Lymphoproliferative disorders & renal disease

All of them can affect kidneys: Hodgkins/non- hodgkins, post immunosuppressive (EBV etc) CLL, Waldenstroms etc

Almost all patterns of injury can occur. The unique factor is that a monoclonal protein may light up on the IF. Hence the benefit of doing Kappa and Lamda and CD3,CD20 when suspicious.

Renal involvement

  • Direct infiltration
  • Glom/tubulointerstitial/vascular lesions due to monocloncal protein
  • Glom lesions due to cytokines
  • Paraneoplastic (amyloid, acid-base)
  • Intravascular invasion – gloms can become occluded by the atpypical lymphoid cells- A wee bit like tx glomerulitis – AKI, fever, weight loss
  • Indirect: nephrocalcinosis, tumour lysis, hyperviscosity syn, DIC, TMA, TIN, Drugs

Glomerular lesions:

Hodgkin: MCD, FSGS, AA Amyloid

Non-Hodgkin: T cell Cytoine med podocytopathy, MCD, FSGS

B cell with monocolonal gammopathy:

  • Cryoglobulins – granular/tubule-fibrillar
  • Non cryos: granular/tubule-fibrillar/crystalline
  • Other: AL amyloid, cast nephropathy, light chain tubulopathy

CLL can make a gammopathy and has a tissue phase

Waldenstroms is the lymphoma that pumps out IgM. 30-40% of IgM kappa can be cryoglobulins, so test for same if you find it on bx.

Suss

  • Older age group
  • History of MGUS/lymphoma – can be historical
  • Any abnormal pattern on bx, anything weird about an interstitial infiltrate ( like monomorphic, nesting and clumping a bit)
  • Get a CD3 (t-cell marker) CD20 (B- cell marker) and Kappa and lamda LC stains

Notes

  • Treat the underlying cause to improve/cure kidney disease

  • Kidney recurrence can herald lymphoproliferative recurrence, or be a first presentation/predate

  • Wide age range of patients but many series report older predominance (>60) ?male

  • Duration between lymphoma and renal disease can be >10 years

  • In glomerular lesions, tend to be CKD picture, nephrotic syndrome common, about 20% haematuria, gammopathy common, 60% perhaps

  • In parenchymal lesions, no NS obviously, only about 13% have a gammopathy but mass on imaging sometimes

  • LN and BM biopsy useful adjunctive tests

  • Primary extra nodal lymphoma in a kidney is a thing, but extremely rare

  • Make friends with a haematologist