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LETTERS TO EDITOR
Year : 2016  |  Volume : 26  |  Issue : 1  |  Page : 62-63
 

Nephrotic syndrome and acute renal failure as a presenting symptom of acute lymphoblastic leukemia


Department of Medicine, Dr. S.N. Medical College, Jodhpur, Rajasthan, India

Date of Web Publication30-Dec-2015

Correspondence Address:
H R Pahadiya
Department of Medicine, Dr. S.N. Medical College, Jodhpur - 342 001, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-4065.168478

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How to cite this article:
Pahadiya H R, Lakhotia M, Gandhi R, Choudhary A. Nephrotic syndrome and acute renal failure as a presenting symptom of acute lymphoblastic leukemia. Indian J Nephrol 2016;26:62-3

How to cite this URL:
Pahadiya H R, Lakhotia M, Gandhi R, Choudhary A. Nephrotic syndrome and acute renal failure as a presenting symptom of acute lymphoblastic leukemia. Indian J Nephrol [serial online] 2016 [cited 2019 Dec 10];26:62-3. Available from: http://www.indianjnephrol.org/text.asp?2016/26/1/62/168478


Sir,

A 15-year-old boy presented with low-grade fever, generalized body swelling and decreased urine output. On examination, he had pallor, pitting edema, and facial puffiness with no lymphadenopathy. His blood pressure, pulse rate, and respiratory rate were within normal limit. Hemoglobin was 7.6 g/dl, platelets 57,000/mm 3, leukocytes 22,300/mm 3 with 19.2% neutrophils and 64.5% lymphocytes, with blasts cells. Biochemistry revealed serum creatinine 3.16 mg/dl, uric acid 5.4 mg/dl, bilirubin 0.98 mg/dl, total protein 4.2 g/dl with albumin 1.90 g/dl, aspartate aminotransferase 198 IU/L, alanine aminotransferase 154 IU/L, lactate dehydrogenase 564 IU/L, serum cholesterol 325 mg/dl, and triglyceride 365 mg/dl. The electrolytes were within normal limits. Urinanalysis showed proteinuria of 3+ without hematuria and 24 urinary protein was 3 g. Bone marrow examination showed hypercellular marrow, 34% blast cells, 10% myelocytes and metamyelocytes, 20% lymphocytes, and 10% neutrophils. Immune-phenotyping study showed blast cells positive for CD-3, CD-5, CD-7, cCD-3, CD-45, and TdT markers which were suggestive of mature T-cell acute lymphoblastic leukemia (ALL). He tested negative for HIV-1 and -2, hepatitis B surface antigen, hepatitis C virus, and malaria. Ultrasound of abdomen showed mildly enlarged kidneys and increased cortical echogenicity with the loss of cortico-medullary differentiation without evidence of obstruction in the urinary tract. Hepatosplenomegaly was present. Hemodialysis was done thrice. Dexamethasone, allopurinol, renal safe antibiotics, and blood products were given. He did not respond to treatment and expired 10 days after because of multiorgan dysfunction.

Nephrotic syndrome is commonly reported in Hodgkin and non-Hodgkin lymphomas, chronic lymphoblastic leukemia, and acute myeloid leukemia.[1] Acute renal failure (ARF) is a rare presenting symptom of ALL.[2] The patients with male sex, advanced age, history of previous kidney disease, refractory leukemia, and hyper-leukocytosis are at higher risk for developing renal complications. The renal dysfunction in leukemia occurs because of preexisting renal disorders, leukemic infiltration of kidneys, nephrotoxic drug exposure, obstructive uropathy, tumor lysis syndrome, and infections.[3],[4] The renal dysfunction because of the leukemic infiltration of the kidneys is uncommon but should be suspected in patients presenting with ARF and diffusely enlarged kidneys.[4],[5] The tubular or glomerular injury because of tumor cells or immune complex deposition and paraneoplastic manifestation of leukemia can lead to renal dysfunction.[5]

In our case, there was no evidence of hyperuricemia, infection, dehydration, exposure to nephrotoxic drugs, or obstructive pathology of the urinary tract. Anasarca and proteinuria were consistent with the diagnosis of nephrotic syndrome. The renal failure might be due to the leukemic infiltration of the kidney as both kidneys were slightly enlarged with increased cortical echogenicity along with hepatosplenomegaly.

To conclude, the patient presenting with clinical picture suggestive of nephrotic syndrome with anemia and atypical cells in the peripheral blood film should be evaluated for hematological malignancy, and a rare presentation of ALL should be kept in differential diagnosis in children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Levi I, Dinour D, Ben-Bassat I, Raanani P. Acute myeloid leukemia associated with nephrotic syndrome: Case report and literature review. Leuk Lymphoma 2002;43:1133-6.  Back to cited text no. 1
    
2.
Bhatia NG, Sneha LM, Selvan SM, Scott JJ. Acute renal failure as an initial manifestation of acute lymphoblastic leukemia. Indian J Nephrol 2013;23:292-3.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Munker R, Hill U, Jehn U, Kolb HJ, Schalhorn A. Renal complications in acute leukemias. Haematologica 1998;83:416-21.  Back to cited text no. 3
    
4.
Banday KA, Sirwal IA, Reshi AR, Najar MS, Bhat MA, Wani MM. Renal involvement in hematologic neoplasia. Indian J Nephrol 2004;14:50-2.  Back to cited text no. 4
  Medknow Journal  
5.
Vankalakunti M, Rohan A, Vishwanath S, Rampure S, Bonu R, Babu K, et al. Spectrum of renal involvement in hematolymphoid neoplasms: Renal biopsy findings of 12 cases. Indian J Nephrol 2015;25:201-5.  Back to cited text no. 5
[PUBMED]  Medknow Journal  




 

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