BIG SPLEEN, BIG KIDNEYS, SMALL CELL LYMPHOMA: A RARE CASE REPORT OF SEVERE AKI IN CLL

A BENDALL1, S KUO1, M ALYOUSEF3, M FINLAY3, K MASON2, K NICHOLLS1,4

1Department of Nephrology, Royal Melbourne Hospital, Melbourne , Australia , 2Department of Clinical Haematology, Peter MacCallum Cancer Centre and the Royal Melbourne Hospital, Melbourne , Australia , 3Department of Anatomical Pathology, Royal Melbourne Hospital , Melbourne , Australia, 4The University of Melbourne, Melbourne , Australia

Background: Acute kidney injury (AKI) is frequent in haematological malignancy, however, malignancy associated interstitial infiltrate is rare and seldom detectable by radiology. Chronic lymphocytic leukaemia (CLL), a common adult leukaemia, presents with monoclonal mature B cell lymphocytosis, and is called small lymphocytic lymphoma (SLL) when there is nodal or solid organ involvement. Although any organ can be affected, renal involvement with AKI is rare, however has implications for prognosis, treatment and clinical trials.
Case report: A 69 year old presents with 8 weeks of vomiting, severe dehydration and urea 34.9mmol/L and creatinine 790umol/L, with normal baseline function. Significant history includes CLL diagnosed 10 years prior, monitored without requiring treatment, bronchiectasis and seronegative arthritis. Additional investigations revealed haemoglobin 84g/L, white cell count 14.3×10^9/L (lymphocytosis 5.6×10^9/L), platelets 203×10^9/L. Blood film demonstrated no fragments, potassium, liver function, albumin and paraprotein studies were normal. Urine confirmed non-active sediment, with elevated protein/creatinine (189mg/mmol) and albumin/creatinine (32.4mg/mmol). Non-contrast computer tomography demonstrated cervical chain and left axillary lymphadenopathy, splenomegaly (20cm), and bilateral renal enlargement (right 13cm, left 15cm) without hydronephrosis. Positron emission tomography revealed Fluorodeoxyglucose-avid lymphadenopathy, stomach compression between liver and spleen, and bilateral nephromegaly. Lymph node and bone marrow biopsies demonstrated non-transformed CLL/SLL. Renal biopsy revealed normal glomeruli, extensively infiltrated interstitium with lymphocytes that stained diagnostically for CLL/SLL. After hydration and initiation of chemotherapy, renal function normalised (creatinine 70umol/L, urea 5mmol/L) and remains stable.
Conclusion: AKI from interstitial CLL/SLL infiltrate is uncommon, but recognition may be crucial for treatment decisions. Classically nephromegaly is considered a diagnostic clue, however clinically it is rare to have radiological evidence of CLL/SLL infiltrate. Thus, renal biopsy is recommended when AKI is suspected secondary to CLL/SLL.


Biography:
I am a Victorian first year nephrology advanced trainee. I am currently working full time in the department of nephrology at Royal Melbourne Hospital.

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