Acute renal failure from xanthine nephropathy during management of acute leukemia

Tumor lysis syndrome is a potentially life-threatening complication of induction chemotherapy for treatment of lymphoproliferative malignancies. Serious complications of tumor lysis syndrome are rare with the preemptive use of allopurinol, rasburicase, and urine alkalinization. We report a case of oliguric acute renal failure due to bilateral xanthine nephropathy in an 11-year-old girl as a complication of tumor lysis syndrome during the treatment of T-cell acute lymphoblastic leukemia. Xanthine nephrolithiasis results from the inhibition of uric acid synthesis via allopurinol which increases plasma and urinary xanthine and hypoxanthine levels. Reports of xanthine nephrolithiasis as a cause of tumor lysis syndrome are rare in the absence of defects in the hypoxanthine-guanine phosphoribosyl transferase (HGPRT) enzyme. Xanthine nephropathy should be considered in patients who develop acute renal failure following aggressive chemotherapy with appropriate tumor lysis syndrome prophylaxis. Urine measurements for xanthine could aid in the diagnosis of patients with nephrolithiasis complicating tumor lysis syndrome. Allopurinal dosage should be reduced or discontinued if xanthine nephropathy is suspected.     

Tumor lysis syndrome: pathogenesis and management

Tumor lysis syndrome refers to the metabolic disturbances (hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia) associated with lymphoproliferative malignancies which occur secondary to cell lysis. In some patients, tumor lysis results in acute renal failure. The nature and severity of the metabolic alterations are variable and may be influenced by the timing and intensity of chemotherapy, the magnitude of cell lysis, and the general condition of the patients with respect to hydration and glomerular filtration rate. Not only do hyperuricemia and hyperphosphatemia result from tumor lysis syndrome, they also contribute to oliguric acute renal failure in patients with tumor lysis. The pathogenesis of tumor lysis syndrome and current therapeutic strategies are discussed.     

Tumor lysis associated with dexamethasone use in a child with leukemia

Postoperative nausea and vomiting (PONV) occurs in every third patient undergoing general anesthesia without PONV prophylaxis. Antiemetic prophylaxis with dexamethasone is commonly used in patients at moderate risk. We present a case in which PONV prophylaxis with a single dose of dexamethasone led to tumor lysis in a patient with acute leukemia. In case of a cancer patient at moderate risk for PONV, the anesthesiologist should contact the oncologist first, or use other antiemetic drugs such as antiserotoninergic agents for PONV prophylaxis.     

Hyperuricemia and renal insufficiency associated with malignant disease: Urate oxidase as an efficient therapy?

Hyperuricemia is a common finding in patients with malignant diseases. Chemotherapy can induce life-threatening tumor lysis syndrome with severe hyperuricemia, other metabolic abnormalities, and acute renal failure. Intrarenal precipitation of uric acid contributes to renal insufficiency in this situation. Allopurinol, by preventing the conversion of hypoxanthine and xanthine to uric acid, has been long considered the standard pharmacological approach to hyperuricemia and prevention of tumor lysis syndrome. However, allopurinol itself may facilitate precipitation of xanthine crystals and has little influence on already-formed uric acid crystals deposited in the kidney. Urate oxidase further oxidizes uric acid to the highly water-soluble allantoin in mammals, except humans, who lack this enzyme. We report four cases of hyperuricemia (initial serum uric acid concentrations, 14.0 to 25.0 mg/dL) associated with malignant diseases treated with exogenous urate oxidase. Two of the patients showed full-blown tumor lysis syndrome. A single urate oxidase infusion (1,000 U) readily reduced serum uric acid levels in all patients. Furthermore, renal insufficiency, determined by serum creatinine concentrations, improved in three of the four patients. No adverse effects were observed. Currently, a recombinant urate oxidase is undergoing clinical testing and may make this efficient therapy more widely available. We believe that treatment with urate oxidase is a safe and efficient therapy for patients with cancer-associated hyperuricemia and may be effective even in individuals with only moderately elevated serum uric acid concentrations.     

AN ENORMOUS ABDOMINAL MASS ASSOCIATED WITH ACUTE RENAL FAILURE

We report a 67-year-old man with acute uric acid nephropathy, secondary to spontaneous tumor lysis syndrome, that presented itself as a huge intra-abdominal tumor that led to acute renal failure, hyperuricemia, and azotemia. Initial finding of hydronephrosis detected by ultrasonography led us to believe that the azotemia and decreasing amount of urine resulted from obstructive uropathy, a common complication of malignancy, caused by either a direct renal invasion or a urinary outflow tract compression because of a tumor mass effect. However, clinical observations and the response to therapeutic intervention confirmed the diagnosis of spontaneous tumor lysis syndrome, which is a rare cause of acute uric acid nephropathy.     

