renal failure due to a malignant lymphoma infiltration uncovered by renal biopsy

A case of conjunctival precursor T cell lymphoblastic lymphoma presenting with salmon colored conjunctival mass

Purpose

Observations

Conclusions and importance

Kidney injury and disease in patients with haematological malignancies

Acute kidney injury (AKI) is common in patients with cancer, especially in those with haematological malignancies. Kidney injury might be a direct consequence of the underlying haematological condition. For example, in the case of lymphoma infiltration or extramedullary haematopoiesis, it might be caused by a tumour product; in the case of cast nephropathy it might be due to the presence of monoclonal immunoglobulin; or it might result from tumour complications, such as hypercalcaemia. Kidney injury might also be caused by cancer treatment, as many chemotherapeutic agents are nephrotoxic. High-intensity treatments, such as high-dose chemotherapy followed by haematopoietic stem cell transplantation, not only increase the risk of infection but can also cause AKI through various mechanisms, including viral nephropathies, engraftment syndrome and sinusoidal obstruction syndrome. Some conditions, such as thrombotic microangiopathy, might also result directly from the haematological condition or the treatment. Novel immunotherapies, such as immune checkpoint inhibitors and chimeric antigen receptor T cell therapy, can also be nephrotoxic. As new therapies for haematological malignancies with increased anti-tumour efficacy and reduced toxicity are developed, the number of patients receiving these treatments will increase. Clinicians must gain a good understanding of the different mechanisms of kidney injury associated with cancer to better care for these patients.

Clinicopathological features of Chinese patients with B-cell lymphoproliferative disorders and kidney infiltration

AIM

Direct kidney involvement in B-cell lymphoproliferative disease is a rare disorder with only a few studies reported in Caucasian patients. The clinicopathological characteristics and outcome of this entity remain poorly described.

METHODS

We retrospectively studied all adult Chinese patients who had histology-proven renal parenchymal infiltration by malignant B-cells between 1 January 2000 and 31 December 2018 at two tertiary hospitals in Hong Kong. Clinical, pathological and radiological data were collected from 20 patients. Follow-up data were analysed until 31 December 2019.

RESULTS

Median follow-up duration was 22 (1-171) months. Only seven patients (35%) had established diagnosis of haematological cancer before kidney biopsy. Diffuse large B-cell lymphoma (DLBCL) was the most common subtype in our cohort (n = 5, 25%). Others included low-grade B-cell lymphoma (n = 11), intravascular large B-cell lymphoma (n = 1), mantle cell lymphoma (n = 1) and multiple myeloma (n = 2). Fourteen patients (70%) presented with AKI while 12 patients (60%) had proteinuria. Seven patients (35%) had unilateral renal mass, one had bilateral renal masses and one had bilateral diffuse nephromegaly in computed tomography. Lymphomatous tubulointerstitial infiltration was the prevalent histological finding. Nine patients (45%) had coexisting renal lesions other than direct tumour infiltration. All but one patient received chemotherapy. Ten patients died and renal responders had a significantly better survival than non-renal responders (p = .03).

CONCLUSION

Direct tumour infiltration can occur in a wide variety of B-cell lymphoproliferative disorders. Coexisting immunoglobulin-related nephropathy is frequently found. Renal biopsy is required for early diagnosis which allows timely and appropriate treatment.

Lymphomatous Interstitial Nephritis Coexistent with Paraneoplastic Crescentic Membranoproliferative Glomerulonephritis in a Case of Mantle Cell Lymphoma

Mantle cell lymphoma (MCL) is a rare aggressive lymphoproliferative disorders (LPD) of B-cell lymphoma, which usually presents in advanced stages at initial diagnosis. Renal involvement in MCL is very rare, especially the combined presence of both glomerular and interstitial disease. We report on a patient with lymphomatous interstitial nephritis (LIN) coexistent with paraneoplastic crescentic membranoproliferative glomerulonephritis (MPGN), subsequently diagnosed to have disseminated MCL with bone marrow and lymph nodal infiltration. He was treated with rituximab-based chemotherapy and went into complete renal remission at 6-months of follow up.

