Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Allied Health Professionals’ Corner
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Commentary : Patient’s Voice
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guideline
Guidelines
Image in Nephrology
Images in Nephrology
In-depth Review
Letter to Editor
Letter to the Editor
Letter to the Editor – Authors’ reply
Letters to Editor
Literature Review
Nephrology in India
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Allied Health Professionals’ Corner
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Commentary : Patient’s Voice
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guideline
Guidelines
Image in Nephrology
Images in Nephrology
In-depth Review
Letter to Editor
Letter to the Editor
Letter to the Editor – Authors’ reply
Letters to Editor
Literature Review
Nephrology in India
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
View/Download PDF

Translate this page into:

Case Report
23 (
4
); 292-293
doi:
10.4103/0971-4065.114472

Acute renal failure as an initial manifestation of acute lymphoblastic leukemia

Department of Pediatrics, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India
Department of Pediatric, Division of Pediatric Hematology and Oncology, Sri Ramachandra Medical Centre, Chennai, Tamil Nadu, India

Address for correspondence: Dr. J. Julius Xavier Scott, Division of Pediatric Hematology and Oncology, Sri Ramachandra Medical Centre, Chennai - 600 116, Tamil Nadu, India. E-mail: jxscott@hotmail.com

Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Acute lymphoblastic leukemia (ALL) is the most common malignancy in children. Acute renal failure is a well-recognized complication of ALL after initiation of chemotherapy. Renal failure as the primary manifestation of ALL is rare. Here, we report three children who presented with acute renal failure and hyperuricemia and were subsequently diagnosed to have ALL.

Keywords

Acute renal failure
children
hyperuricemia
leukemia

Introduction

In acute leukemia, renal complications occur due to several factors including leukemic infiltration of the kidneys, therapy-related side effects such as tumor lysis syndrome, nephrotoxic drugs, and septicemias.[1] Hyperuricemia, as a manifestation of tumor lysis syndrome, is a well-recognized complication,[2] and in most cases, it occurs after the initiation of chemotherapy. Renal failure as the primary manifestation of acute lymphoblastic leukemia (ALL) is rare. Here, we report three children who presented with acute renal failure and hyperuricemia and were subsequently diagnosed to have ALL despite initial normal white cell counts and normal peripheral smear in one of them.

Case Reports

Case 1

An 8-year-old boy presented with fever, arthralgia, and oliguria. He was treated elsewhere symptomatically. On examination, he had pallor, no lymphadenopathy or hepatosplenomegaly. His blood pressure was 110/70 mm Hg. Investigations showed hemoglobin of 5.2 g/dl; white blood cell count 5,410/cumm; differential count – polymorph 54.8%, lymphocytes 27.2%, monocytes 4.4%, basophils 0.4%, eosinophils 0.2%, platelets 90,000/cumm; and renal functions showed BUN 48 mg/dl and creatinine 3 mg/dl. The peripheral smear was normal. Urine analysis was normal. Serum electrolytes and arterial blood gas analysis were normal. He was given peritoneal dialysis for a week. In view of severe pain in the joints, considering leukemia, uric acid was found to be 18.4 mg/dl and lactate dehydrogenase (LDH) 1,658 U/L. Ultrasound abdomen showed mild nephromegaly. In view of fever, cytopenia involving two cell lineages (anemia and thrombocytopenia), hyperuricemia, and elevated LDH levels, bone marrow biopsy was performed which showed acute leukemia. Flow cytometry confirmed Pre B-cell ALL. Renal parameters normalized within a week of treatment with steroids as per induction protocol, hydration, rasburicase therapy indicating uric acid nephropathy as a cause of renal failure. Currently he is on chemotherapy and is doing well since past 1 year.

Case 2

A 7-year-old girl was brought with complaints of fever, joint pain, and decreased urine output for 3 days. On examination, she was pale, had cervical lymphadenopathy, but no hepatosplenomegaly. She was normotensive. Investigations showed hemoglobin 7.1 g/dl; white blood cell count 24,700/cumm; differential count: Polymorph 30.2%, lymphocytes 68.1%, monocytes 2.2%, eosinophils 0.3%, basophils 0.2%, and platelets 80,000/cumm. Renal function tests showed BUN of 44 mg/dl and creatinine 2.9 mg/dl; renal ultrasound was normal. Peripheral smear showed occasional blast cells. Uric acid was 30 mg/dl and LDH 2,163 U/L. Serum electrolytes, arterial blood gas analysis, and urine analysis were normal. In view of fever, lymphadenopathy, anemia, leukocytosis, blasts in the peripheral smear, hyperuricemia, and raised LDH levels, bone marrow biopsy was planned to rule out hematologic malignancies. Bone marrow biopsy showed acute leukemia and flow cytometry was suggestive of T-cell ALL. She was treated with steroids as per induction protocol with rasburicase and hydration therapy. Renal parameters were normalized after 2 days, which indicates that renal failure was due to uric acid nephropathy. Currently she is receiving chemotherapy and is doing well since 1 year.

