QW15-12-2024 – Nephro Critical Care Society

QW15-December 2024

Question 1: Select each option to validate with explanations

“A 22-year-old male with Burkitt lymphoma arrives at oncology day care with acute abdominal pain, nausea, vomiting, and confusion shortly after starting R-CODOX-M (rituximab, cyclophosphamide, vincristine, doxorubicin, and methotrexate). His vitals are BP 90/67 mmHg, HR 121/min, SpO2 95% on room air, and respiratory rate 25/min. Venous blood gas analysis shows: pH 7.23, PCO2 26 mmoL/L, HCO3 17 mmoL/L, Lactate 2.24 mmoL/L.
Laboratory tests reveal the following:

Question: Despite initial aggressive intravenous fluid resuscitation and treatment with rasburicase, the patient's urine output has dropped significantly, and he is now anuric. Which of the following is the most likely complication this patient is experiencing?

A. Hyperphosphatemia-induced AKI

B. Obstructive uropathy

C. Uric acid nephropathy

D. Sepsis-induced AKI

Wrong Answer:A. Hyperphosphatemia-induced AKI

Wrong Answer:B. Obstructive uropathy

Right Answer: C. Uric acid nephropathy

Explanation:
In this scenario, the patient is likely experiencing uric acid nephropathy (Option C), which is a common complication of Tumour Lysis Syndrome (TLS) in patients with rapidly proliferating tumors such as Burkitt lymphoma. Despite treatment with rasburicase (which helps to reduce uric acid levels), the high serum uric acid indicates that uric acid crystals have precipitated in the renal tubules, leading to obstructive nephropathy and subsequent acute kidney injury.
Hyperphosphatemia (Option A) can contribute to kidney injury, but given the high level of uric acid and the patient's anuric state, uric acid nephropathy is more likely.
Enlarged lymph nodes in Burkitt’s lymphoma can compress the urinary tract, causing obstructive uropathy ((Option B) and reduced urine output, though anuria is unlikely. This should be considered if tumor lysis is ruled out. An ultrasound of the urinary tract is essential to confirm this.
Sepsis (option D) is a frequent complication in patients with high-grade hematological malignancies like Burkitt's lymphoma, potentially resulting in multi-organ dysfunction, including acute kidney injury. However, the clinical indicators provided (high WBC, low platelets, and high lactate) are insufficient to confirm sepsis. Biomarkers (Such as S-reactive protein and procalcitonin), imaging (such as chest X-rays, CT scans, or ultrasounds to identify infection sources like pneumonia or abscesses), and body fluid cultures are necessary to rule out sepsis.

Wrong Answer: D. Sepsis-induced AKI

Reference:

1. Kasparian, S., Burns, E., Shehabeldin, A. et al. Recurrent small bowel obstruction caused by Burkitt lymphoma in an elderly man: a case report and review of the literature . J Med Case Reports 14, 127 (2020). https://doi.org/10.1186/s13256-020-02449-y
2. Nally Jr JV. Uric acid nephropathy: Management pearls. Cleveland Clinic journal of medicine. 1990 Sep;57(6):505-7.
3. Barichello, T., Generoso, J.S., Singer, M. et al. Biomarkers for sepsis: more than just fever and leukocytosis—a narrative review. Crit Care 26, 14 (2022). https://doi.org/10.1186/s13054-021-03862-5
4. Canet E, Zafrani L, Lambert J, Thieblemont C, Galicier L, Schnell D, Raffoux E, Lengline E, Chevret S, Darmon M, Azoulay E. Acute kidney injury in patients with newly diagnosed high-grade hematological malignancies: impact on remission and survival. PloS one. 2013 Feb 14;8(2):e55870