Dear Editor,
Renal involvement in non-Hodgkin lymphoma is frequently encountered in advanced disease; however, clinically overt renal dysfunction resulting from lymphomatous renal infiltration remains relatively uncommon, although several cases and case series have been reported in the literature, and thus may be underrecognized in routine clinical practice [1]. This diagnostic uncertainty may lead to delays in appropriate treatment. Herein, we report a case of high-grade B-cell lymphoma presenting with acute kidney injury (AKI) secondary to bilateral renal involvement, with complete reversibility following systemic chemotherapy.
A 71-year-old female presented with abdominal pain, weight loss, and night sweats. Initial laboratory evaluation revealed elevated serum creatinine levels consistent with AKI. FDG PET/CT imaging demonstrated intense bilateral renal hypermetabolism, along with paraaortic lymphadenopathy and diffuse bone marrow involvement as depicted in Fig. 1 (A-D). Bone marrow biopsy confirmed high-grade B-cell lymphoma, showing hypercellularity with marked lymphoid infiltration (~ 70%).
Fig. 1.
A patient with a high grade B cell lymphoma underwent FDG PET/CT for staging and response assessment. (A) Pre-treatment maximum intensity projection (MIP) FDG PET image demonstrates intense FDG uptake in both kidneys (red arrows) and diffuse bone marrow involvement (white arrow). (B) Axial fused FDG PET/CT image confirms bilateral renal hypermetabolism. (C) Axial fused image shows hypermetabolic paraaortic lymphadenopathies (blue arrow) and diffuse bone marrow uptake, more pronounced at the T11 vertebral level. (E–G) Post-treatment axial fused FDG PET/CT images and (H) post-treatment FDG PET MIP image demonstrates complete metabolic response with resolution of previously observed renal, nodal, and bone marrow FDG uptake, with residual activity in the urinary system representing physiological urinary excretion of FDG
The patient was initially treated with DA-EPOCH; however, due to poor tolerance, the regimen was subsequently modified and continued with R-CHOP. Notably, renal function improved rapidly after treatment initiation, with a significant decline in serum creatinine levels. Follow-up FDG PET/CT demonstrated a complete metabolic response, including the resolution of bilateral renal uptake, as depicted in Fig. 1 (E-H). Treatment response was assessed according to the Deauville 5-point scale. Following R-CHOP therapy, the previously observed diffuse bilateral renal cortical uptake markedly decreased and completely resolved, together with the nodal and bone marrow involvement. Small residual foci of renal FDG activity corresponded to physiologic urinary tracer excretion within the collecting systems and were not considered evidence of persistent lymphomatous infiltration. Therefore, the overall findings were consistent with a complete metabolic response (Deauville score 1). This parallel improvement in imaging and renal function strongly supports lymphomatous renal infiltration as the underlying mechanism of AKI.
Recent literature highlights that renal involvement in lymphoma is frequently misdiagnosed, particularly in the absence of discrete renal masses, and may mimic interstitial nephritis or other common causes of AKI [2, 3]. Bilateral renal infiltration presenting with AKI is rare but increasingly recognized with the expanded use of FDG PET/CT, which provides superior sensitivity in detecting extranodal disease [4, 5]. Importantly, contemporary reports emphasize that renal dysfunction secondary to lymphomatous infiltration is potentially reversible with prompt initiation of systemic therapy, underscoring the need for early recognition [2, 4, 6].
In conclusion, lymphoma-associated renal infiltration should be considered in the differential diagnosis of unexplained AKI, especially in the presence of systemic symptoms or suggestive imaging findings. Early diagnosis is critical, as timely initiation of chemotherapy may result in complete reversal of renal dysfunction and improved clinical outcomes.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
Declarations
Conflict of interest
The author declares that there is no conflict of interest.
Ethical approval
Ethical approval was not required for this case report in accordance with institutional policies.
Informed consent
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
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References
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