Acute renal failure as an initial manifestation of acute lymphoblastic leukemia
A 7-year-old girl was brought with complaints of fever, joint pain, and decreased urine output for 3 days. On examination, she was pale, had cervical lymphadenopathy, but no hepatosplenomegaly. She was normotensive. Investigations showed hemoglobin 7.1 g/dl; white blood cell count 24,700/cumm; differential count: Polymorph 30.2%, lymphocytes 68.1%, monocytes 2.2%, eosinophils 0.3%, basophils 0.2%, and platelets 80,000/cumm. Renal function tests showed BUN of 44 mg/dl and creatinine 2.9 mg/dl; renal ultrasound was normal. Peripheral smear showed occasional blast cells. Uric acid was 30 mg/dl and LDH 2,163 U/L. Serum electrolytes, arterial blood gas analysis, and urine analysis were normal. In view of fever, lymphadenopathy, anemia, leukocytosis, blasts in the peripheral smear, hyperuricemia, and raised LDH levels, bone marrow biopsy was planned to rule out hematologic malignancies. Bone marrow biopsy showed acute leukemia and flow cytometry was suggestive of T-cell ALL. She was treated with steroids as per induction protocol with rasburicase and hydration therapy. Renal parameters were normalized after 2 days, which indicates that renal failure was due to uric acid nephropathy. Currently she is receiving chemotherapy and is doing well since 1 year.