Learning Objective Recognize uncontrolled blood pressure and acute renal failure (ARF) as unusual presentations of non-Hodgkin's lymphoma (NHL).
Case A 56-year-old WM with a seven-year history of hypertension and diabetes mellitus was referred to nephrology for poorly controlled hypertension (HTN). At the time of referral he was on 6 different ant-hypertensive medications with BP being 150/80 mm Hg. Lab data: Hb 13.5 g/dL and serum creatinine 1.5 mg/dL. A workup for a secondary cause for HTN was recommended. He was subsequently lost to follow-up. A year later, he presented with fatigue, arthralgias, early satiety, and weight loss of 70 lbs. On evaluation his BP was 220/120 mm Hg, Hb 9.6 g/dL, MCV 83.2 fl, WBC 5.5 K/mm3 (N65%, L21%, M12.6%), serum creatinine 2.6 mg/dL. Multiple urine analyses done earlier were unremarkable. Over the next few days, he developed oliguric renal failure with serum creatinine increasing to 6.4 mg/dL, LDH 569 U/L, and uric acid 9.8 mg/dL. Renal imaging revealed a lobulated right kidney measuring 14 cm and the left measuring 12 cm without obstruction. A renal biopsy was performed which revealed lymphomatous infiltration of the kidney with acute tubular necrosis. Subsequently, infiltration of the gastric mucosa and bone marrow were also demonstrated. A diagnosis of NHL was made and chemotherapy with cyclophosphamide, hydroxydoxorubicin, Oncovin, and prednisone (CHOP) along with hemodialysis was started. Over the next 2 weeks, his renal function recovered and hemodialysis was discontinued. The BP control also improved requiring only 2 antihypertensive medications. Several months later, the patient died of CNS complications of lymphoma.
Discussion ARF in NHL is rare, although renal involvement may occur with widespread extranodal disease. In this patient, tumor infiltration caused compressive alteration of tubules and impaired renal vascularization resulting in ARF and uncontrolled HTN. As seen in this case, BP tends to normalize with chemotherapy along with concomitant improvement in renal function.