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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 3  |  Page : 395-398
Acute Renal Failure due to Lymphomatous Infiltration: An Unusual Presentation


Military Hospital of Tunis, Tunis, Tunisia

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   Abstract 

Renal lymphoma occurs most often as a part of a multi-systemic disseminated lymphoma or as a recurrence of the tumor. Renal involvement usually occurs late in the course of the disease and is clinically silent. Acute renal failure (ARF) from lymphomatous infiltration has been described but is quite rare. We report a 50-year-old Caucasian woman, who presented with features of ARF. Physical examination showed that her arterial blood pressure was 190/100 mm Hg with no lymphadenopathy or hepatosplenomegaly. Her urine output was about 100 ml/day, and urinanalysis revealed + proteinuria and microscopic hematuria. Biochemical findings revealed severely impaired renal function with a serum creatinine of 693 µmol/L. The patient's lactate dehydrogenase was elevated at 632 U/L. An abdominal ultrasound showed bilateral, large non-obstructed kidneys and a hypoechoic mass arising in the right lobe of the liver. An ultrasound-guided percutaneous liver biopsy showed typical features of B-cell lymphoblastic lymphoma. The patient expired two days later, even before any specific treatment could be started.

Keywords: Lymphoma, Acute renal failure, Intrarenal infiltration.

How to cite this article:
Harzallah K, Laadidi J, Chatti K, Hlel I, Bougrine F, Bouziani A, Abdallah NB, Louzir B, Othmani S, Boussema E. Acute Renal Failure due to Lymphomatous Infiltration: An Unusual Presentation. Saudi J Kidney Dis Transpl 2006;17:395-8

How to cite this URL:
Harzallah K, Laadidi J, Chatti K, Hlel I, Bougrine F, Bouziani A, Abdallah NB, Louzir B, Othmani S, Boussema E. Acute Renal Failure due to Lymphomatous Infiltration: An Unusual Presentation. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2021 Mar 6];17:395-8. Available from: https://www.sjkdt.org/text.asp?2006/17/3/395/35774

   Introduction Top


Renal involvement occurs in approximately 50% of patients with lymphoma due to direct infiltration, as suggested by autopsy studies. [1]

It usually occurs late in the course of the disease and is clinically silent.[2] Acute renal failure (ARF) from lymphoma is quite rare. [3] We report this unusual case of a patient with lymphoblastic lymphoma who presented with ARF.


   Case Report Top


A 50-year-old Caucasian woman, without any significant past medical history, initially visited her family doctor with a one-month history of abdominal pain, vomiting, and abnormal uterine bleeding. At this stage, she had mildly impaired renal function (creatinine 213 µmol/L). Seven days after, she was transferred to our hospital for further care. At admission, a physical examination showed pallor and epigastric and hypogastric tender­ness. The patient's arterial blood pressure was 190/100 mm Hg, body weight 65 kg and body mass index 29 kg/m 2 . The patient did not have any lymphadenopathy or hepato­splenomegaly. A gynecological examination revealed that the cervix was hard in consistency and had a nodular surface.

Neurological, cardiovascular, and respiratory system examinations were normal. The urine output was about 100 ml/day, and a urinalysis revealed + proteinuria and microscopic hematuria. biochemical analysis showed severely impaired renal functions (urea 41.7 mmol/L, creatinine 693 µmol/L, sodium 131 mmol/L, potassium 5.5 mmol/L). The serum calcium was 2.29 mmol/L, and the serum phosphorus was 2,99 mmol/L. Liver function tests showed a bilirubin of 12 µmol/L, aspartate aminotransferase (AST) 12 U/L and alanine aminotransferse (ALT) of 10 U/L; the hepatitis viral serology was normal. The total white blood cell count (WBC) was normal; the patient had a hypochromic microcytic anemia with a mean corpuscular volume (MCV) of 67 µm 3 and a mean corpuscular hemoglobin (MCH) of 21.1 pg/ cell. Plasma protein electrophoresis showed hypoproteinemia with a serum total protein of 52 g/L and a serum albumin of 27 g/L. The patient's lactate dehydrogenase level was elevated at 632 U/L. An auto-antibody screen, including anti­neutrophil cytoplasmic antibodies (ANCA), was negative. The C-reactive protein level was elevated at 22 mg/L. The level of the tumor-marker CA125 was elevated (43.54 U/ml, Normal < 35). Other biochemical parameters, such as serum uric acid, sodium, potassium, glucose, cholesterol and triglycerides, were in the normal range.

