Acute renal failure and normal blood count: A rare presentation of T-cell acute lymphoblastic leukemia
A 10-year-old previously healthy Caucasian boy presented with blurred vision, headache, nausea, and vomiting. The symptoms occurred intermittently without circadian variability. The patient had bilateral papilledema. He was pale but otherwise unaffected without enlarged lymph nodes or abdominal organs by palpation. Urinary production was normal. The blood pressure was elevated: 128/91 mmHg. Creatinine 101 μmol/l, urea 6.7 mmol/l, hemoglobin 9.5 g/l, platelets 150×109/l, white blood cell count 4.5×109 cells/l, absolute neutrophil count 1.75×109 cells/l, and lactate dehydrogenase 645 IU/l. Uric acid was 0.97 mmol/l and rasburicase was administrated twice, resulting in a rapid decrease (). Urine analysis showed marginal proteinuria of 0.2 g/day. An MRI scan of the cerebrum performed on day 3 showed no signs of malignancies or increased intracranial pressure.\nThe renal failure progressed reaching a peak creatinine level of 534 μmol/l. An ultrasound of the kidneys and urinary tract showed no signs of obstruction but bilateral diffuse enlargement of the kidneys (16 cm in craniocaudal length on both sides). A renal biopsy and a bone marrow aspiration and biopsy were performed on the fourth day from admission. The kidney biopsy showed massive infiltration of immature lymphoblasts (). The bone marrow biopsy showed 90% blasts of T-cell linage (CD3+, CD4+, CD10+, CD117+, CD7+, CD5+, and CD8−). Lumbar puncture showed CNS involvement with 12×106 cells/l; most of the cells were lymphoblasts.\nTreatment was initiated according to the NOPHO-ALL 2008 high-risk protocol. Due to high risk of tumor lysis, treatment was started with low-dose prednisolone alone (). Kidney function improved rapidly following initiation of therapy and dialysis did not become necessary.\nThe patient responded well to the leukemia treatment and remains in first complete remission three years after diagnosis. No further renal complications have occurred during the course of therapy and kidney size has returned to normal.