Kidney damage from lymphoma
Introduction
Introduction to kidney damage caused by lymphoma Lymphoma is a malignant tumor of the immune system related to various immune cells produced by abnormal proliferation and differentiation in the immune response of lymphoid tissues. Can be divided into Hodgkin's disease and non-Hodgkin's lymphoma, the common clinical manifestations are painless lymphadenopathy, hepatosplenomegaly, fever, anemia and cachexia, although lymphoid tissue is mainly concentrated in lymph nodes, spleen, bone marrow Organ tissues such as tonsils, but they are widely distributed throughout the body. Therefore, lymphomas can originate from any part of the body in addition to organs that are mainly concentrated in lymphoid tissues. Clinical manifestations of nephrotic syndrome. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: acute renal failure, renal vein thrombosis
Cause
Causes of renal damage caused by lymphoma
Immunity (30%):
Lymphoma patients have many immunodeficiencies, kidney disease is related to immunity, and possible mechanisms of HD complicated with nephrotic syndrome are:
(1) Lymphocytes produce certain toxic substances, which increase the permeability of the glomerular basement membrane.
(2) In relation to humoral immunity, in patients with Hodgkin's disease with nephrotic syndrome, HD tumor-associated antigens are found in the kidney, kidney tumors are found in HD tumor-causing virus particles, and mixed cryoglobulin is detected in the blood circulation.
(3) It is associated with defects in T lymphocyte function in patients with lymphoma.
Invasiveness (20%):
One third of the lymphoma patients had infiltration of the kidney, and lymphosarcoma and reticulum sarcoma were more common. Richmond et al reported that 52% of lymphoma and kidney infiltrates had azotemia.
Malignant lymphoma can cause posterior peritoneal lymphadenopathy, compression of the ureter to cause obstructive nephropathy, or compression of the inferior vena cava (or renal vein) to damage the kidney.
Metabolic or therapeutic (20%):
Hypercalcemia and hyperuricemia caused by lymphoma may involve the kidney, patients with abnormal proteinemia can damage the kidney, lymphoma patients 3% to 8% with amyloidosis, nephrotic syndrome, posterior peritoneal lymphoma Radiotherapy, methotrexate or nitrosourea chemotherapy can damage the kidneys such as uric acid nephropathy or radiation nephritis.
Prevention
Prevention of kidney damage caused by lymphoma
The prevention of lymphoma is classified into three levels of prevention as other malignant tumors.
1. Primary prevention is caused by cause
Its goal is to prevent the occurrence of cancer. Its tasks include studying various cancer causes and risk factors, taking specific preventive measures against chemical, physical, biological and other specific carcinogenic factors, cancer-promoting factors and in vitro and in vivo pathogenic conditions, and taking measures against healthy organisms. Strengthen environmental protection, suitable for diet, suitable for sports, to promote physical and mental health.
(1) Avoid smoking: Smoking has become a well-known carcinogenic factor, which is related to 30% of cancers. Tobacco tar contains many carcinogens and cancer-promoting substances. Smoking mainly causes lung, pharynx, larynx and esophagus. Cancer can increase the risk of developing tumors in many other areas.
(2) Adjusting the diet structure: A reasonable diet has a preventive effect on most cancers, especially in plant-type foods, there are various anti-cancer ingredients, and these ingredients are effective for the prevention of all cancers. It shows that colon cancer, breast cancer, esophageal cancer, stomach cancer and lung cancer are most likely to be prevented by changing eating habits.
(3) Prevention of tumors in different parts caused by occupational and environmental pollution, drugs, etc.: such as lung cancer (asbestos), bladder (aniline dye), leukemia (benzene), etc. are related to the above factors, some infectious diseases and Some cancers are also closely related: such as hepatitis B virus and liver cancer, human papillomavirus and cervical cancer. In some countries, parasitic infection of schistosomiasis significantly increases the risk of bladder cancer, exposure to some ionizing rays and a lot of ultraviolet light, especially Ultraviolet rays from the sun can also cause skin cancer. Commonly used carcinogenic drugs include estrogen and androgen, anti-estrogen drug tamoxifen, and estrogen and endometrial cancer and breast cancer widely used in postmenopausal women. related.
