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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 1088-1089
Hematuria and renal involvement at presentation in acute lymphoblastic leukemia


Division of Pediatric Hematology-Oncology, Advanced Pediatric Center, PGIMER, Chandigarh, India

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Date of Web Publication13-Sep-2012
 

How to cite this article:
Marwaha R K, Kulkarni K P. Hematuria and renal involvement at presentation in acute lymphoblastic leukemia. Saudi J Kidney Dis Transpl 2012;23:1088-9

How to cite this URL:
Marwaha R K, Kulkarni K P. Hematuria and renal involvement at presentation in acute lymphoblastic leukemia. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Oct 31];23:1088-9. Available from: https://www.sjkdt.org/text.asp?2012/23/5/1088/100965
To the Editor,

We read with interest the article by Suriya et al on hematuria at presentation in acute lymphoblastic leukemia (ALL). [1] Although renal invol­vement has been described in ALL, we agree that hematuria is an unusual sole or predomi­nant presenting feature of ALL. Microscopic in­filtration of the genito-urinary tract often cannot be ruled out in these patients.

It is unclear as to why the authors are eva­luating their patient with pre-B ALL having nor­mal cytogenetics in complete remission for bone marrow transplant (BMT).

Was isolated microscopic renal involvement perceived to be a high-risk disease sufficient to justify BMT? Additionally, details of the the­rapy protocol used need to be mentioned.

We would like to report an additional child with ALL having isolated gross hematuria at pre­sentation and describe our experience of other patients with renal involvement at diagnosis and its plausible prognostic and therapeutic impli­cations. In our series of 762 children [2] managed over 18 years (1990-2008), we had 12 patients (1.5%) with impairment of renal function (oligoanuria and elevation of urea and creatinine) at diagnosis of ALL, ten of whom had bulky extramedullary disease. Palpable nephromegaly was present in one of these. None of them had hematuria at presentation.

In addition, a 7-year-old female child presen­ted with a 2-week history of increasing tiredness, fatigue, gross hematuria and pallor. There was no history of flank pain, fever, joint or bony pain and prior infection. There was no bleeding from any other site. Her past medical and family history were non-contributory. She had lymphadenopathy (<2 cm) in the cervical and inguinal areas. The liver was 2 cm below the right costal margin while the spleen was just palpable. The hemoglobin was 5 g/dL. The white cell count (WCC) and platelet count were 90.1 × 10 2 /L and 0.8 × 10 2 /L, respectively. The peripheral blood film revealed over 90% blasts. The renal and liver function tests were normal. There was no coagulopathy. Bone marrow aspiration confirmed the diagnosis of ALL, L1 morphology. There was no mediastinal widening on the chest X-ray. Ultrasound abdomen and imaging studies did not show nephromegaly, stones, congenital abnorma­lities, masses or gross leukemic infiltration of the genito-urinary tract.

Therapy was started according to the United Kingdom ALL (UKALL) XI protocol with four drugs (vincristine, L-asparaginase, dauno-rubicin and prednisolone) induction along with supportive therapy and blood and platelet transfusions. Gross hematuria cleared by Day 5 of therapy, followed by more gradual clearing of micros­copic hematuria. However, in view of financial constraints, the caretakers defaulted therapy at Day 15 of induction after the child developed sepsis with septic shock.

High WCC in our patient made it a high-risk disease. Because only isolated case reports or small series have been published, the prognostic implications of gross hematuria with micros­copic infiltration remain to be elucidated. Its association with other high-risk features of ALL is open to speculation. In our experience, eight of the 12 patients with overt renal involvement opted for therapy. However, five died, two re­lapsed while one was lost to follow-up. Hence, overt renal involvement may plausibly be associated with adverse outcome in resource-limited settings, indicating need of more aggressive therapy and supportive care with more facilities for renal replacement therapy. [5]

Our patient cleared hematuria much later than mentioned by the authors, despite therapy and supportive platelet transfusions. Although thrombocytopenia is contributory, relative contribu­tions of leukemic infiltrate, thrombocytopenia and impact of treatment on clearance of leukemic infiltrate and on hematuria need further delinea­tion. Because of the rarity of the condition, further collaborative studies assessing the mole­cular, cytogenetic and biological characteristics of ALL with genito-urinary involvement and hematuria are necessary to delineate whether renal involvement or hematuria represent a unique subset of ALL.

 
   References Top

1.Suriya OM, Aleem A. Frank hematuria as the presentation feature of acute leukemia. Saudi J Kidney Dis Transpl 2010;21:940-2.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Kulkarni KP, Marwaha RK, Trehan A, Bansal D. Survival outcome in childhood ALL: expe­rience from a tertiary care centre in North India. Pediatr Blood Cancer 2009;53:168-73.  Back to cited text no. 2
[PUBMED]    
3.Seo-Mayer P, Kenney B, McNamara J, Stein J, Moeckel GW. Hematuria and decreased kidney function as initial signs of acute B-cell lymphoblastic leukemia. Am J Kidney Dis 2010;56:1001-5.  Back to cited text no. 3
[PUBMED]    
4.Kalbani NA, Weitzman S, Abdelhaleem M, Carcao M, Abla O. Acute lymphoblastic leuke­mia presenting with gross hematuria. Paediatr Child Health 2007;12:573-4.  Back to cited text no. 4
[PUBMED]    
5.Kulkarni KP, Arya LS. Infantile acute lymphoblastic leukemia with nephromegaly. Indian J Pediatr 2010;77:1199-200.  Back to cited text no. 5
[PUBMED]    

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Correspondence Address:
R K Marwaha
Division of Pediatric Hematology-Oncology, Advanced Pediatric Center, PGIMER, Chandigarh
India
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DOI: 10.4103/1319-2442.100965

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