Nonoliguric Acute Renal Failure in Non-Hodgkin’s Lymphoma

Dr. Vijay Kher, Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226001 (India) Dear Sir, The kidney represents one of the most common extranodal sites of metastatic lymphoma [1, 2]. However, renal failure, whenever present, is a late and rare manifestation of lymphomatous process [3, 4], but renal failure as a presenting manifestation due to lymphomatous infiltration of the kidneys is unusual [5, 6]. We report a case with nonoliguric acute renal failure as a presenting manifestation caused by diffuse infiltration of non-Hodgkin’s lymphoma in both kidneys. A 19-year-old male was admitted to our hospital with a 2-month history of fever, anorexia, and vomiting. Serum creatinine and serum urea done prior to admission were 7.7 mg/dl (680.7 μmol/l) and 165 mg/dl (58.90 μmol/l), respectively. There was no history of nephrotoxic drug intake. Physical examination revealed an ill-looking restless and irritable boy who was pale, normotensive, afe-brile and anicteric. The lungs were clear and cardiac examination was normal. There was no organomegaly. Laboratory tests revealed a hemoglobin concentration of 8.6 g% (869 μmol/l) with ESR 45 mm/h and normal total and differential white cell counts. Urinalysis showed a specific gravity of 1,010 and 1 + protein. Urinary protein excretion was 0.279 g/day. The sediment contained few red cells, numerous leukocytes and no casts. Urine culture was negative. Urine osmolality was 288 mosm/kg and plasma osmolality was 280 mosm/kg. Urinary FENa was 1.9%. The peak serum creatinine and urea concentrations were 16.9 mg/dl (1,493.9 μmol/l) and 375 mg/ dl (133.8 mmol/l), respectively. Endogenous creatinine clearance was 6.5 ml/min (0.108 ml/s). Serum sodium 132.9 mmol/l, potassium 5.12 mmol/l, calcium 9.4 mg/dl (2.34 mmol/l), phosphorus 9.72 mg/dl (3.14 mmol/ 1), albumin 43 g/l and uric acid 11.6 mg/dl (689.9 μmol/l). Blood glucose and liver function tests were normal. C3 was normal and ANA was negative. Chest X-ray did not reveal any mediastinal enlargement. Abdominal sonography revealed bilateral diffusely enlarged kidneys (size 16 cm) with increased echogenicity of the renal cortex. Histological examination of percutaneous renal biopsy revealed a markedly widened interstitium due to dense and diffuse infiltration by small round to oval cells having hyperchromatic nuclei, and only a very thin rim of pale blue cytoplasm. Intermixed with these were somewhat larger cells with partially distorted to collapsed