2. Secondary prevention or preclinical prevention
The goal is to prevent the development of early-onset diseases, including early detection of cancer, early diagnosis, early treatment, to prevent or slow the progression of the disease, and reverse to phase 0 as soon as possible.
3. Tertiary prevention is clinical (stage) prevention or rehabilitation prevention
The goal is to prevent the deterioration of the disease and the occurrence of disability. The task is to adopt multidisciplinary diagnosis (MDD) and treatment (MDT), correct choice of reasonable and best treatment plan to fight cancer as soon as possible, try to promote recovery function and recovery, prolong life and improve quality of life. And even return to society.
Complication
Lymphoma-induced complications of renal damage Complications acute renal failure renal vein thrombosis
The main complications may be acute renal failure caused by uric acid obstructive nephropathy, or obstructive nephropathy caused by enlarged intraperitoneal lymph nodes, and enlarged lymph nodes to compress the renal vein, resulting in unilateral or bilateral renal veins. Thrombosis, etc.
Symptom
Lymphoma caused by kidney damage symptoms Common symptoms Liver splenomegaly fatigue kidney damage hematuria kidney involvement urine routine abnormal cachexia edema skin itching hypertension
Lymphoma clinical manifestations of painless lymphadenopathy, hepatosplenomegaly, fever, anemia and cachexia, males than women, all age groups can be onset, with 20 to 40 years old.
Extrarenal performance
(1) systemic symptoms: systemic symptoms mostly occur in the late stage of the disease, the most common symptoms are fatigue, fatigue, fever, sweating, weight loss, HD patients also common skin itching, generalized itching can be the only systemic symptoms of HD patients.
(2) lymphadenopathy: superficial lymphadenopathy is the most common early symptom, generally no tenderness, solid, scattered, asymmetrical, movable, varying in size, most progressive progressively increased, late several swollen Lymph nodes can be fused together to form larger lumps and fixed. NHL patients have the most common cervical lymphadenopathy, followed by lymph nodes in the groin and axilla.
(3) Extranodal organ involvement symptoms: In patients with HD, symptoms of extranodal organs often indicate that the disease develops to advanced stages such as the digestive system, lungs, heart, bones, skin and nervous system, while for NHL, 20% 30% of patients mainly showed symptoms of extranodal organ involvement, and large cell type lymphoma involved most of the extranodal organs.
(4) Hepatosplenomegaly: NHL is more common in patients with HD than hepatosplenomegaly. When NHL is involved in the liver, the spleen will almost enlarge.
2. Kidney manifestations Lymphoma Kidney involvement, only a few people have symptoms before birth, there are reports of 423 cases of lymphoma, the clinical diagnosis rate is only 0.5%, common clinical manifestations are:
(1) nephrotic syndrome: urinary protein > 3.5g / 24h, plasma albumin <30g / L, seen in the early stage of the disease, sometimes nephrotic syndrome is the first manifestation of lymphoma, after the emergence of lymphadenopathy, most nephrotic syndrome It appears in the course of the disease, and with the worsening or improvement of lymphoma deterioration or remission, B-ultrasound shows an increase in both kidneys.
(2) Nephritis syndrome: typical manifestations of proteinuria, hematuria (which can be gross hematuria), high blood pressure, edema, etc., may have tubular urine, dull pain in the kidney area, and occasionally touch the mass in the kidney area.
(3) renal insufficiency: lymphoma cells infiltrate bilateral kidneys, produce hypertension, oliguria and elevated serum creatinine and other symptoms of renal insufficiency, may cause acute renal failure due to uric acid obstructive nephropathy, malignant lymphoma may be caused by Abdominal enlarged lymph nodes compress the urinary tract to cause obstructive nephropathy, and severe cases of acute renal failure.
(4) Lymph nodes with enlarged lymphoma compress the renal vein, causing unilateral or bilateral renal vein thrombosis.
At present, renal damage caused by lymphoma has gradually attracted attention in China, and there have been reports of more and more malignant lymphoma complicated with renal damage.