An Unusual Presentation of T-Cell Lymphoblastic Lymphoma with Isolated Renal Involvement

The clinical presentation of Non-Hodgkin lymphoma (NHL) is frequently associated with the involvement of the abdomen and mediastinal lymphadenopathies, but rarely the kidney, ovaries, and testicles. Here, we report a rare case of T-cell lymphoblastic lymphoma (T-LBL) presenting with bilateral nephromegaly without acute renal failure (ARF) as the first manifestation. A 30-month-old boy was admitted to the department of pediatric nephrology exhibiting abdominal distension. Physical examination revealed bilateral renal palpation up to the inguinal region. Elevated lactate dehydrogenase (LDH) levels were detected in his blood. Bilateral diffuse enlarged kidneys with increased hypoechogenicity were found on abdominal ultrasonography. In the next step, contrast-enhanced computed tomography showed diffusely enlarged kidneys, which were compressing the intestinal bowels and midline structures. Renal biopsy demonstrated precursor T-LBL. We wish to report our patient with renal T-LBL presenting with diffuse renal enlargement, which has rarely been reported in the literature.

Marginal zone lymphoma causing accelerated progression of chronic kidney disease

A 75-year-old man with stage IV chronic kidney disease due to type 2 diabetes mellitus, presented with increasing proteinuria and rapidly declining renal function despite excellent glycaemic control. Investigations organised to assess his suitability for renal transplantation included an abdominal CT scan, which revealed extensive intra-abdominal lymphadenopathy. A ¹⁷fluorodeoxyglucose (FDG)-positron emission tomography scan to further characterise the lymphadenopathy demonstrated activity in the lymph nodes, as well as both kidneys. Following a lymph node biopsy and flow cytometry he was diagnosed with a marginal zone lymphoma. A subsequent kidney biopsy confirmed lymphomatous infiltration of the kidney. Marginal zone lymphoma is an uncommon type of non-Hodgkin's lymphoma, and renal involvement is rare. This case highlights the importance of considering alternative diagnoses when there is deviation from the expected clinical trajectory and the importance of liaising with colleagues in other disciplines to enable an accurate diagnosis to be made.

Renal Dysfunction in Patients With Direct Infiltration by B-Cell Lymphoma

Background

B-cell lymphoproliferative disorders with renal involvement are relatively frequent, but remain poorly described. A kidney biopsy is usually required to detect the renal lesions that are often missed using other diagnostic tools.

Methods

We retrospectively identified 34 patients with renal lymphoma diagnosed by percutaneous kidney biopsy (PKB) at Rennes University Hospital and its affiliated hospital centers between January 1, 2004, and May 1, 2016. Clinical, biological, radiological, and histological characteristics were collected at biopsy time.

Results

The included patients had Waldenström macroglobulinemia (n = 12; 35.3%), chronic lymphocytic leukemia/lymphocytic lymphoma (n = 10; 29.5%), high-grade B-cell lymphoma (n = 6; 17.6%), and low-grade B-cell lymphoma (n = 6; 17.6%). The median follow-up was 29 months. Renal involvement led to renal function impairment in 29 patients (85.3%), among whom 20 had acute kidney injury (70%), and to nephrotic syndrome in 4 patients (11.8%). Only 13 patients (38.2%) presented morphological kidney anomalies among whom 5 showed bilateral infiltration. Histologically, interstitial infiltrate (97.1%) was the most common kidney lesion, and 9 patients (26.5%) had specific lymphomatous intraglomerular lesions. After hematological treatment (n = 29), a renal response was observed only in 8 patients (27.6%).

Conclusion

Renal involvement in the context of B-cell lymphoproliferative disorders is not uncommon. PKB is the best method to confirm this diagnosis. It should be performed early to rapidly initiate the hematological treatment to preserve kidney function.

Primary renal diffuse large B-Cell lymphoma causing haemodialysis-dependent nephromegaly in a child

A 4-year-old boy presented with fatigue and was found to have severe kidney injury requiring haemodialysis. A renal ultrasound demonstrated bilateral nephromegaly with mild loss of corticomedullary differentiation but preserved echogenicity. He had a persistent isolated monocytosis. Renal biopsy revealed extensive infiltration by primary renal diffuse large B-cell lymphoma. He required haemodialysis for 18 days and received chemotherapy with cyclophosphamide, doxorubicin, vincristine, prednisone, rituximab and intrathecal methotrexate. He achieved remission with an estimated glomerular filtration rate of 50 mL/min/1.73 m², and his kidneys returned to normal size. Nephromegaly due to renal-limited haematolymphoid disease is extremely rare, especially in children.

Plasma Cell Infiltration of the Kidney as a Manifestation of Myeloma: A Report of Three Cases

Infiltration of renal parenchyma by neoplastic plasma cells in myeloma patients is an unusual finding. We report 3 cases of myeloma, with renal biopsy being the first clue to the diagnosis in one. The plasma cell infiltrate in other two cases was not so evident but immunofluorescence (IF) and immunohistochemical (IHC) stains for light chains helped establish the monoclonal nature of the infiltrate. We surmise that plasma cell infiltration in the kidney can be an important clue to the diagnosis of an underlying myeloma and could in future be regarded as a myeloma-defining event (MDE) if monoclonality is confirmed. This finding could directly affect the prognosis and be a direct indicator of the tumor burden. Further studies are however required to determine the exact prognostic value and precise relationship of such a finding with deranged renal functions in myeloma.

