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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 28  |  Issue : 3  |  Page : 645-647
Oliguric acute kidney injury as initial presentation of renal non-Hodgkin’s lymphoma infiltration


1 Division of Nephrology, Hospital Geral de Fortaleza, Fortaleza, Ceará, Brazil
2 Division of Nephrology, Hospital Geral de Fortaleza; Department of Internal Medicine, Post- Graduation Program in Medical Sciences, Federal University of Ceará, Fortaleza, Ceará, Brazil
3 Department of Internal Medicine, Post-Graduation Program in Medical Sciences, Federal University of Ceará; School of Medicine, Master in Collective Health, University of Fortaleza, Fortaleza, Ceará, Brazil

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Date of Web Publication18-May-2017
 

   Abstract 

We report a case of a 20-year-old man presented to the emergency department with oliguria and renal failure requiring urgent dialysis. An ultrasound revealed enlarged kidneys, and a renal biopsy showed non-Hodgkin’s lymphoma, subtype diffuse large B-cell.

How to cite this article:
Leite TT, Libório AB, Silva Junior GB, Daher ED. Oliguric acute kidney injury as initial presentation of renal non-Hodgkin’s lymphoma infiltration. Saudi J Kidney Dis Transpl 2017;28:645-7

How to cite this URL:
Leite TT, Libório AB, Silva Junior GB, Daher ED. Oliguric acute kidney injury as initial presentation of renal non-Hodgkin’s lymphoma infiltration. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2019 Aug 18];28:645-7. Available from: http://www.sjkdt.org/text.asp?2017/28/3/645/206459

   Introduction Top


Secondary involvement of the kidney by lymphomatous disease is well known, but it is not documented due to the low rate of kidney biopsies performed in such patients.[1] Renal manifestations of kidney lymphomas are rare, occurring in only 10% of non-Hodgkin’s lymphoma and <1% in primary lymphoma of the kidney. Oliguric acute kidney injury as the first manifestation of renal evolvement is even rarer.[2] In this paper, we report a case of small bowel non-Hodgkin’s lymphoma with secondary kidney involvement presenting as oliguric and severe acute kidney injury requiring emergency dialysis.


   Case Report Top


A 20-year-old man presented to the emergency department with fever, dry cough, subcostal pain, nausea and vomiting, oliguria, and dark-colored urine. One day after admission, he had a generalized tonic-clonic convulsion. Physical examination was unremarkable, except for lower and upper limbs edema and hypertension (180/120 mm Hg). Cranial computed tomography (CT) was normal. Laboratory tests showed a serum creatinine of 20.8 mg/dL and urea of 161 mg/dL. Laboratory data during hospital stay are shown in [Table 1]. Emergency hemodialysis was started. An ultrasound showed enlarged kidneys (right kidney: 18.1 x 10.3 cm, left kidney: 17.8 x 10.1 cm). These findings were confirmed by abdominal CT [Figure 1]a.
Table 1: Laboratory data during hospital stay.

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Figure 1: (a) Abdominal computed tomography evidencing large-sized kidneys (right kidney: 18.2 × 8.8cm, left kidney: 18.6 × 9.7cm), with dense images in the periphery; (b) Renal biopsy showing large lymphoid cells proliferation, atypical, pleomorphics, with evident nucleus, surrounded by a small amount of lymphocytes, without atypias, arranged as nodular infiltrate in the renal parenchyma.

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He had a prior history of an intestinal tumor mass resection five months ago in another hospital. The histopathological analysis of the intestinal mass was suggestive of lymphoproli- ferative lesion.

A renal biopsy revealed large lymphoid cells proliferation, atypical, pleomorphics, with evident nucleus, surrounded by a small amount of lymphocytes, without atypias, arranged as nodular infiltrate in the renal parenchyma [Figure 1]b. The immunohistochemical pattern was 70% positive for Ki-67 antibody and also for bcl-6 and CD20. The final diagnosis was non-Hodgkin’s lymphoma, subtype diffuse large B-cell lymphoma (DLBCL).

Chemotherapy was started with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP schema). The patient became clinical stable and was discharged to the hematology outpatients’ clinics, but with no renal function recovery and continuing hemodialytic treatment.


