Year : 2006 | Volume
: 17 | Issue : 3 | Page : 395--398
Acute Renal Failure due to Lymphomatous Infiltration: An Unusual Presentation
Kais Harzallah, Jannet Laadidi, Kais Chatti, Imed Hlel, Fethi Bougrine, Ammar Bouziani, Nejib Ben Abdallah, Bassam Louzir, Salah Othmani, Ezzedine Boussema
Military Hospital of Tunis, Tunis, Tunisia
Military Hospital of Tunis, 1008 Tunis
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«SQ»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.
|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;17:395-398
|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 2022 Dec 2 ];17:395-398
Available from: https://www.sjkdt.org/text.asp?2006/17/3/395/35774
Renal involvement occurs in approximately 50% of patients with lymphoma due to direct infiltration, as suggested by autopsy studies. 
It usually occurs late in the course of the disease and is clinically silent. Acute renal failure (ARF) from lymphoma is quite rare.  We report this unusual case of a patient with lymphoblastic lymphoma who presented with ARF.
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  Mostly, renal lymphoma results from hematogenous dissemination or contiguous extension of retroperitoneal disease.  Primary isolated kidney lymphoma is rare, while association with extranodal involvement is common and is seen in most patients at the time of diagnosis.  Common extra-nodal sites include the kidneys, bone marrow, the liver, and the gastrointestinal tract.  Many other extra-nodal sites have been reported in the literature.  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.  Acute renal failure from lymphomatous infiltration has been described, but it is quite rare. ,,,,, In a series of 48 patients with aggressive lymphomas with renal involvement, ARF as the presenting feature was observed in only three patients. 
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,  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.  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.
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.  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. , 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. 
|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.|
|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.|
|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.|
|4||Urban BA, Fishman EK. Renal lymphoma: CT patterns with emphasis on helical CT. Radiographics 2000;20:197-212.|
|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.|
|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.|
|7||Reznek RH, Mootoosamy I, Webb JA, Richards MA. CT in renal and perirenal lymphoma: a further look. Clin Radiol 1990;42:233-8.|
|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.|
|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.|
|10||Madaio MP: Renal biopsy. Kidney Int 1990;38:529-43.|
|11||Tornroth T, Heiro M, Marcussen N, Franssila K. Lymphomas diagnosed by percutaneous kidney biopsy. Am J Kidney Dis 2003;42:960-71.|
|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.|
|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.|
|14||Axelsen RA, Laird PP, Horn M. Intravascular large cell lymphoma: Diagnosis on renal biopsy. Pathology 1991;23:241-3.|
|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.|
|16||Magrath IT. Management of high-grade lymphomas. Oncology 1998;12:40-8.|