Lymphoblastic lymphoma presenting as bilateral renal enlargement diagnosed by percutaneous kidney biopsy: Report of three cases

Renal involvement by lymphoma can be a diagnostic challenge. Acute kidney injury (AKI) is an unusual manifestation of lymphomatous infiltration in the kidneys. We report three cases of lymphoblastic lymphoma, a very rare form of lymphoma, presenting with AKI and bilateral enlargement of kidneys, diagnosed by percutaneous kidney biopsy. Lymphomatous infiltration should be suspected with such clinical presentation. Kidney biopsy is a valuable diagnostic tool, to establish the correct diagnosis and subtype of lymphoma for timely initiation of therapy for these aggressive hematological malignancies.

Kidney Disease and the Nexus of Chronic Kidney Disease and Acute Kidney Injury: The Role of Novel Biomarkers as Early and Accurate Diagnostics

Chronic kidney disease (CKD) and acute kidney injury (AKI) are interconnected and the presence of one is a risk for the other. CKD is an important predictor of AKI after exposure to nephrotoxic drugs or major surgery, whereas persistent or repetitive injury could result in the progression of CKD. This brings new perspectives to the diagnosis and monitoring of kidney diseases highlighting the need for a panel of kidney-specific biomarkers that reflect functional as well as structural damage and recovery, predict potential risk and provide prognosis. This article discusses the kidney-specific biomarkers, symmetric dimethylarginine (SDMA), clusterin, cystatin B, and inosine.

Acute renal failure and type B lactic acidosis as first manifestation of extranodal T-cell lymphoblastic lymphoma

We describe a rare case of a 19-year-old male patient with a history of epilepsy and developmental delay who presented with acute renal failure (ARF) and lactic acidosis (LA) as the first manifestation of T-cell lymphoblastic lymphoma. Renal ultrasound and CT of the abdomen showed renal parenchymal infiltration, and renal biopsy demonstrated T-cell lymphoblastic lymphoma. LA, ARF and electrolyte abnormalities were refractory to the initial treatment of bicarbonate infusion and hydration. However, these abnormalities rapidly normalised after the initiation of chemotherapy, suggesting that the LA and ARF were secondary to lymphomatous renal infiltration.

Association of Acute Interstitial Nephritis with Carnivora, a Venus Flytrap Extract, in a 30-Year-Old Man with Hodgkin's Lymphoma

Acute interstitial nephritis (AIN) is a common cause of acute kidney injury and has been associated with a variety of medications. This is the case of 30-year-old man with Hodgkin's lymphoma who on routine labs before chemotherapy was found to have acute nonoliguric renal failure. A kidney biopsy was performed and confirmed the diagnosis of acute interstitial nephritis. The patient had taken several medications including a higher dose of Carnivora, a Venus flytrap extract, composed of numerous amino acids. The medication was discontinued and kidney function improved towards the patient's baseline indicating that this may be the possible cause of his AIN. Proximal tubular cell uptake of amino acids increasing transcription of nuclear factor-kappaB is a proposed mechanism of AIN from this compound.

Acute kidney injury as first presentation of lymphoma: the role of renal biopsy

A 65-year-old man with an insidious history of being generally unwell with weight loss, a poor appetite and night sweats was transferred to a tertiary nephrology unit after being found to be in acute kidney injury (AKI). A renal biopsy was performed on the same day which revealed lymphomatous infiltration of the renal parenchyma. He required temporary haemodialysis as he was oliguric and was started on chemotherapy. His renal function improved to baseline 3 weeks after treatment. This case illustrates the uncommon presentation of direct lymphomatous infiltration as a cause of AKI and the integral role of renal biopsy in ascertaining the diagnosis.

Paediatric T cell Lymphoma with Nephrotic Syndrome: A Rare Association

Renal involvement is frequent in hematologic malignancies especially Hodgkin's lymphoma. Renal complications in children with malignancies primarily arise from tumour lysis syndrome, malignant infiltration or obstruction of the urinary tract, deposits of immunoglobulin fractions or crystals, renal infiltration by malignant cells, paraneoplastic or storage glomerulopathies. Nephrotic syndrome has been described in B cell type Non Hodgkin's lymphomas. There are very few reports of association of T cell lymphoma and nephrotic syndrome in pediatric patients. We present a case of peripheral T cell lymphoma with nephrotic syndrome in a 10 year old boy.

