Acute renal failure and non-Hodgkins lymphoma in a patient with minimal change glomerulonephritis

[Paraneoplastic dermatopolymyositis with mild glomerular lesion nephropathy associated with non-Hodgkin's lymphoma]

INTRODUCTION

Dermatopolymyositis is an inflammatory disorder of an unknown origin. Twenty to thirty percent cases of this disease are associated with a cancer. Glomerular lesions in dermatopolymyositis are rare.

EXEGESIS

We describe the case of a patient who presented a dermatopolymyositis together with a glomerulopathy and then a non Hodgkin's lymphoma. A treatment by corticoid and secondary intravenous immune globulins because of corticoid-resistance of the dermatopolymyositis and oesophagus injury led to a significant improvement of the cutaneous signs and of the muscular weakness. This favourable evolution was also determined by the chemotherapy for lymphoma. Nine months after the diagnosis of dermatopolymyositis remission for dermatopolymyositis and lymphoma is obtained. We also noticed a regression of the glomerular signs.

CONCLUSION

A diagnosis of dermatopolymyositis must lead to a meticulous search for an associated cancer. Data from literature indicate that a cancer is usually discovered within the first year of dermatopolymyositis' diagnosis but it can appear until five years after this diagnosis. The most frequent organs concerned by cancer are ovary and the digestive tract. A meta-analysis showed an incidence-standardised rate for lymphoma important in patients suffering from dermatopolymyositis. The treatment of the cancer can improve the evolution of the dermatopolymyositis. However corticoid must be the first treatment for dermatopolymyositis. In case of corticoid-resistant dermatopolymyositis or dermatopolymyositis involving oesophagus treatment by intravenous immune globulins is justified. At last when a glomerular nephropathy is discovered in such a situation, paraneoplasic glomerulopathy, renal lymphomatous infiltration or another associated immune disease must be called to mind.

Myelodysplastic syndromes with nephrotic syndrome

It is sometimes reported that the immunological abnormalities in myelodysplastic syndromes (MDS) induce autoimmune disease (i.e., acute systemic vasculitic syndrome, chronic cutaneous vasculitis, polyneuropathy, relapsing polychondritis, and steroid-responsive pulmonary disorders). We investigated the clinical features of patients with MDS accompanied by nephrotic syndrome. We enrolled 125 patients with MDS who were admitted between January 1979 and May 1996 in this study. The renal function was assessed based on the laboratory data and the findings at the physical examination. The diagnoses of nephrotic syndrome and glomerular disease were established when 24-hr urinary excretion was more than 3.5 g and serum total protein was less than 6.0 g/dl, and when the 24-hr protein excretion was more than 1.5 g. Five patients (4%) had glomerular disease, and three (2.4%) had nephrotic syndrome. Of the five patients with glomerular disease, two had refractory anemia (RA), and three had chronic myelomonocytic leukemia (CMMOL). Three of the total 11 patients with CMMOL were diagnosed as having nephrotic syndrome. Among the CMMOL patients, those with nephrotic syndrome showed higher absolute monocyte numbers than did those without nephrotic syndrome (8830 +/- 4677/microl vs. 3061 +/- 2887/microl, P = 0.03). One CMMOL patient was treated with VP-16 and hydroxyurea. As the white blood cell count in this patient decreased, the 24-hr urine protein excretion and the serum tumor necrosis factor alpha level decreased. The relationship between nephrotic syndrome and CMMOL was not clear. High monocyte count and the serum cytokines in MDS patients may play a partial role in the evolution of glomerulonephritis, and CMMOL may be closely related to nephrotic syndrome.

[Glomerulonephritis and malignant lymphoma. Mostly men with low-grade lymphoma with various forms of glomerulonephritis]

BACKGROUND

The association of non-Hodgkin's lymphoma with different types of glomerulonephritis is well-known for many years. Whereas in Hodgkin's disease, minimal change glomerulonephritis is mainly observed, in non-Hodgkin's lymphoma various forms of glomerulonephritis are found.

PATIENTS AND RESULTS

We describe 3 cases of non-Hodgkin's lymphoma, which were associated with glomerulonephritis. Two cases of glomerulonephritis showed nephrotic syndromes, which improved by medicinal treatment. In 2 cases glomerulonephritis and non-Hodgkin's lymphoma developed simultaneously. In a third lymphoma was followed by glomerulonephritis after 3 years.

CONCLUSION

Although the pathogenetic relationship between non-Hodgkin's lymphoma and glomerulonephritis is not fully understood, the high number of reported cases yield interdependence. Lymphoma associated glomerulonephritis is found more often in men than in women. Low-grade non-Hodgkin's lymphomas--especially chronic lymphatic leukemias--seem to develop glomerulonephritis more frequently than high-grade. The majority of non-Hodgkin's lymphoma do not show any predisposition to a special type of glomerulonephritis, only in cutaneous lymphoma IgA-nephropathy predominates.

Association of primary renal non-Hodgkin's lymphoma with mesangioproliferative glomerulonephritis

A 27-year-old male developed nonoliguric renal failure. Renal biopsy of the left kidney showed infiltration by a diffuse large-cell non-Hodgkin's lymphoma (NHL). Laparoscopy, CT scans of the abdomen and thorax, and bone-marrow biopsy revealed no further manifestations of lymphoma. Primary renal NHL was diagnosed. The patient attained complete remission with cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP) chemotherapy and remained disease-free for 13 years. Eight years after his first presentation, the patient developed acute oliguric renal failure with nephrotic syndrome. Mesangioproliferative glomerulonephritis was diagnosed in a biopsy of the left kidney. Chronic hemodialysis was required until cadaver kidney transplantation was successfully performed 5 years later. Although the association of NHL and glomerulonephritis has been described several times before, to our knowledge this is the first report of glomerulonephritis in primary renal lymphoma.

Nephrotic syndrome and renal insufficiency associated with lithium therapy

Although the therapeutic administration of lithium in the psychiatric setting has been associated with various renal side effects, only a few reported cases have suggested a possible link to glomerular disease. We report two patients who, while taking lithium, developed heavy proteinuria caused by minimal change disease and acute renal insufficiency attributable to acute tubular necrosis. These clinical findings resolved on discontinuation of the drug, suggesting a role for lithium in their development. We also postulate that lithium, with its unique properties as a modulator of the phosphoinositol pathway, may play a key role in the pathogenesis of minimal change disease.

Glomerulonephritis and non-Hodgkin's lymphoma: a report of two cases and review of the literature

Two cases of glomerulonephritis associated with non-Hodgkin's lymphoma (NHL) are described. The first patient presented with the nephrotic syndrome and normal renal function, whereas the second suffered from recurrent acute renal failure together with a unique pattern of IgM deposition within glomerular capillaries. Our review of the literature suggests that this association, although rare, has been documented in a sufficient number of cases to show that it is more than coincidental. Whereas the most common renal lesion associated with Hodgkin's disease is minimal change disease, more advanced glomerular changes are found in the patients with NHL. This is reflected in the higher incidence of renal failure in the latter patients. Treatment of the lymphomas has been shown to result in improvement or even cure of the renal disease, although long-term follow-up is rarely available in the reported cases.