Acute kidney injury secondary to renal large B-cell lymphoma: role of early renal biopsy

Renal involvement in large B-cell lymphoma represents an exceptional manifestation of non-Hodgkin lymphomas. Acute kidney injury (AKI) by lymphomatous infiltration is extremely rare and so far only 19 cases have been reported in the literature. We report a 67-year-old woman who presented with AKI and was found to have large B-cell lymphoma infiltrating her kidneys. The patient was treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with rituximab, and a dramatic improvement of renal function was noticed after two weeks of treatment. Her renal function completely recovered after four weeks of treatment. In conclusion, lymphomatous infiltration of kidneys can directly lead to AKI. Rapid diagnosis and treatment is essential to preserve the renal function. Renal biopsy is the gold standard for the early diagnosis of non-Hodgkin lymphoma as a cause of AKI.     

Early renal involvement in acute lymphoblastic leukemia and nonHodgkin's lymphoma in children

Clinical manifestations of kidney disease, particularly renal failure, caused by malignant infiltration in patients with acute lymphoblastic leukemia or nonHodgkin's lymphoma have been described rarely. We report 1 case of acute lymphoblastic leukemia and 3 cases of nonHodgkin's lymphoma in which renal disease was the only or one of the presenting manifestations of malignancy. Of these patients 2 had rapidly progressive renal failure with nephromegaly, 1 presented with bilateral abdominal masses caused by severe nephromegaly and with microscopic hematuria, and 1 had microscopic hematuria without nephromegaly. In all 4 patients kidney biopsy revealed malignant infiltration. In the 2 patients who presented with renal failure kidney function promptly returned to normal after chemotherapy and irradiation of the kidneys. Prompt and correct diagnosis of nephropathy, when it is the only or one of the presenting signs of acute lymphoblastic leukemia or nonHodgkin's lymphoma, is necessary to expedite initiation of specific antitumor therapy.     

Acute renal failure due to mantle cell lymphoma--a case report and discussion of the literature

Acute renal failure secondary to lymphomatous infiltration of the kidneys is a rare manifestation raer mantle cell lymphoma (MCL). We present the case of a 76-year-old gentleman with acute renal failure an a background of previously treated low grade non-hodgkin lymphoma. At the time of presentation he complained only of mild lethargy und had no lymphadenopathy or organomegaly. Renal ultrasound revealed bilaterally enlarged kidneys and renal biopsy confirmed MCL. Mantle cell lymphoma runs an aggressive course and accurate diagnosis is very important in guiding appropriate treatment. This case demonstrates the importance of renal biopsy in the diagnosis of renal lymphomatous infiltration but also highlights the potential utility of histological examination in guiding targeted therapy.     

Insuffisance rénale aiguë révélatrice d’un lymphome rénal. À propos d’un cas

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 μmol/l. A 24-hour urine collection analysis allowed the detection of 1 g 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.     

Bilateral renal inflammatory pseudotumour effectively treated with corticosteroid

Inflammatory pseudotumour (IPT) is a rare disease of unknown cause that most commonly involves the lung but can occur in almost any site in the body. Occurrence in the kidneys is very rare and bilateral renal involvement even rarer. There are 34 previously reported cases in the English-language medical literature between 1966 and 2008. Herein we report a case of IPT infiltrating both kidneys. We have also reviewed the clinical features, radiological findings, treatment and outcome of renal IPT. Clinical features at presentation are commonly non-specific. Features on imaging are inadequate to make a diagnosis of IPT or to clearly distinguish it from malignancy. Consequently diagnosis has frequently been made after nephrectomy and on a few occasions with the aid of percutaneous or open biopsies. The majority of renal IPT (83%) have been treated with nephrectomy and those cases with bilateral IPT have received corticosteroids.     

Bilateral renal oncocytomatosis in a patient with renal failure

Bilateral multifocal renal oncocytomas are very rare disorders with only 6 previously reported cases in the world literature, of which only 3 have had pathologic confirmation. We present the first reported case of diffuse, bilateral, multifocal renal oncocytomatosis in a patient with end-stage renal disease requiring hemodialysis. Our patient was found to have hundreds of nodular tumors in both kidneys on exploration, representing the second such reported finding.     