Membranoproliferative glomerulonephritis, mantle cell lymphoma infiltration, and acute kidney injury

Mantle cell lymphoma (MCL) is a rare aggressive lymphoid neoplasm occurring in about 3-7 % of non-Hodgkin lymphomas in the United States and Europe. Although lymphomas infiltrations are recognized in about half of post-mortem studies, in available literature we found only eight cases of mantle cell lymphoma with renal involvement. Five of them present MCL related glomerulonephritis, two show renal MCL infiltration with acute kidney injury and the last one describes MCL infiltration with acute tubulo-intrerstitial nephritis. We present the first case of a patient with the coexistence of renal mantle cell lymphoma infiltration, subacute membranoproliferative glomerulonephritis and acute kidney injury.

Renal involvement of mantle cell lymphona leading to end stage renal disease

Mantle cell lymphoma (MCL), owing to its insensitivity to chemotherapy, has a poor prognosis, with a median survival of 3 years to 4 years. MCL frequently infiltrates other organs. However, reports involving kidney in living patients are rare. Here, we report a case of MCL with renal involvement leading to end stage renal disease that required renal replacement therapy. A 69-year-old man diagnosed with MCL 3 years earlier was admitted to our emergency room due to uremic symptoms. After eight cycles of chemotherapy, he had displayed complete remission, but experienced a recurrence 1.5 years later; after refusing chemotherapy, the patient was lost on follow-up in the final 10 months. On presentation at the emergency room, the patient's serum blood urea nitrogen was 109.5 mg/dL, and creatinine was 11.1 mg/dL. All serological markers for secondary glomerulonephritis were negative. Renal biopsy revealed 50% sclerosis of the glomerulus and small dense lymphocyte infiltration of the tubulo-interstitium. Similar cells were found on the gastric mucosa. Despite our recommendation for chemotherapy, he refused all treatments except for hemodialysis, which was maintained for 12 months until his death. This patient represents the first case report of the renal involvement of MCL leading to end stage renal disease.

A case of acute renal failure caused by Hodgkin's lymphoma: concurrent membranous glomerulonephritis and interstitial HL-CD 20 lymphoid infiltration

Although acute renal failure developing due to malignancies is a frequent condition, malignant renal infiltration is rarely observed among these causes. Among all malignant diseases, the hematolymphoid malignancies are the most prone to renal infiltration. Other types involved in cases with lymphoma are glomerulopathies, including immune-complex glomerular diseases such as minimal change disease, membranous glomerulonephritis, membranoproliferative glomerulonephritis, and focal segmental glomerulosclerosis. We present herein the rare case of a 22-year-old male with both membranous glomerulonephritis and CD20 (+) lymphoid infiltration related to Hodgkin's lymphoma in the renal interstitial tissue, as detected on biopsy. The patient was treated with adriamycin, bleomycin, vinblastine, and dacarbazine protocol after pulse corticosteroid treatment, and a dramatic improvement in renal function was observed after 2 days of treatment. In this article, an exceptional renal involvement of Hodgkin's lymphoma is discussed in light of the related literature.

[Acute renal failure due to malignant lymphoma infiltration]

We present two cases of renal lymphoma revealed by acute renal failure (ARF), which remains a rare clinical entity. Case 1 was a 29-year-old man with an ARF. The diagnosis was a primitive kidney immunophenotype B lymphoma. The patient died after three courses of chemotherapy due to rapid spread lymphoma. The second case was a high-grade renal lymphomatous infiltration, with an unusual computer tomography image of two large kidneys compressing the stomach. Death happened early before initiating therapy. In both cases the diagnosis has been established by renal pathology. Early diagnosis is a key component of therapeutic success, however, the rapid spread of lymphoma worsened renal and vital prognosis.

Renal failure caused by plasma cell infiltration in multiple myeloma

We report on a case of severe renal failure in a 61-year-old female with multiple myeloma (MM). Two months prior to admission, the patient was diagnosed to have anemia and progressive renal failure associated with urinary Bence Jones protein and was referred to our hospital. A bone marrow biopsy revealed 40% plasma cells with κ light chain restriction. Thus, she was considered to have MM. A renal biopsy revealed neoplastic plasma cell infiltration within the kidney, moderate interstitial fibrosis, tubular atrophy, and punctate, electron-dense material along the peripheral capillary walls, tubular basement membrane, and in the interstitium of the kidney. This suggested that a combination of compression of the tubules and the microvasculature by the infiltrative process, and local light chain deposition-mediated tissue damage might be implicated in the development of renal failure in this patient. Despite a remission of bone marrow plasmacytosis with a bortezomib-based regimen, her renal function gradually deteriorated and a periodic hemodialysis program was finally required. Although the clinical impact of the direct kidney infiltration of neoplastic plasma cells on the longitudinal changes in renal function remains to be delineated, it is reasonable to consider that the infiltration of neoplastic plasma cells associated with local light chain depositions may result in irreversible renal injuries. Obviously, further studies and accumulation of additional experience with renal biopsy are required to better determine the precise and prognostic relationship between renal outcome and morphological alterations among MM patients with varying degrees of renal impairment.

