Abstract: FR-PO002

Spontaneous Tumor Lysis Syndrome Presenting as Acute Renal Failure from Numerous Bilateral Obstructing Uric Acid Stones

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Binari, Laura, Vanderbilt University Medical Cente, Nashville, Tennessee, United States
  • Burgner, Anna Marie, Vanderbilt University Medical Center, Nashville, Tennessee, United States
Background

Tumor lysis syndrome (TLS) causes a recognized collection of metabolic abnormalities including hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. TLS can result in acute renal failure (ARF) from multiple mechanisms including intra-renal precipitation of uric acid, xanthine, or calcium phosphate crystals resulting in obstruction and inflammation. It is an anticipated complication after initiation of chemotherapy for lymphoproliferative malignancies or in patients with high tumor burden; it can also occur spontaneously. We report an unusual case of a B-cell lymphoma presenting as ARF from extensive obstructing bilateral uric acid nephrolithiasis from spontaneous TLS.

Methods

A 36-year-old male with HIV was admitted to the hospital with oliguric ARF after presenting with 2 weeks of weight loss and dysphagia. He had started Bactrim and Atripla one month prior to presentation. Admission plasma lab values: creatinine 17.44 mg/dl, BUN 158 mg/dl, potassium 7.7 mEq/l, LDH 2097 u/l, phosphorous 11.7 mg/dl, and calcium 9.1 mg/dl. Urine studies were notable for 130 RBC/hpf and spot urine protein to creatinine ratio of 12. He underwent emergent hemodialysis for his hyperkalemia and work up of his ARF was initiated. A peripheral blood smear demonstrated the presence of lymphoma cells. Uric acid was found to be 24.5 mg/dL. Renal ultrasound demonstrated bilateral enlarged and echogenic kidneys with mild hydronephrosis of the left kidney and multiple bilateral renal calculi. A cystoscopy revealed heavy stone burden bilaterally with numerous calculi requiring placement of double J-stents for bilateral obstructive nephrolithiasis. Bone marrow biopsy and PET scan showed an aggressive B-cell lymphoma and he was started on rasburicase and chemotherapy while on renal replacement therapy. He ultimately regained kidney function and was able to stop dialysis 3 weeks after presentation.

Conclusion

To our knowledge, there is only one other case report of a patient with HIV and lymphoma who presented with spontaneous TLS. Despite multiple case reports discussing ARF due to spontaneous TLS, there are limited reports of nephrolithiasis as the etiology for renal failure. This case demonstrates the importance of including TLS in the differential when a patient presents in new ARF with significant bilateral nephrolithiasis despite no known malignancy.