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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2004  |  Volume : 15  |  Issue : 2  |  Page : 167-169
Renal Amyloidosis Complicating Bladder Carcinoma Associated with Supra Renal Insufficiency


1 Department of Nephrology, Monastir Hospital, Tunisia
2 Department of Pathology, Monastir Hospital, Tunisia
3 Department of Urology, Monastir Hospital, Tunisia

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   Abstract 

A 61-year-old white man was admitted for evaluation of hematuria. His medical history revealed endoscopic resection of bladder carcinoma 10 years earlier. A diagnosis of relapse of this carcinoma was made. Few months later, he developed low blood pressure and the nephrotic syndrome. Examination of a renal biopsy specimen showed amyloid deposits. Results of immunofluorescence were positive for AA protein. Furthermore, laboratory tests demonstrated suprarenal insufficiency probably due to amyloidosis. A diagnosis of bladder carcinoma- induced amyloidosis of the kidneys and suprarenal glands was made since no other identifiable cause for AA amyloidosis was found.

Keywords: Renal AA amyloidosis, Bladder carcinoma, Suprarenal insufficiency

How to cite this article:
Habib S, Ahmed L, Sabra A, Wissal S, Sinda M, Samia B, Ameur FM, Abdellatif A, Nasr BD, Abdelfetteh Z, Hammadi S, Mezri E. Renal Amyloidosis Complicating Bladder Carcinoma Associated with Supra Renal Insufficiency. Saudi J Kidney Dis Transpl 2004;15:167-9

How to cite this URL:
Habib S, Ahmed L, Sabra A, Wissal S, Sinda M, Samia B, Ameur FM, Abdellatif A, Nasr BD, Abdelfetteh Z, Hammadi S, Mezri E. Renal Amyloidosis Complicating Bladder Carcinoma Associated with Supra Renal Insufficiency. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2019 Oct 18];15:167-9. Available from: http://www.sjkdt.org/text.asp?2004/15/2/167/32900

   Introduction Top


AA amyloidosis or secondary amyloidosis constitutes a known cause of the nephrotic syndrome and chronic renal failure. Several conditions have been reported to cause amyloidosis. Tuberculosis remains the major etiology of AA renal amyloidosis in poor countries.[1]

Many cancers have been reported to cause AA renal amyloidosis; [2],[3],[4],[5] however, bladder carcinoma has been reported very rarely. We report herewith a case of bladder carcinoma associated with AA renal amyloidosis and suprarenal insufficiency.


   Case Report Top


A 61-year-old white man was diagnosed to have bladder carcinoma in 1989 and received treatment with endoscopic resection. He was well till September 1999, when he presented with hematuria. Clinical examination was normal. Laboratory investigations were unre­markable and there was no proteinuria. The serum creatinine was 85 µmol/l. Ultrasound examination of the abdomen and pelvis showed irregular bladder wall with two solid vegeta­tions arising from its mucosa. Both kidneys were normal. Intravenous pyelography (IVP) showed mild dilatation of the collecting system of the right kidney along with lacunar images in the bladder. Abdominal computed tomography (CT) scan demonstrated marked irregular thickening of the bladder wall and dilatation of the right renal collecting system. Cystoscopic examination and biopsy revealed papillary carcinoma with moderately differentiated transitional cells classified as G2, PT1 in WHO bladder tumor classification.

Chest x-ray, abdominal ultrasound and bone scintigraphy did not reveal any tumor extension. In November 1999, total cysto­prostatectomy and bilateral percutaneous ureterostomy were performed. Pre-operative serum creatinine was 80 µmol/l and serum total protein was 77 g/l.

In March 2000, he was re-hospitalized with five days history of pyrexia, anorexia and lumbar pain. On physical examination, the patient was pale, his blood pressure was 90/60 mm Hg and he had peri-orbital, ankle and sacral edema.

Laboratory investigations showed impaired renal function with serum creatinine of 838 µmol/l. The serum total protein was 37 g/l, serum albumin was 9 g/l and proteinuria was 8 g/24 hours. The blood chemistry demon­strated sodium of 122 mmol/l, potassium of 4.9 mmol/l and blood sugar of 3.7 mmol/l. Ultrasound examination showed diffuse enlargement of both kidneys. Renal biopsy specimens showed amyloidosis with immuno­fluorescence suggesting it to be type AA amyloidosis.

