Acute renal failure as an initial manifestation of acute lymphoblastic leukemia
An 8-year-old boy presented with fever, arthralgia, and oliguria. He was treated elsewhere symptomatically. On examination, he had pallor, no lymphadenopathy or hepatosplenomegaly. His blood pressure was 110/70 mm Hg. Investigations showed hemoglobin of 5.2 g/dl; white blood cell count 5,410/cumm; differential count – polymorph 54.8%, lymphocytes 27.2%, monocytes 4.4%, basophils 0.4%, eosinophils 0.2%, platelets 90,000/cumm; and renal functions showed BUN 48 mg/dl and creatinine 3 mg/dl. The peripheral smear was normal. Urine analysis was normal. Serum electrolytes and arterial blood gas analysis were normal. He was given peritoneal dialysis for a week. In view of severe pain in the joints, considering leukemia, uric acid was found to be 18.4 mg/dl and lactate dehydrogenase (LDH) 1,658 U/L. Ultrasound abdomen showed mild nephromegaly. In view of fever, cytopenia involving two cell lineages (anemia and thrombocytopenia), hyperuricemia, and elevated LDH levels, bone marrow biopsy was performed which showed acute leukemia. Flow cytometry confirmed Pre B-cell ALL. Renal parameters normalized within a week of treatment with steroids as per induction protocol, hydration, rasburicase therapy indicating uric acid nephropathy as a cause of renal failure. Currently he is on chemotherapy and is doing well since past 1 year.