An abdominal ultrasound was performed which showed: bilateral, large, non-obstructed kidneys, 16 cm in length; three hypoechoic masses arising in the right lobe of the liver, with the largest mass having a diameter of 5 cm (one of these masses was compressing the inferior vena cava); peri-hepatic lymph nodes; a hypoechoic mass in the pancreas; and mild ascitis.

A percutaneous renal biopsy was not performed because of the possibility of a renal neoplasm. Computerized abdominal tomography (CAT) confirmed the results of abdominal ultrasound, and revealed, in addition, bilateral adrenal and ovarian masses and multiple retro-peritoneal lymph node enlargements [Figure - 1].

A biopsy of the uterine cervix showed features of condyloma of a low degree. An ultrasound-guided percutaneous liver biopsy showed features typical of B-cell lympho­blastic lymphoma (CD20+; KL1-; EMA-; CD3-) [Figure - 2].

During her stay in the hospital, the patient developed shock of unexplained etiology and, despite intensive care, she expired two days later. We could not establish the pathological staging of the lymphoma because the family refused an autopsy.


   Discussion Top


Renal lymphoma is most often a part of multi-systemic disseminated lymphoma, or may be part of tumor recurrence. [4] Mostly, renal lymphoma results from hematogenous dissemination or contiguous extension of retro­peritoneal disease. [5] Primary isolated kidney lymphoma is rare, while association with extra­nodal involvement is common and is seen in most patients at the time of diagnosis. [6] Common extra-nodal sites include the kidneys, bone marrow, the liver, and the gastrointestinal tract. [7] Many other extra-nodal sites have been reported in the literature. [7] Our patient presented with diffuse infiltration of the liver, kidney, pancreas, adrenals, and ovaries.

Renal involvement usually occurs late in the course of the disease and is clinically silent. [2] Acute renal failure from lymphomatous infil­tration has been described, but it is quite rare. [3],[4],[5],[6],[7],[8] In a series of 48 patients with aggressive lymphomas with renal involvement, ARF as the presenting feature was observed in only three patients. [9]

Our patient presented with a sudden loss of renal function. The ultrasonographic and CAT scan findings showed diffuse organ infiltration with non-obstructed enlarged kidneys. The mechanisms, other than direct lymphomatous infiltration of the kidneys, capable of causing ARF, such as ureteral obstruction, hypertension from compression of renal vessels, urate nephropathy, hyper­calcemia, sepsis, volume depletion, para­proteinemia and immunologically mediated glomeular injury, were excluded in this patient. As reported by Madaio, [10] it is better that a percutaneous renal biopsy is not performed when there is a suspicion of a renal neoplasm. The diagnosis of B-cell lymphoblastic lymphoma was confirmed by liver biopsy, but we did not have sufficient time to initiate treatment.

The precise mechanisms of ARF due to intra-renal lymphomatous infiltration are still unknown. [11] The frequently seen increase in renal size in patients with lymphoma is due to the interstitial proliferation of lymphoma cells that probably cause an increase in interstitial pressure. This, in turn, can cause impaired renal function by tubular obstruction, compression of peri-tubular capillaries with increased post-glomerular vascular resistance, or modulation of the tubuloglomerular feed­back mechanism.[12]

In intra-glomerular lymphoma or angiotropic large-cell lymphoma, the mechanisms of ARF may resemble those proposed in acute proli­ferative glomerulonephritis with obstruction of glomerular circulation. [13] Our patient, with the findings of proteinuria and microscopic hematuria, probably had an intra-glomerular lymphoma. Proteinuria is probably related to the local release, by the lymphoma cells or endothelial cells, of permeability enhancing cytokines. [14],[15] As expected, high-grade lymphomas are associated with the worst prognosis, and the outcome, with appropriate treatment, might not have been more favorable in our patient in view of the severity of the disease. [16]

