Lymphoproliferative disorders and renal dysfunction: a case of CLL-related AKI
Introduction: An 81-year-old man presented with acute kidney injury (AKI) in March 2024. He had initially been admitted with symptoms of diplopia and headache. He was referred to the renal team because of a significant decline in renal function, with his serum creatinine rising to 296 µmol/L and an...
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| Main Authors: | , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2025-07-01
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| Series: | Clinical Medicine |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S1470211825000661 |
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| Summary: | Introduction: An 81-year-old man presented with acute kidney injury (AKI) in March 2024. He had initially been admitted with symptoms of diplopia and headache. He was referred to the renal team because of a significant decline in renal function, with his serum creatinine rising to 296 µmol/L and an estimated glomerular filtration rate (eGFR) of 18 mL/min/1.73 m2, compared with an eGFR of 45 mL/min/1.73 m2 a year previously. Initial assessment, including computed tomography (CT) head, ruled out a stroke. His past medical history included glaucoma, hypercholesterolaemia and chronic lymphocytic leukaemia (CLL), diagnosed in 2019 following marginal lymphocytosis on routine blood tests. His treatment history involved a ‘watch and wait’ approach because of the indolent progression of his CLL, which had evolved into low-grade B cell non-Hodgkin’s lymphoma (NHL) in 2020. He had recently been referred for a suspected scalp lesion, excised in February 2024, with histology suggesting a CLL/small lymphocytic lymphoma (SLL)-related lesion. This case highlights lymphoproliferative infiltration as a cause of AKI in this subset of patients, as shown in Table 1. Materials and Methods: The patient’s clinical assessment revealed normal cardiovascular, respiratory and abdominal examinations, with no neurological signs. Blood tests showed anaemia (Hb 93 g/L), a white cell count of 123 × 109/L, and a platelet count of 179 × 109/L. A blood film confirmed CLL, but there was no evidence of haemolysis. Renal function was significantly impaired, with creatinine of 296 µmol/L and an eGFR of 18 mL/min/1.73 m2. Urine analysis showed red blood cells (RBCs), white blood cells and negative culture. An ultrasound revealed a complex cyst in the left kidney and splenomegaly (14.8 cm). A renal biopsy was performed under real-time ultrasound guidance, showing a prominent lymphocytic infiltrate with evidence of mild chronic renal damage.1 Immunohistochemistry identified small lymphocytes with lambda light chain restriction.2 The patient started treatment with acalabrutinib after discussions with the All-Wales Lymphoma panel. Results and Discussion: The renal biopsy revealed lymphocytic infiltration consistent with CLL/ SLL, with aggregates of small B cells identified through immunohistochemistry. This infiltration, without blast cells or casts, was associated with mild chronic renal damage, contributing to the patient's AKI. Renal involvement in CLL/SLL, although uncommon, can cause kidney dysfunction through direct infiltration by neoplastic lymphocytes or immune-mediated damage.Imaging confirmed progressive lymphadenopathy, including enlarged lymph nodes in the neck, axilla and mediastinum, alongside splenomegaly, supporting systemic lymphoma progression. These findings highlighted the need for targeted therapy to manage both the lymphoma and associated renal involvement.3,4Acalabrutinib, a Bruton's tyrosine kinase (BTK) inhibitor,5 was initiated after discussion with the All-Wales Lymphoma panel. This targeted approach is crucial in patients with CLL/SLL and organ involvement, offering a promising treatment strategy for controlling disease progression.5 Conclusion: This case highlights the diagnostic challenges in an elderly patient with indolent lymphoma presenting with AKI and systemic lymphadenopathy.3 A comprehensive diagnostic approach, including renal biopsy and close collaboration with a multidisciplinary team, was essential in guiding appropriate treatment.6 The decision to initiate acalabrutinib represents a targeted therapeutic approach for managing CLL/SLL-related renal disease and lymphoma progression. |
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| ISSN: | 1470-2118 |