Abstract: FR-PO246
AKI due to Chronic Lymphocytic Leukemia Infiltration with Necrotizing Granulomas
Session Information
- Onconephrology: From AKI to CKD and Everything in Between
November 03, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Onconephrology
- 1700 Onconephrology
Authors
- Critell, Erika Druzina, The Ohio State University, Columbus, Ohio, United States
- Yau, Amy, The Ohio State University, Columbus, Ohio, United States
- Biederman, Laura, The Ohio State University, Columbus, Ohio, United States
Introduction
Chronic lymphocytic leukemia (CLL) can commonly affect the kidneys. In autopsy findings, leukemic infiltration can be seen in up to 64-90% of cases, but direct involvement to the renal parenchyma causing acute kidney injury (AKI) is rare. In addition to leukemic inflammation, non-necrotizing granulomatous interstitial nephritis has been described.
Case Description
A 61 year old male with a past medical history of type 2 diabetes mellitus, ulcerative colitis, and immunoglobulin heavy chain variable region gene (IgHV) mutated CLL (not previously requiring therapy) presented in the outpatient setting with creatinine elevation from 1.0 mg/dL to 1.9 mg/dL. Work up revealed normal kidney size and new proteinuria of 493mg/24 hours. The creatinine rise was seen alongside a rise in his white blood cell (WBC) count from baseline 13-19 K/uL to 24-39 K/uL. Renal biopsy revealed leukemic infiltration with cells staining positive for CD20 and CD5 indicating direct involvement of the renal parenchyma along with necrotizing granulomas. The granulomas were found to be non-infectious, indicating a severe form of inflammation. He was started on acalabrutinib and obinutuzumab with hopes for AKI resolution.
Discussion
Other case reports note the appearance of necrotizing granulomatous inflammation seem to affect younger men; additionally, there is no correlation with WBC. Most cases have complete to partial renal recovery after initiation of chemotherapy, however case reports suggest patients with granulomatous inflammation may have a poorer response. The mechanism of renal injury is not clear. Some suggest leukemic cells secrete monoclonal immunoglobulins whereas others suggest renal damage from a hypersensitivity reaction to leukemic cells. Of note, previous case reports did not classify IgHV mutation status, which is now routinely evaluated for. Renal biopsy remains critical to diagnose this potentially reversible, specific, and rare cause of acute renal failure and dictate initiation and guidance of chemotherapy.
PAS stain showing leukemic infiltration