An enormous abdominal mass associated with acute renal failure.

We report a 67-year-old man with acute uric acid nephropathy, secondary to spontaneous tumor lysis syndrome, that presented itself as a huge intra-abdominal tumor that led to acute renal failure, hyperuricemia, and azotemia. Initial finding of hydronephrosis detected by ultrasonography led us to believe that the azotemia and decreasing amount of urine resulted from obstructive uropathy, a common complication of malignancy, caused by either a direct renal invasion or a urinary outflow tract compression because of a tumor mass effect. However, clinical observations and the response to therapeutic intervention confirmed the diagnosis of spontaneous tumor lysis syndrome, which is a rare cause of acute uric acid nephropathy.     

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.     

Renal biopsy diagnosis of acute lymphocytic leukemia.

Hyperuricemia, due to inborn errors of metabolism, dehydration, or tumor lysis, may cause renal insufficiency. Hyperuricemia from tumor lysis syndrome in malignancy is usually associated with electrolyte disturbances such as hyperkalemia, hyperphosphatemia or hyper or hypocalcemia. Tumor infiltration into the kidneys can occur, yet this accounts for renal insufficiency in only 1% of patients. This infiltration of tumor cells into the kidneys is usually associated with evidence of malignancy elsewhere as identified by physical exam, radiographic studies, and examination of the peripheral smear or bone marrow. We report an unusual presentation of a child with acute lymphocytic leukemia presenting with acute renal failure, nephromegaly and hyperuricemia without electrolyte disturbances or systemic evidence of tumor elsewhere. We stress the importance of kidney biopsy in order to identify the etiology of the renal failure and hyperuricemia.     

Hyperphosphatemia in tumor lysis syndrome: the role of hemodialysis and continuous veno-venous hemofiltration

We report a 4-year-old boy who developed tumor lysis syndrome complicated by severe hyperphosphatemia and acute renal failure, following chemotherapy for T-cell acute lymphoblastic leukemia. Despite successful treatment of hyperphosphatemia with hemodialysis, there was an immediate rebound in the high serum phosphorus level. The patient underwent a second treatment with hemodialysis which was then followed by continuous veno-venous hemofiltration (CVVH). CVVH maintained his serum phosphorus at a stable level until his renal function improved. CVVH can be used in conjunction with hemodialysis to successfully treat the hyperphosphatemia associated with tumor lysis syndrome.     

Conversion from tacrolimus to neoral for postrenal transplant diabetes

Diabetes mellitus (DM) is a well-recognized complication of immunosuppressive therapy in the post-transplant (Tx) period. The DM encountered in the setting of tacrolimus therapy has been managed in the past by tacrolimus dose reduction and a rapid corticosteroid taper; frequently insulin therapy is also required to maintain normoglycemia. However, the dose reduction of immunosuppressive agents has often resulted in acute allograft rejection. We are reporting our experience in managing three pediatric renal Tx recipients who developed DM in the post-Tx period while on triple immunosuppressive therapy including tacrolimus and corticosteroids. All of our patients were managed by substitution of tacrolimus with conventional doses of neoral while maintaining their usual corticosteroid dose. All three patients had resolution of hyperglycemia and none experienced acute rejection. Tacrolimus was then successfully reinitiated 4.6 months later; at last follow-up, all of our patients have good allograft function and have maintained a normal blood sugar. In conclusion, we feel that conversion of patients from tacrolimus to neoral should be attempted as a safer alternative to tacrolimus dose reduction, for managing post-Tx DM in tacrolimus treated patients. Received: 28 April 2000 / Revised: 21 July 2000 / Accepted: 27 July 2000     

Remission of membranous glomerulonephritis after pancreatectomy for pancreatic neuroendocrine neoplasm - a rare coincidence

The concomitant existence of a non-malignant neuroendocrine tumor (NET) and membranous glomerulonephritis (MGN) is rare. We report a subject with kidney biopsy proven MGN and nephrotic syndrome in which a computerized scan tomography (CT) examination was performed revealing a pancreatic tumor. A pancreatectomy was performed and the tumor was shown to be a non-malignant NET with a malignant potential. Although treatment with corticosteroids was initiated remission of MGN was observed within the next month after pancreatectomy. The rapid remission observed shortly after pancreatectomy pointed to that tumor removal contributed to, and that neither spontaneous nor corticosteroid treatment alone did induce the rapid remission of the MGN. The coexistence of the two disorders NET and MGN is very rare, however. This is the first report on remission of MGN after pancreatectomy for a NET.     