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.

[Acute renal failure caused by renal lymphoma. A case report]

Acute renal failure, as the initial manifestation of lymphoma, has been reported only in a few cases. In this work, we report the case of a 28-year-old women admitted for acute renal failure. Her physical examination detected bilateral kidney enlargement. Laboratory evaluation revealed a serum creatinine value 218 micromol/l. A 24-hour urine collection analysis allowed the detection of 1g of protein. No red cells were found after urinanalysis. Renal ultrasound showed massively enlarged kidneys. Renal biopsy of the kidney and pathologic examination showed diffuse infiltration of the interstitium with lymphocytes and atypical cells positive for CD20 markers. A diagnosis of diffuse large B-cell type non-Hodgkin lymphoma was made. However, investigations revealed the presence of two others sites of lymphoma: gastric and ophthalmic. The patient's renal function and kidney size as well as the other lymphoma locations were normalized after the initiation of chemotherapy.

Diffuse lymphomatous infiltration of kidney presenting as renal tubular acidosis and hypokalemic paralysis: case report

We report the case of a 22-year-old woman who presented with acute onset flaccid quadriparesis. Physical examination showed mild pallor with cervical and axillary lymphadenopathy, hepatomegaly, and bilateral smooth enlarged kidneys. Neurological examination revealed lower motor neuron muscle weakness in all the four limbs with hyporeflexia and normal sensory examination. Laboratory investigations showed anemia, severe hypokalemia, and metabolic acidosis. Urinalysis showed a specific gravity of 1.010, pH of 7.0, with a positive urine anion gap. Ultrasound revealed hepatosplenomegaly with bilateral enlarged smooth kidneys. Renal biopsy was consistent with the diagnosis of non-Hodgkin lymphoma (B cell type). Metabolic acidosis, alkaline urine, and severe hypokalemia due to excessive urinary loss in our patient were suggestive of distal renal tubular acidosis. Renal involvement in lymphoma is usually subclinical and clinically overt renal disease is rare. Diffuse lymphomatous infiltration of the kidneys may cause tubular dysfunction and present with hypokalemic paralysis.

Acute renal failure caused by renal infiltration by hematolymphoid malignancy

Renal involvement by a malignant infiltrative process is often suspected in patients with bilaterally enlarged kidneys and concurrent malignancies. Acute renal failure (ARF) can rarely occur secondary to such an infiltrative process. We present 2 cases in which ARF is attributable to malignant hematolymphoid infiltration. The first case involves diffuse, bilateral involvement of the kidneys by non-Hodgkin's lymphoma. The patient's renal function improved dramatically after the initiation of chemotherapy, clearly linking the development of ARF to the malignant process. In the second case, infiltration of the kidneys by plasma cell leukemia resulted in dialysis dependence. To our knowledge, this represents the first reported case of ARF attributable to documented renal infiltration by plasma cell leukemia. A review of the potential causes of renal failure in hematolymphoid malignancy, focusing on the direct impact of the infiltrative process and on the spectrum of renal disease in plasma cell dyscrasia, is presented.

The role of ultrasound in renal insufficiency: the essentials

Sonography is the best screening modality to evaluate patients presenting with renal insufficiency. Ultrasound findings can be normal in patients with renal disease, especially in prerenal azotemia and acute parenchymal renal disease. Echogenic kidneys indicate the presence of parenchymal renal disease; the kidneys may be of a normal size or enlarged. Small kidneys suggest advanced stage chronic kidney disease. Uncommonly, cystic disease of the kidney, especially adult type polycystic kidney disease may be the cause of the patient's renal insufficiency with bilaterally enlarged kidneys containing multiple cysts of various sizes. If hydronephrosis is present, the level and cause of the obstruction should be sought. When ultrasound cannot diagnose the level and cause of obstruction, other imaging modalities, including CT and MRI may be useful. When renovascular disease (arterial stenosis or venous thrombosis) is suspected, spectral and color Doppler can be useful in detecting abnormalities.