Progressive renal failure due to renal invasion and parenchymal destruction by adult T-cell lymphoma

A 43-year-old patient of occult adult T-cell lymphoma (ATL) presenting with systemic illness and progressive renal failure due to lymphomatous infiltration of kidneys is described. The striking feature observed was destructive infiltration of the kidneys, by malignant CD4 cells, virtually replacing the normal renal architecture. The diagnosis of lymphoma was made by renal biopsy. Clinical features typical of ATL were hypercalcemia, lytic bone lesions, and profound wasting and inanition. The patient died rapidly despite attempted therapy. The case illustrates the potential of ATL for direct renal parenchymal destruction.     

Acute renal failure in a patient with hemophagocytic syndrome

Acute renal failure (ARF) occurred in a 47-year-old man with hemophagocytic syndrome. Histological findings of the kidney revealed diffuse infiltration of interstitium by phagocytosing cells mixed with atypical lymphoid cells of varying size. The cytological features of the lymphoid population in liver and spleen were consistent with a diagnosis of peripheral T-cell lymphoma. We believe that this ARF could have been exacerbated by the interstitial infiltration of phagocytosing cells, reactive lymphoid cells, and T-cell lymphoma cells. Received: September 25, 1998 / Accepted: July 22, 1999     

Acute renal failure after bilateral nephrectomy is associated with cytokine-mediated pulmonary injury

Clinical studies demonstrate that acute renal failure (ARF) is associated with increased mortality, which may be due to pulmonary complications. ARF may affect the lung via increased renal production or impaired clearance of mediators of lung injury, such as proinflammatory cytokines. Bilateral nephrectomy is a method to examine directly the deleterious systemic effects of absent renal clearance in ARF without the confounding effects that are associated with ischemia-reperfusion injury (e.g., ischemic ARF) or systemic toxicity (e.g., cisplatin-induced ARF). This study contrasts the effects of ischemic ARF and bilateral nephrectomy on serum cytokines and lung injury. It demonstrates that the acute absence of kidney function after both ischemic ARF and bilateral nephrectomy is associated with an increase in multiple serum cytokines, including IL-6 and IL-1beta, and that the cytokine profiles were distinct. Lung injury after ischemic ARF and bilateral nephrectomy was similar and was characterized by pulmonary vascular congestion and neutrophil infiltration. For investigation of the role of proinflammatory cytokines in pulmonary injury after ARF, the anti-inflammatory cytokine IL-10 was administered before bilateral nephrectomy. IL-10 treatment improved pulmonary architecture and was associated with a reduction in inflammatory markers, including bronchoalveolar lavage fluid total protein, pulmonary myeloperoxidase activity (a biochemical marker of neutrophils), and the chemokine macrophage inflammatory protein 2. These data demonstrate for the first time that the acute absence of kidney function results in pulmonary injury independent of renal ischemia and highlight the critical role of the kidney in the maintenance of serum cytokine balance and pulmonary homeostasis.     

Acute renal failure from spontaneous acute tumor lysis syndrome: a case report and review

Acute tumor lysis syndrome (ATLS), a condition which results from a rapid destruction of tumor cells with massive release of cellular breakdown products, has been well described. However, only a few cases of spontaneous ATLS have been reported in the literature. Acute renal failure (ARF) from spontaneous ATLS has been reported only in three patients who were diagnosed to have Burkitt's lymphoma, adenocarcinoma, and acute myeloid leukemia. We report a similar case of a patient with non-Hodgkin's lymphoma, who developed ARF from spontaneous ATLS. ARF can complicate the clinical course of spontaneous ATLS. Since only one patient survived, patients who develop ARF from spontaneous ATLS have a poor outcome. This paper illustrates the need to anticipate the development of ARF, despite aggressive therapy, in a patient with spontaneous ATLS. Prospective studies on renal function prior to and during therapy are required in order to develop a clinical profile reliably detecting patients at risk for developing renal failure and subsequent complication.     

Acute bilateral renal cortical necrosis as a cause of postoperative renal failure

Acute renal failure after a major intra-abdominal operation is, unfortunately, not an infrequent occurrence. Acute tubular necrosis, the most common cause of postoperative renal failure, usually follows a predictable clinical course, with most patients recovering full renal function. We describe a patient who developed acute renal failure after orthotopic liver transplantation. Subsequent workup revealed the patient to have acute bilateral renal cortical necrosis. Bilateral renal cortical necrosis is an extremely rare cause of renal failure and an even rarer cause of postoperative renal failure. We discuss the diagnosis and management of this uncommon disorder and review the salient literature. Of the approximately 15 known reported cases involving native kidneys after a major nonobstetric abdominal operation in the world literature, we believe this is the first to be related to an orthotopic organ transplant.     