Soon thereafter, the patient was discovered to have an atrio-ventricular nodal heart block and a cardiac pace maker was introduced. Echocardiogram showed septal hypertrophy. These findings were highly suggestive of cardiac amyloidosis.

Assessment of the adrenocortical hormone status showed Adrenocortin Tropic Hormone level of 87.2 ng/ml (normal: 9-52 ng/ml), serum cortisol of 66 ng/ml (normal: 100-250 ng/ml) and T2h of 158 ng/ml (after tetracosactide injection). A diagnosis of suprarenal insuffi­ciency probably caused by amyloidosis was made.


   Discussion Top


AA amyloidosis or secondary amyloidosis is constituted by amyloid deposits containing AA protein derived from its serum precursor, SAA protein (serum amyloid A), belonging to the group of inflammatory proteins. Hence, it is called inflammatory amyloidosis. The main causes of this condition include, particularly in poor countries, chronic infection especially tuberculosis [1] followed by chronic infla­mmatory arthritis, and more uncommonly, by lymphoproliferative diseases and neoplasms [2] particularly, renal carcinoma, [3] carcinoma of the lung [4] and small bowel. [5]

Other solid tumors such as bladder carci­noma [6] as seen in our case, have also been rarely reported. In general, AA amyloidosis appears many years (ten years on an average) after the causal disease. The association bet­ween AA amyloidosis and cancer seems to be frequent, especially renal cell carcinoma, since 25% of carcinomas complicated by AA amyloidosis were adenocarcinomas which represent only 2 or 3% of all visceral cancers.

Many hypotheses have been put forward to explain the pathogenesis of amyloidosis. The tumors probably synthesize an enzyme which is able to cleave SAA in order to obtain AA protein; or an amyloidosis precursor is released by the tumor cells. [7]

In our case, the relationship between amyloi­dosis and bladder carcinoma was established since no other possible etiology was found.

Amyloid deposits are reported to affect the suprarenal gland in about 50% of the cases, [8] resulting in suprarenal insufficiency. Heart involvement has been less frequently reported in AA amyloidosis. Our patient had renal amyloidosis and in addition, probably had cardiac and suprarenal amyloidosis as well.


   Conclusion Top


Our case suggests that patients with solid cancer should be monitored in order to detect the occurrence of amyloidosis. Conversely, patients with amyloidosis require a thorough evaluation to localize the possible cause, particularly a neoplasm.

 
   References Top

1.Erk O, Turfanda T, Uysal V. Frequency of renal amyloidosis secondary to tuberculosis. Nephron 1995;71(3):367.  Back to cited text no. 1    
2.Dhar MC, Ghosh KC, Basu K, Chakraborty A. Amyloidosis in a case of non-Hodgkin's lymphoma. J Assoc Physicians India 1999; 47(2): 249.  Back to cited text no. 2    
3.Toyoda M, Kudo M, Ebihara Y. Amyloid deposition in renal angiomyolipoma. Pathol Int 1999;49(2):180-4.  Back to cited text no. 3    
4.Dacic S, Colby TV, Yousem SA. Nodular amyloidoma and primary pulmonary lymphoma with amyloid production: a differential diagnostic problem. Mod Pathol 2000; 13(9):934-40.  Back to cited text no. 4    
5.Peny MO, Debongnie JC, Haot J, Van Gossum A. Localized amyloid tumor in small bowel. Dig Dis Sci 2000; 45(9):1850-3.  Back to cited text no. 5    
6.Biyani CS, Fitzmaurice RJ, Upsdell SM. Localized amyloidosis of the urethra with transitional cell carcinoma of the bladder. B Int 1999;83(6):722-3.  Back to cited text no. 6    
7.Amylose MF. In:Fries D (ed). Maladies renales. Hermann Press Ltd 1992;275-86.  Back to cited text no. 7    
8.Gmar Bouraoui S, Achour A, Abbes S, Mahjoub S, Frih A, Skhiri H, ben Dhia N, El May M. Adrenocortical insufficiency in renal amyloidosis. Ann dEndocrinol 2001; 62(1):4-6.  Back to cited text no. 8    

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Correspondence Address:
Skhiri Habib
Department of Nephrology, Monastir Hospital
Tunisia
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PMID: 17642770

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    Abstract
    Introduction
    Case Report
    Discussion
    Conclusion
    References
 

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