   Discussion Top


Renal involvement has been reported frequent in non-Hodgkin’s lymphoma.[3] Flank pain, he- maturia, weight loss, and palpable abdominal mass are the most common manifestations. In primary renal lymphoma, most patients present with acute kidney injury.[4] Our presented as severe oliguric acute kidney injury requiring dialysis, a rare manifestation of secondary infiltration of the kidney by non- Hodgkin’s lymphoma. In these patients, the renal infiltration is usually diagnosed in post mortem analysis. Tumor lysis syndrome was excluded in this case as his serum uric acid level was normal.

Renal lymphoma in the majority of cases originates from a multisystemic dissemination but can also occur as a primary lymphoma, which is extremely rare.[5] Secondary renal involvement is found in 30%-40% of autopsies from patients with lymphoma[5] and primary lymphoma in only 0.7% of extranodal lymphomas.[6]

Renal lymphomas are indistinguishable from other renal tumors through clinical manifestations and radiological findings.[7] The lesions can be solitary masses (10%-20%) or multiple (60%). They are generally bilateral and its extension occurs through contiguity (25%- 30%), diffuse infiltration (20%), or perirenal involvement (10%). Radiological findings frequently indicate renal involvement with multiple nodules and help elucidate diagnosis. Renal lymphoma is generally represented by a bilateral nodular infiltrate associated with diffuse kidneys enlargement.[8] Non-Hodgkin’s DLBCL is the most common type of lymphoma in adults, and it is responsible for 30%- 40% of non-Hodgkin’s lymphomas.[9]

Imaging is very important to diagnose renal lymphomas as the clinical presentation is often unspecific. It is more probable that kidneys are involved in diffuse forms of lymphomas.[1] The diagnosis is confirmed with histopathological examination and immunohistochemistry. Renal biopsy is the best method to establish the diagnosis of renal involvement and has a high sensitivity and specificity.[6] Treatment is determined according to the classification of lym- phoma subtype.

Conflict of interest: None declared.

 
   References Top

1.
Martina MN, Sole M, Masso E, Perez N, Campistol JM, Quintana LF. Mixed cryoglobulinemia not related to hepatitis C virus, mesangiocapillary glomerulonephritis and lymphoplasmocytic lymphoma. Nefrologia 2011;31:743-6.  Back to cited text no. 1
    
2.
Martin Laborda y Bergasa F, Lozano Lozano D, Gil Fernandez JJ, Serrado Pardo R, Fernandez Ranada JM. Non-Hodgkin’s lymphoma and urinary tract. About a case reported. Actas Urol Esp 2005;29:427-32.  Back to cited text no. 2
    
3.
Carvalho JG, Tafarel JR, Carvalho WB, Azambuja AP, Zenaro ES, Bendlin R. Acute renal failure as first clinical presentation of Burkitt’s renal lymphoma. J Bras Patol Med Lab 2006;42:179-83.  Back to cited text no. 3
    
4.
Olusanya AA, Huff G, Adeleye O, et al. Primary renal non-Hodgkins lymphoma presenting with acute renal failure. J Natl Med Assoc 2003;95:220-4.  Back to cited text no. 4
    
5.
Jhamb R, Gupta N, Garg S, et al. Diffuse lymphomatous infiltration of kidney presenting as renal tubular acidosis and hypokalemic paralysis: Case report. Croat Med J 2007; 48:860-3.  Back to cited text no. 5
    
6.
Dash SC, Purohit K, Mohanty SK, Dinda AK. An unusual case of bilateral renal enlargement due to primary renal lymphoma. Indian J Nephrol 2011;21:56-8.  Back to cited text no. 6
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7.
Torrecilla Garcia-Ripoll JR, Pascual Samaniego M, Martin Blanco S, Rivera Ferro J, Peral Martinez JI, Fernandez del Busto E. Primary renal lymphoma. Actas Urol Esp 2003;27:555- 8.  Back to cited text no. 7
    
8.
Barreto F, Dall’Oglio MF, Srougi M. Renal lymphoma. Atypical presentation of a renal tumor. Int Braz J Urol 2006;32:190-2.  Back to cited text no. 8
    
9.
Araujo JH, Victorino AP, Melo AC, et al. Linfoma nao-Hodgkin de alto grau - Revisao de literatura. Rev Bras Cancerol 2008;54:175- 83.  Back to cited text no. 9
    

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Correspondence Address:
Elizabeth De Francesco Daher
Division of Nephrology, Hospital Geral de Fortaleza, Fortaleza, Ceará
Brazil
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DOI: 10.4103/1319-2442.206459

PMID: 28540907

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    Abstract
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