Une étiologie exceptionnelle de l’insuffisance rénale aiguë : le lymphome de Burkitt

IntroductionBurkitt's lymphoma (BL) is an exceptional cause of acute renal failure (ARF). The origin of the tumor clone may be lymphoid follicles secondary to renal Epstein-Barr virus (EBV) infection. With the presentation of this clinical case, the pathogenesis, diagnostic criteria and evolution of this extremely rare affection will be discussed.ObservationA 4-year-old patient with a recent history of acute osteomyelitis of the right thigh presented an ARF without indications of post-infectious glomerulonephritis. Ultrasound showed enlarged kidneys without dilation of the excretory cavities. Diffuse interstitial infiltration of atypical lymphoid cells of medium size were noted upon renal biopsy. The tumor cells expressed antibodies against CD20, CD10, Bcl6, and Ki67 but not against Bcl2 or CD3. The search for an EBV infection was positive. A few days after diagnosis, the evolution was spontaneously fatal.Discussion/conclusionBL of the kidney is a rare condition that accounts for less than 1 % of kidney tumors, associated almost invariably with EBV infection. The diagnosis is confirmed histologically by renal biopsy and the criteria of Malbrain affirms the primitive character of the lymphoma. BL of the kidney is a diagnostic and therapeutic emergency and may be fatal.     

肾脏原发性淋巴瘤一例报告并文献复习

目的 提高肾脏原发性淋巴瘤的诊治水平.方法 回顾性分析1例肾脏原发性淋巴瘤患者的临床病理资料,结合文献复习讨论.患者,女,61岁.因左侧腰痛2周入院.查体:左上腹压痛,左肾区叩击痛.B超检查见左肾正常结构未显示,集合系统分离,最宽处约1.0 cm,左肾区可探及一巨大低回声肿物,大小9.7cm×5.3cm,边界模糊.CT检查见左肾中下极肿物,大小9.8 cm×8.9 cm ×8.8 cm,边界不清,平扫CT值为39 HU,增强后为61 HU,强化不明显.术前诊断:左肾恶性肿瘤.结果 患者行根治性左肾切除术.病理报告:左肾大部分被肿瘤组织占据,中下极见10.0cm×9.5 cm ×8.5 cm类圆形肿物,质硬,肿物切面呈灰白色,质地细腻.镜下瘤细胞呈弥漫性浸润,卵圆形或多边形,略大于正常淋巴细胞,核大深染呈不规则形.病理诊断:肾弥漫性大B细胞性淋巴瘤.骨髓穿刺检查未见异常.行环磷酰胺+吡喃阿霉素+长春新碱+泼尼松+利妥昔单抗方案化疗6周期.术后每3个月复查胸部X线片、腹部B超及CT等.随访20个月,未见肿瘤复发.结论 肾脏原发性淋巴瘤临床罕见,症状与肾癌相似,影像学检查无特征性改变,确诊需依靠病理学检查.本病预后不良,手术切除患肾联合规范的全身化疗,可延长患者的生存期.     

Acute renal failure in man: new aspects concerning pathogenesis. A morphometric study

The morphometric investigation of the proximal and distal tubules, the cortical interstitium, the intertubular capillaries, the renal corpuscles and the juxtaglomerular apparatuses (JGAs) in 56 cases in the oligoanuric, polyuric, and normuric phases of human acute renal failure (ARF), 6 cases of myeloma kidney with clinically confirmed ARF and 21 control kidneys revealed the following: (1) The main pathological change in human ARF is swelling of the epithelial cells of the proximal and distal tubules. Necrosis of these cells was observed in some cases but usually only as single cell necroses. (2) The interstitium of the cortex and of the outer stripe of the outer medulla is significantly widened in most cases of ARF. (3) In proximal tubules proximal to occluding casts (which were observed only in the plasmacytoma cases), the lumina are not widened but are narrower than normal, and the cross-sectional area of the epithelium is not greater but smaller than normal. (4) The JGAs were significantly larger in kidneys in the oligoanuric phase of ARF (with 1 exception) than in normal kidneys. In the normuric and polyuric phases they were slightly (not significantly) smaller than normal. In myeloma kidneys with occluding casts and/or diffuse interstitial fibrosis, the JGAs were significantly smaller than normal. From these findings it is concluded that: (1) The fall in glomerular filtration rate (GFR) in the postshock phase of ARF is not caused by nonselective back-diffusion of the primary urine through necrotic tubules or by compression of the lumina of the proximal and distal tubules by interstitial edema. A fall in GFR associated with occluding casts in the distal tubules is found only in the myeloma kidney and does not lead to widening of the proximal tubules but to tubular atrophy and narrowing of the lumen. (2) The casts seen in the lumina of the ascending limb of Henle's loop in some cases of ARF, which consist of hemoglobin, Tamm-Horsfall protein or desquamated blebs, do not occlude the lumen, since they are not associated with atrophy or luminal dilatation of the proximal tubules. (3) The JGAs with their secretory product renin-angiotensin II, together with adenosine, which is released in kidneys with ischemic or toxic damage, play a critical role in the pathogenesis of ARF. (4) In myeloma kidneys with ARF, in which the JGAs are markedly atrophic, the potentiated effect of adenosine that has been observed with a chronic absence of urine flow probably leads to a progressive, irreversible drop in GFR associated with tubular atrophy.     

