Renal Presentation in Pediatric Acute Leukemia

Renal enlargement at time of diagnosis of acute leukemia is very unusual. We here in report 2 pediatric cases of acute leukemia who had their renal affection as the first presenting symptom with no evidences of blast cells in blood smear and none of classical presentation of acute leukemia. The first case is a 4-year-old girl who presented with pallor and abdominal enlargement. Magnetic resonance imaging showed bilateral symmetrical homogenous enlarged kidneys suggestive of infiltration. Complete blood picture (CBC) revealed white blood count 11 10/L, hemoglobin 8.7 g/dL and platelet count 197 10/L. Bone marrow aspiration was performed, and diagnosed precursor B-cell ALL was made. The child had an excellent response to modified CCG 1991 standard risk protocol of chemotherapy with sustained remission, but unfortunately relapsed 11 month after the end of therapy. The second child was 13-month old, presented with pallor, vomiting, abdominal enlargement, and oliguria 2 days before admission. Initial CBC showed bicytopenia, elevated blood urea, creatinine, and serum uric acid, while abdominal ultrasonography revealed bilateral renal enlargement. Bone marrow examination was done and showed 92% blast of biphenotypic nature. So, biphynotypic leukemia with bilateral renal enlargement and acute renal failure was subsequently diagnosed. The patients admitted to ICU and received supportive care and prednisolone. Renal function normalized and chemotherapy was started. The child achieved complete remission with marked reduction of kidney size but, unfortunately she died from sepsis in consolidation phase of therapy. This case demonstrates an unusual early renal enlargement in childhood acute leukemia. Renal involvement of acute leukemia should be considered in child presenting with unexplained bilateral renal enlargement with or without renal function abnormalities and bone marrow examination should be included in the workup. (Medicine 94(37):e1461) Abbreviations: ALL = acute lymphoblastic leukemia, CBC = complete blood picture, CNS = central nervous system, HB = arwa M. Zakaria al, MD, MD, and Mohamed Abd Alhady, MD INTRODUCTION A cute leukemia is the most common malignancy in children. It account for 30% of all cancer diagnosed in children younger than 15 years. Leukemic infiltration is most frequently seen in bone marrow, spleen, lymph nodes, and liver. Extramedullary involvement of the kidneys is uncommon finding at diagnosis. There are only a few reports of children with palpable renal enlargement at initial presentation. We report a case of young girl who present with unexplained bilateral renal enlargement and further investigation revealed acute lymphoblastic leukemia. Acute renal failure has a large variety of etiologies but when associated with acute leukemia it is typically due to leukemic infiltration of the kidneys, therapy-related side effects, metabolic changes arising from chemotherapy, nephrotoxic drugs, and septicemias. Hyperuricemia, as a manifestation of tumor lysis syndrome, is a well-recognized complication, it occurs before chemotherapy (due to large tumor burden) or after the initiation of chemotherapy. However, initial presentation of acute leukemia as bilateral renal enlargement with renal failure is rather rare. Here, we report a child who presented with bilateral nephromegaly, acute renal failure, and hyperuricemia and was subsequently diagnosed to have biphenotypic leukemia. The study was approved by the research and ethical committee of Faculty of Medicine, Zagazig University, Egypt.