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Uncontrolled hypertension secondary to leukemic cell infiltration of kidneys in a hemodialysis patient.

Turkmen K, Altintepe L, Guney I, Aydogdu I, Koc O, Erkut MA, Tonbul HZ - Int J Nephrol Renovasc Dis (2010)

Bottom Line: Acute lymphoblastic leukemia, hypertensive crisis due to bilateral leukemic cell infiltration of kidneys, tumor lysis syndrome, and leukemic involvement of the facial nerve were diagnosed.After prednisolone, daunorubicine, and vincristine therapy, the size of kidneys diminished and his BP dropped under normal range.In conclusion, pathological findings such as uncontrolled hypertension, flank pain, skin rashes, and abnormal blood count should be considered carefully, even in patients with end-stage renal disease receiving renal replacement therapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Nephrology, Meram School of Medicine, Selcuk University.

No MeSH data available.


Related in: MedlinePlus

Abdominal computed-tomography scan showing bilaterally enlarged kidneys.
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f1-ijnrd-3-065: Abdominal computed-tomography scan showing bilaterally enlarged kidneys.

Mentions: The initial biochemistry and complete blood counts of the patient are shown in Table 1. Urinalysis revealed trace protein, and no red blood cells per high-power field. There was no active urinary sediment. 24-hour urine protein was 1 g. Anti-nuclear antibody, Anti-ENA, ANCA, and cryoglobulins were negative, and C3 and C4 levels were normal. Hepatitis B surface antigen, anti-HBs, Anti-HAV, and Anti-HCV were also negative. His previous ultrasonography (USG) revealed bilaterally diminished kidney sizes (the right kidney measured 90 × 40 mm, and the left kidney measured 85 × 45 mm). On a blood smear, atypical lymphocytes were seen, and bone marrow biopsy showed hypercellularity, with cells containing minimal cytoplasm and abnormal nuclear-cytoplasmic ratio. Flow cytometric studies of bone marrow tissues showed a population of T-cells that expressed CD2, CD3, CD4, CD5, CD7, and cytoplasmic CD3. These findings were consistent with precursor T-cell ALL. Despite the combination of 5 different classes of antihypertensive therapy (ramipril 10 mg/day, losartan 100 mg/day, amlodipin 10 mg/day, doxazosin 4 mg/day, and intravenous nitroglycerin), and aquate hemodialysis, his blood pressure did not drop under 180/110 mmHg. To establish the diagnosis, we performed abdominal computed tomography (CT), which showed bilaterally enlarged kidneys (Figure 1). We consulted over the patient with a hematologist and initiated peripheral vascular disease (PVD) chemotherapy (daunorubicine 45 mg/m2 per day for 7 days, vincristine 2 mg/m2 per day for 7 days, and prednisolone 64 mg/day for 28 days). To treat hyperuricemia, the patient was also given allopurinol and alkalized fluids, with ongoing hemodialysis. After the first cycle of PVD, his blood pressure dropped under 130/80 mmHg, and the renal USG revealed bilaterally atrophic kidneys. In this case, we hypothesized that ALL can bilaterally infiltrate the kidney in patients with ESRD. Kidney biopsy was considered before chemotherapy, but this procedure could not be performed because of uncontrolled hypertension and severe thrombocytopenia. After the first chemotherapy, his neutrophil counts dropped under 500/mm3, and febrile neutropenia developed. On the following days, despite the appropriate antibiotherapy, he had severe dyspnea and tachypnea. To establish the diagnosis, we performed thoracic CT. Cavitary lesion secondary to aspergillosis was diagnosed. We initiated antifungal therapy and the patient was entubated in an intensive care unit. Despite the intensive therapy, he died secondary to respiratory failure.


Uncontrolled hypertension secondary to leukemic cell infiltration of kidneys in a hemodialysis patient.

Turkmen K, Altintepe L, Guney I, Aydogdu I, Koc O, Erkut MA, Tonbul HZ - Int J Nephrol Renovasc Dis (2010)

Abdominal computed-tomography scan showing bilaterally enlarged kidneys.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3108775&req=5

f1-ijnrd-3-065: Abdominal computed-tomography scan showing bilaterally enlarged kidneys.
Mentions: The initial biochemistry and complete blood counts of the patient are shown in Table 1. Urinalysis revealed trace protein, and no red blood cells per high-power field. There was no active urinary sediment. 24-hour urine protein was 1 g. Anti-nuclear antibody, Anti-ENA, ANCA, and cryoglobulins were negative, and C3 and C4 levels were normal. Hepatitis B surface antigen, anti-HBs, Anti-HAV, and Anti-HCV were also negative. His previous ultrasonography (USG) revealed bilaterally diminished kidney sizes (the right kidney measured 90 × 40 mm, and the left kidney measured 85 × 45 mm). On a blood smear, atypical lymphocytes were seen, and bone marrow biopsy showed hypercellularity, with cells containing minimal cytoplasm and abnormal nuclear-cytoplasmic ratio. Flow cytometric studies of bone marrow tissues showed a population of T-cells that expressed CD2, CD3, CD4, CD5, CD7, and cytoplasmic CD3. These findings were consistent with precursor T-cell ALL. Despite the combination of 5 different classes of antihypertensive therapy (ramipril 10 mg/day, losartan 100 mg/day, amlodipin 10 mg/day, doxazosin 4 mg/day, and intravenous nitroglycerin), and aquate hemodialysis, his blood pressure did not drop under 180/110 mmHg. To establish the diagnosis, we performed abdominal computed tomography (CT), which showed bilaterally enlarged kidneys (Figure 1). We consulted over the patient with a hematologist and initiated peripheral vascular disease (PVD) chemotherapy (daunorubicine 45 mg/m2 per day for 7 days, vincristine 2 mg/m2 per day for 7 days, and prednisolone 64 mg/day for 28 days). To treat hyperuricemia, the patient was also given allopurinol and alkalized fluids, with ongoing hemodialysis. After the first cycle of PVD, his blood pressure dropped under 130/80 mmHg, and the renal USG revealed bilaterally atrophic kidneys. In this case, we hypothesized that ALL can bilaterally infiltrate the kidney in patients with ESRD. Kidney biopsy was considered before chemotherapy, but this procedure could not be performed because of uncontrolled hypertension and severe thrombocytopenia. After the first chemotherapy, his neutrophil counts dropped under 500/mm3, and febrile neutropenia developed. On the following days, despite the appropriate antibiotherapy, he had severe dyspnea and tachypnea. To establish the diagnosis, we performed thoracic CT. Cavitary lesion secondary to aspergillosis was diagnosed. We initiated antifungal therapy and the patient was entubated in an intensive care unit. Despite the intensive therapy, he died secondary to respiratory failure.

Bottom Line: Acute lymphoblastic leukemia, hypertensive crisis due to bilateral leukemic cell infiltration of kidneys, tumor lysis syndrome, and leukemic involvement of the facial nerve were diagnosed.After prednisolone, daunorubicine, and vincristine therapy, the size of kidneys diminished and his BP dropped under normal range.In conclusion, pathological findings such as uncontrolled hypertension, flank pain, skin rashes, and abnormal blood count should be considered carefully, even in patients with end-stage renal disease receiving renal replacement therapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Nephrology, Meram School of Medicine, Selcuk University.

No MeSH data available.


Related in: MedlinePlus