Tumor lysis under anesthesia in a child

Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency characterized by metabolic derangements caused by massive lysis and release of cellular components. TLS has been reported to occur under various circumstances. There have however, been only two reports of precipitation of TLS by anesthesia in the current medical literature. We report on the development of TLS in a 7-year-old child with a pelvic neuroectodermal tumor following induction of anesthesia and discuss the peri-operative concerns while dealing with patients with high tumor burdens.     

Adult-onset minimal change nephrotic syndrome: a long-term follow-up

A series of 89 adult-onset nephrotic patients with minimal changes on renal biopsy was analyzed to compare the rate of response to corticosteroids and cytotoxic agents and the stability of remission or frequency of relapses at different ages. Severe hypertension and diminished renal function were more common in patients aged over 60 years, who formed 22.5% of the group. Seventy-five patients were given a first course of prednisolone in an initial dose of 60 mg/24 hr. After an eight week course of tapering doses of corticosteroids, only 45 of the 75 patients were in complete remission, 55 patients after 16 weeks and eventually 58 lost their proteinuria. The respective estimates of remission were 60%, 76% and 81%. Subsequently, of the 58 treated patients who responded, 24% never relapsed. Fifty-six percent of the patients relapsed on a single occasion or infrequently, and only 21% were frequent relapsers. Cyclophosphamide was used in 36 patients, in two as initial treatment, in 11 because of corticosteroid resistance, and in the remainder because of relapses. The time-course of loss of proteinuria was similar to that following treatment with corticosteroids, 25 (69%) losing proteinuria within 16 weeks. Only four patients failed to lose their nephrotic syndrome. Two of them had presented in acute renal failure and all four were over 60 years of age. The stability of remission after cyclophosphamide was better than that reported for children, only 13 of 36 showing relapses and 66% being in remission at five years, after which no further relapses were seen.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care.

BACKGROUND: Oral corticosteroids used in short courses for acute asthma are regarded as safe, although the frequent use of these drugs may result in patients suffering from systemic side effects. It has become common practice for patients to increase their own inhaled corticosteroid intake when their asthma goes out of control, but it has never been established whether a high dose of inhaled corticosteroid can be as effective as a short course of oral corticosteroid in the treatment of acute exacerbations. METHODS: A multicentre, randomised, double blind, double dummy, parallel group study was undertaken to determine whether the introduction of a high dose of inhaled fluticasone propionate (2 mg daily) is as effective as a short reducing course of oral prednisolone (starting at 40 mg/day and reducing by 5 mg every other day) in the treatment of acute exacerbations of asthma not considered severe enough for admission to hospital but requiring treatment with oral corticosteroid. RESULTS: Four hundred and thirteen adult asthmatic subjects who presented to their general practitioner with an acute exacerbation of asthma were recruited in 47 general practices in the United Kingdom. Treatment failures, defined as a reduction in peak expiratory flow (PEF) to below 60% of the patient's best/predicted value on two consecutive occasions or persistent symptoms with no improvement on three consecutive days, occurred in 23% of patients who received oral prednisolone and 27% who received inhaled fluticasone propionate (difference in percentage of treatment failures 4.3, 95% CI -4.1 to 12.8, p = 0.31). In each group 48% were classified as treatment successes, defined as a 10% or greater increase in percentage best/predicted morning PEF. Both treatments were equally well tolerated. CONCLUSIONS: There is no evidence of a significant difference in efficacy between a reducing dose course of oral prednisolone and high dose inhaled fluticasone propionate in mild exacerbations of asthma which do not require admission to hospital.     