Examine
Examination of renal damage caused by lymphoma
Urine routine abnormalities can be seen in proteinuria, hematuria, oliguria and elevated serum creatinine and other symptoms of renal insufficiency, urine protein > 3.5g / 24h, plasma albumin <30g / L.
Bone marrow biopsy
Most of them have no specific findings, and it is possible to find RS cells in bone marrow biopsy in advanced cases.
2. Lymph node biopsy
First, you should choose the appropriate lymph node for biopsy. It is best to choose the enlarged lymph nodes on the clavicle or on the pulley, and try to avoid the inguinal, deep and deep cervical lymph nodes. You should cut one or the best several intact lymph nodes. When cutting, pay attention to avoiding damage such as squeezing and pulling; this kind of injury can cause difficulty in histological diagnosis. The capsule on the surface of the lymph node should be intact. After the lymph node is cut, the longitudinal surface of the lymph node is cut from the outer circumference with a sharp blade. Open, make a few prints on a clean glass slide; then place the lymph nodes in the fixative immediately. The pathology of lymphoid tissue can be divided into HD and NHL according to its pathological features.
(1) Hodgkin's disease: its lymph node tissue pathology can be divided into 4 types:
1 lymphocyte-based.
2 nodular hardening type.
3 mixed cell types.
4 lymphopenia type.
Among the various types, nodular sclerosis type and mixed cell type are the most common, and each type can be mutually changed, and only the nodular sclerosis type is relatively fixed.
(2) Non-Hodgkin's lymphoma: The international classification in 1982 is as follows:
1 low malignancy: including small lymphocyte type, follicular small split cell-based and follicular small split and large cell mixed type.
2 Moderate malignancy: including follicular large cell type, diffuse small cell type, diffuse large, small cell mixed type and diffuse large cell type.
3 Highly malignant: including immunoblast type, lymphoblastic type (tortuous nucleus or non-bending nucleus) and small non-cracked cell type (Burkitt or non-Burkitt lymphoma).
4 miscellaneous (low to high malignant): including hair cell type, skin T cell type, tissue cell type, extramedullary plasmacytoma, not typed and others.
3. Renal pathology examination
The weight of the diseased kidney increased, the multiple nodules were seen by the naked eye, and a few appearances were normal. The tumor cells under the kidney biopsy showed diffuse infiltration in the renal interstitium, causing renal parenchymal degeneration, necrosis and atrophy. Hodgkin's disease complicated with glomerular disease. There are many pathological types of small lesions, but there are reports of focal nephritis, membranous nephropathy, membrane proliferative nephritis and anti-renal antibody nephritis. Hodgkin's disease patients may have amyloid deposits in the kidney.
Immunofluorescence showed granules or massive deposits of IgG and C3 on the glomerular capillary wall in some cases of glomerular disease.
Under the electron microscope, the foot process fusion can be seen in the small lesion nephropathy.
4. B-ultrasound, intravenous pyelography, CT or magnetic resonance imaging showed double kidney enlargement or deformation.
Diagnosis
Diagnosis and diagnosis of renal damage caused by lymphoma
Diagnostic criteria
The diagnosis of lymphoma mainly depends on lymph node biopsy needle smear, lymph node print and pathological section, and the characteristics of nephrotic syndrome in lymphoma:
1. Nephrotic syndrome occurs mostly in the course of lymphoma, but can also occur before lymphoma or months to years after lymphoma.
2. Nephrotic syndrome can be aggravated or alleviated as lymphoma worsens or resolves.
In order to improve the diagnosis rate of lymphoma and renal infiltration, patients with lymphoma should be closely observed, and the following abnormalities may be considered for renal infiltration:
(1) B-ultrasound, intravenous pyelography, CT or magnetic resonance imaging showed enlargement or deformation of the kidneys.
(2) Abnormal urine (proteinuria or hematuria).
(3) Hypertension or renal insufficiency that cannot be explained by other reasons.
Differential diagnosis
Renal damage caused by lymphoma should be differentiated from other lymphoproliferative malignant lesions, leukemia and other chronic inflammatory diseases with lymphadenopathy, connective tissue disease and kidney damage caused by solid tumors.