Case 3

A 13-year-old boy presented with bilateral swelling in the neck for one week, cough, dyspnea, and reduced urine output for 3 days. Physical examination showed cervical lymphadenopathy and hepatosplenomegaly. He was found to have hypertension, which was controlled with nifedipine. Investigations revealed hemoglobin of 5 g/dl; white blood cell count 300,100/cumm; platelet count 75,000/cumm; uric acid 32.2 mg/dl; LDH 12,720 U/L; and peripheral smear showed 90% blast cells. Renal functions showed BUN 38 mg/dl and creatinine 2.4 mg/dl; urine analysis was normal. Serum electrolytes and arterial blood gas analysis were normal. Renal ultrasound was normal. Bone marrow biopsy and flow cytometry showed features suggestive of ALL (T-cell type). He was started on dialysis, chemotherapy, and tumor lysis supportive measures. Renal parameters normalized after 2 weeks, indicating again the possibility of uric acid nephropathy. Currently he is on chemotherapy.

A renal biopsy was not performed in our patients as there was complete resolution of renal failure and a definite diagnosis of leukemia was obtained.

Discussion

Renal involvement is not uncommon in ALL, but renal failure is a rarely a presenting symptom in ALL.[34] Renal involvement can present as renal enlargement due to leukemic infiltrates or as renal failure due to uric acid nephropathy.[56] However, other causes such as nephrotoxic drugs, infections, and obstructive uropathy due to para-aortic lymph nodes, retroperitoneal mass, urolithiasis, or ureteral clots can also occur.

Urate nephropathy as the sole presentation of acute leukemia without other evidence of malignancy is rare.[7] The reason why some patients develop hyperuricemia in the absence of significant tumor load still remains unclear. It is presumed that tumors with a high mitotic index may predispose to more spontaneous lysis and cell deaths.

Although leukemic infiltration of kidney may present in all types of leukemia, it more often occurs with lymphoblastic leukemia. Leukemic infiltrates may lead to significant impairment of renal function if it is bilateral and diffuse and in particular involves the cortical region.[8] In all our patients, there was no significant renal enlargement (although case 1 had mild nephromegaly) or any obstructive evidence in ultrasonogram such as any significant lymph node enlargement. None of our patients were dehydrated or given nephrotoxic drugs prior, or found to have septicemia. Uric acid was very high in all cases, and with normalization of uric acid, there was resolution of renal failure, which could explain that renal failure in our patients could be due to urate nephropathy. However, renal biopsy was not performed in our patients as there was complete and dramatic resolution of renal failure in all the three patients.

We recommend that uric acid estimation be done in the event of unexplained renal failure. Hyperuricemia and acute renal failure without any obvious cause met in clinical practice should arouse a suspicion of occult malignancy. Bone marrow biopsy should be performed even if blood counts and peripheral smear are normal with no evidence of leukemia clinically. Bone marrow aspirate should be repeated if normal initially, particularly if hyperuricemia and/or acute renal failure persists.

Source of Support: Nil

Conflict of Interest: None declared.

References

  1. , , , , , . Renal complications in acute leukemias. Haematologica. 1998;83:416-21.
    [Google Scholar]
  2. , , , , . Acute renal failure caused by renal infiltration by hematolymphoid malignancy. Ann Diagn Pathol. 2006;10:230-4.
    [Google Scholar]
  3. , , . Acute renal failure with hyperuricemia as initial presentation of leukemia in children. J Pediatr Hematol Oncol. 1996;18:191-4.
    [Google Scholar]
  4. , , , , , , . Acute lymphoblastic leukemia presenting as acute renal failure. Nat Clin Pract Nephrol. 2007;3:106-10.
    [Google Scholar]
  5. , , , , . Renal enlargement as primary presentation of acute lymphoblastic leukaemia. Indian J Cancer. 2002;39:154-6.
    [Google Scholar]
  6. , . Hyperuricaemia and renal failure preceding the onset of acute lymphoblastic leukaemia. Proc R Soc Med. 1971;64:728.
    [Google Scholar]
  7. , , . Hyperuricemia and renal failure-presenting manifestations of occult hematologic malignancies. J Pediatr. 1976;89:775-7.
    [Google Scholar]
  8. , , , , , , . Acute lymphoblastic leukaemia presenting with acute renal failure: Report of two cases. J Pak Med Assoc. 2008;58:512-4.
    [Google Scholar]
Show Sections