Successful relatively low-dose corticosteroid therapy for diclofenac-induced acute interstitial nephritis with severe renal failure

We report a case of nephrotic syndrome and acute renal failure that developed in a 73-year-old woman after six months of treatment with the non-steroidal anti-inflammatory drug (NSAID) diclofenac. Renal biopsy revealed interstitial nephritis and minimal change nephropathy. Despite discontinuation of treatment with diclofenac, she subsequently became anuric and required hemodialysis for progressive azotemia. Since her anuria was persistent, treatment with prednisone at a dose of 30 mg/day was started. With progressive increase in urine output after the initiation of corticosteroid treatment, a constant decrease in serum creatinine was observed along with improvement of creatinine clearance. In addition, the increased urinary excretion of beta2-microglobulin (beta2MG) and N-acetyl-beta-D-glucosaminidase (NAG) on admission was also improved during the treatment. Our findings suggest that corticosteroid treatment should be reserved for patients with the protracted deterioration of renal function even after discontinuation of offending trigger agents.     

Tumor lysis syndrome and acute renal failure--an increasing spectrum of presentations

Tumor lysis syndrome has historically been associated with hyperuricemia and uric acid crystal deposition. We present three cases of tumor lysis syndrome resulting in renal failure in the context of normouricema, highlighting the spectrum of clinical presentations and mechanisms of renal damage. Two cases occurred following the treatment of hematological malignancies and were associated with hyperphosphatemia; the third resulted from ischemic necrosis following transarterial chemoembolization of a hepatic tumor. We also discuss the role of renal biopsy in the investigation of tumor lysis syndrome.     

Aggravation of minimal change nephrotic syndrome by administration of human albumin.

Human albumin infusions are frequently administered to patients with nephrotic syndrome. We reviewed the clinical course of 27 patients with minimal change nephrotic syndrome (MCNS) in which 16 patients were treated with human albumin (group A) and 11 were not (group B). The percent of body weight gain, serum total protein, serum albumin, urine protein excretion and renal function were equivalent in both groups as was the initial dose of corticosteroid and amount of dietary protein intake. The period from the start of corticosteroid therapy to complete remission for group A (73.4 +/- 19.2 days, mean +/- SEM) was significantly longer than that for group B (17.1 +/- 3.6), (p less than 0.05). 10 patients of group B (10/11 = 90.9%) showed complete remission within 20 days from the start of corticosteroid therapy, but more than 20 days were needed for 9 cases (9/16 = 56.3%) of group A. Moreover, significant correlations were observed between the period required for remission and the duration of albumin administration (p less than 0.01) or the total volume of albumin infused (p less than 0.01). Proportion of relapsers within 2 years after discharge was also higher in group A (68.8%) than in group B (9.1%), (p less than 0.01). In conclusion, administration of albumin may delay the response to corticosteroid therapy and induce more frequent relapses after remission, possibly due to more severe glomerular epithelial changes induced by albumin infusion in addition to preexisting glomerular epithelial changes from the MCNS.     

重度肿瘤溶解综合征的护理

对２例重度肿瘤溶解综合征患者的治疗、护理进行临床分析。总结了对肿瘤溶解综合征患者重要的护理措施包括严密观察电解质、肾功能变化，观察胰岛素应用的副反应，加强饮食护理的心理护理等。     

Prognostic value of sonography in childhood nephrotic syndrome

This retrospective case review of 43 children with primary nephrotic syndrome was designed to evaluate the relationship among renal ultrasound findings at presentation, subsequent corticosteroid responsiveness and histological diagnoses. Fifty-one percent of patients had abnormal sonograms; nephromegaly was present in 42% and increased renal echogenicity in 35%. There was no relationship between nephromegaly and either response to corticosteroids or specific glomerular lesions causing nephrosis. Although the presence of echogenic kidneys did not denote a particular type of renal disease, it was significantly more frequent in corticosteroid-resistant than in corticosteroid-responsive patients (62% vs. 18%,P<0.05). We conclude that increased renal echogenicity at time of presentation is a possible indicator of corticosteroid resistance in children with primary nephrotic syndrome.     

Successful management of postoperative acute respiratory distress syndrome in a patient with lung cancer

Acute respiratory distress syndrome after pulmonary resection for lung cancer frequently has a lethal outcome. Treatment with a combination therapy of neutrophil elastase inhibitor and steroid administration was used to achieve good control, without impairing lung function, in a patient with postoperative acute respiratory distress syndrome. A 74-year-old man was diagnosed with lung cancer and referred to the outpatient department of Chiba University Hospital with double primary lung cancers located in the right upper lobe that were staged at T2N0M0 (stage IB). He underwent right upper lobectomy with hilar and mediastinal lymph node dissection. After 10 postoperative days, he had acute respiratory distress syndrome. He was given a corticosteroid and a neutrophil elastase inhibitor, which resulted in rapid improvement without lung dysfunction.