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.     

Acute renal failure secondary to small cell lung cancer with tumor infiltration of the kidneys

Acute renal failure secondary to tumor infiltration of the kidneys is uncommon and largely described in patients with lymphoma or leukemia. We report a 64-year-old man previously diagnosed with limited stage small cell lung cancer who presented with acute renal failure (ARF). Renal imaging showed bilateral enlargement with features suggestive of an infiltrative process. A kidney biopsy established the diagnosis of metastatic small cell lung cancer with diffuse renal parenchymal infiltration. This case emphasizes the rare potential for cancers to metastasize to the kidneys, which can result in ARF. Early recognition of this cause of ARF is crucial, in particular, when the tumor is amenable to chemotherapy or irradiation.     

Acute Renal Failure Secondary to Small Cell Lung Cancer with Tumor Infiltration of the Kidneys

Acute renal failure secondary to tumor infiltration of the kidneys is uncommon and largely described in patients with lymphoma or leukemia. We report a 64-year-old man previously diagnosed with limited stage small cell lung cancer who presented with acute renal failure (ARF). Renal imaging showed bilateral enlargement with features suggestive of an infiltrative process. A kidney biopsy established the diagnosis of metastatic small cell lung cancer with diffuse renal parenchymal infiltration. This case emphasizes the rare potential for cancers to metastasize to the kidneys, which can result in ARF. Early recognition of this cause of ARF is crucial, in particular, when the tumor is amenable to chemotherapy or irradiation.     

Acute renal failure due to non-Hodgkin lymphoma infiltration of the kidneys detected by ultrasonography and confirmed by positron emission tomography

Acute renal failure (ARF) as a consequence of non-Hodgkin lymphoma infiltration of the kidneys (LIK) is an uncommon complication of non-Hodgkin lymphoma. In literature, ARF due to LIK is reported in progressive disease. A case of non-oliguric acute renal failure secondary to relapse of large B cell non-Hodgkin lymphoma primarily localized in the mediastinum is reported. LIK of both kidneys was diagnosed by ultrasonography, computer tomography scan and 18-fluorodeoxyglucose positron emission tomography. No other causes for renal failure were found. The prognosis of renal involvement in relapsed non-Hodgkin lymphoma is poor, as is demonstrated by our case.     

An unusual cause of acute renal failure: renal lymphoma

Renal involvement is a common finding in non-Hodgkins lymphoma (NHL). Acute renal failure at initial presentation due to lymphomatous infiltration of the kidneys has been described infrequently. We report a 17-year-old male who presented with acute renal failure due to massive lymphomatous infiltration of the kidneys, which necessitated hemodialysis. The diagnosis of B-cell NHL was established by tru-cut biopsy of the kidneys and the patient had an excellent response to high-dose chemotherapy with no major complication. The presence of extrarenal involvement in the testes and the retroperitoneal lymph nodes made the diagnosis of primary renal lymphoma debatable. However, considering the delay in diagnosis and the high proliferative rate of B-cell NHL, we might postulate that the disease had originated primarily in the kidneys. We recommend that in NHL cases with severe renal involvement, full-dose chemotherapy should be instituted with meticulous clinical and laboratory follow-up in order to improve clinical and renal failure status rapidly and to avoid further dissemination of NHL.