 
   References Top

1.Kandel LB, McCullough DL, Harrison LH, Woodruff RD, Ahl ET Jr, Munitz HA. Primary renal lymphoma. Does it exist? Cancer 1987;60:386-91.  Back to cited text no. 1    
2.Hartman DS, David CJ Jr, Goldman SM, Friedman AC, Fritzsche P. Renal lymphoma: radiologic-pathologic correlation of 21 cases. Radiology 1982;144:759-66.  Back to cited text no. 2    
3.Choi JH, Choi GB, Shim KN, Sung SH, Han WS, Baek SY. Bilateral primary renal non-Hodgkin's lymphoma presenting with acute renal failure: successful treatment with systemic chemotherapy. Acta Haematol 1997;97:231-5.  Back to cited text no. 3  [PUBMED]  
4.Urban BA, Fishman EK. Renal lymphoma: CT patterns with emphasis on helical CT. Radiographics 2000;20:197-212.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Hauser M, Krestin GP, Hagspiel KD. Bilateral solid multifocal intrarenal and perirenal lesions: differentiation with ultra­sonography, computed tomography and magnetic resonance imaging. Clin Radiol 1995;50:288-94.  Back to cited text no. 5  [PUBMED]  
6.Richards MA, Mootoosamy I, Reznek RH, Webb JA, Lister TA. Renal involvement in patients with non-Hodgkin's lymphoma: clinical and pathological features in 23 cases. Hematol Oncol 1990;8:105-10.  Back to cited text no. 6  [PUBMED]  
7.Reznek RH, Mootoosamy I, Webb JA, Richards MA. CT in renal and perirenal lymphoma: a further look. Clin Radiol 1990;42:233-8.  Back to cited text no. 7  [PUBMED]  
8.Mills NE, Goldenberg AS, Liu D, Feiner HD, Gallo G, Gray C, Lustbader I. B-cell lymphoma presenting as infiltrative renal disease. Am J Kidney Dis 1992;19:181-4.  Back to cited text no. 8  [PUBMED]  
9.Morel P, Dupriez B, Herbrecht R, et al Aggressive lymphomas with renal involvement: a study of 48 patients treated with the LNH-84 and LNH-87 regimens. Groupe d'Etude des Lymphomes de l'Adulte. Br J Cancer 1994;70:154-9.  Back to cited text no. 9  [PUBMED]  
10.Madaio MP: Renal biopsy. Kidney Int 1990;38:529-43.  Back to cited text no. 10    
11.Tornroth T, Heiro M, Marcussen N, Franssila K. Lymphomas diagnosed by percutaneous kidney biopsy. Am J Kidney Dis 2003;42:960-71.  Back to cited text no. 11    
12.Kelly CJ, Tomaszewski JE, Neilson EG. Immunopathogenic mechanisms of tubulo­interstitial injury, in Tisher CC, Brenner BM (eds): Renal Pathology: With Clinical and functional correlations (ed 2). Philadelphia, PA, Lippincott, 1994 pp 699-772.  Back to cited text no. 12    
13.Pankewycz OG, Strugill BC, Bolton WK. Proliferative glomerulonephritis: postinfectious, noninfectious, and crescentic forms, in Tisher CC, Brenner BM (eds): Renal Pathology: With Clinical and Functional Correlations (ed 2). Philadelphia, PA, Lippincott, 1994, p222-57.  Back to cited text no. 13    
14.Axelsen RA, Laird PP, Horn M. Intra­vascular large cell lymphoma: Diagnosis on renal biopsy. Pathology 1991;23:241-3.  Back to cited text no. 14  [PUBMED]  
15.Nishikawa K, Sekiyama S, Suzuki T, et al. A case of angiotropic large cell lymphoma manifesting nephrotic syndrome and treated successfully with combination chemotherapy. Nephron 1991;58:479-82.  Back to cited text no. 15  [PUBMED]  
16.Magrath IT. Management of high-grade lymphomas. Oncology 1998;12:40-8.  Back to cited text no. 16  [PUBMED]  

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Correspondence Address:
Kais Harzallah
Military Hospital of Tunis, 1008 Tunis
Tunisia
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PMID: 16970262

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    Figures

  [Figure - 1], [Figure - 2]

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    Abstract
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