Volume 46, Issue 6 , Pages e101-e102, December 2005
Quiz Page Answers December 2005
Article Outline
A 29-year-old man with no past medical problems presented to the hospital with urinary incontinence, 100-lb weight loss in 3 months, and paraparesis. Magnetic resonance imaging showed a mass causing spinal cord compression at the level of L5/S1. Serum creatinine level was 3.4 mg/dL (301 μmol/L), and urine protein-creatinine ratio was 0.8 g/g. Ultrasound showed enlarged kidneys of 16 cm (Fig 46A). A test for antibody against human immunodeficiency virus was negative. A diagnostic procedure was done, and appropriate treatment was given. Two months later, serum creatinine level had decreased to 1.1 mg/dL (97 μmol/L), and a repeat ultrasound showed the kidneys now measured 10 cm (Fig 46B). Paraparesis had improved.
Figure 46.
Ultrasound examination of the right kidney (A) on presentation and (B) after treatment.
What is your diagnosis?
On additional laboratory testing, the patient had a lactate dehydrogenase level of 1,252 U/L. A biopsy specimen of the parasacral mass was consistent with large B-cell non-Hodgkin lymphoma. After 2 cycles of chemotherapy with cyclophosphamide, doxorubicin, vincristine (Oncovin), and prednisone-rituximab (rituximab is an antibody against CD20 antigen found on B lymphocytes), the enlarged kidneys had decreased in size from 16 to 10 cm.
At autopsy, infiltration of the kidneys by non-Hodgkin lymphoma is a fairly common finding (30% to 50%).1 Development of renal insufficiency in patients with non-Hodgkin lymphoma also is seen in 0.9% to 23%.1 However, in most cases, kidney failure is a result of urinary obstruction.1, 2 Infiltration of the kidneys by lymphoma leading to kidney failure and bilaterally enlarged kidneys has been reported, but is exceedingly rare.1, 2, 3, 4 Both interstitial and intraglomerular infiltration by malignant B lymphocytes have been described.3 However, kidney failure has been reported most consistently to occur with interstitial infiltration and nephrotic-range proteinuria with intraglomerular infiltration.3 With interstitial infiltration, 87% of patients had acute kidney failure, compared with only 45% of those with intraglomerular lymphoma.3 None of the patients with interstitial infiltration had nephrotic-range proteinuria.3 As in our patient, others have reported good response to chemotherapy with resolution of renal insufficiency; however, long-term patient survival is poor.1, 2, 3, 4
Final diagnosis: Large B-cell non-Hodgkin lymphoma.
Case provided by Mohammad Vaseemuddin, MD, and Ramin Sam, MD, Stroger Hospital of Cook County, Chicago, IL.
If you have an interesting case you would like to submit for consideration, please go to http://ajkd.edmgr.com to do so.
References
- . Acute renal failure as presentation of a Burkitt’s lymphoma . Am J Kidney Dis . 2000;36:E32
- . Rituximab in a patient with acute renal failure due to B-cell lymphomatous infiltration of the kidneys . Leuk Lymphoma . 2004;45:819–820
- . Lymphomas diagnosed by percutaneous kidney biopsy . Am J Kidney Dis . 2003;42:960–971
- . Acute renal failure due to a malignant lymphoma infiltration uncovered by renal biopsy . Nephrol Dial Transplant . 2004;19:2657–2660
PII: S0272-6386(05)01429-0
doi:10.1053/j.ajkd.2005.09.010
Volume 46, Issue 6 , Pages e101-e102, December 2005
