Renal dysfunction is uncommon in patients with leukemic infiltration of the kidney due to Chronic Lymphocytic Leukanemia (CLL). Granulomatous interstitial nephritis (GIN) is also rare, but a characteristic hallmark of certain diseases such as sarcoidosis and tuberculosis. GIN has been associated with medications, infections, inflammation, Wegener's granulomatosis, and jejuno-ileal bypass. GIN combined with leukemic infiltration by CLL is very uncommon. We present a 72-year-old male with Binet stage A CLL who developed progressive renal failure over a period of four years requiring maintenance dialysis. During the course of his illness, he underwent renal biopsies at different time intervals, revealing varying degrees of involvement by GIN together with leukemic infiltration.

Context:This named patient program evaluated the safety and efficacy of ibrutinib, a selective inhibitor of Bruton's tyrosine kinase in Indian patients with relapsed/refractory chronic lymphocytic leukemia (CLL, with/without chromosome 17 deletion [del17p]) and mantle cell lymphoma (MCL).Subjects and Methods:The eight enrolled patients (relapsed/refractory CLL: n = 6 [4/6 patients with del17p] and relapsed/refractory MCL: n = 2) had median age of 55 years (range, 52–60) and had received a median of 3 (CLL patients) and 4 (MCL patients) prior therapies. Patients received once-daily dose of ibrutinib (420 mg: CLL, 560 mg: MCL).Results:In CLL patients, the median time to response was 3 months (range, 0.5–7) and five of six patients had partial response (PR) whereas one achieved complete response (CR). Median time on treatment was 11.5 months (range, 8–14); five patients continued treatment and one was recommended stem cell transplantation (SCT). Of the two MCL patients, one achieved PR and one showed CR and advanced to SCT. In CLL patients, the median (range) hemoglobin level improved from 9.8 g/dL (7.2–11) at baseline to 12.0 g/dL (9.5–13.2) and median (range) platelet count improved from 150,000 cells/μL (21,000–195,000) at baseline to 190,350 cells/μL (130,000–394,000) at the time of analysis (July 2016). Most adverse events (AEs) reported were infections (n = 2). No Grade 3-4 or serious AEs, dose reductions, or treatment discontinuation due to AEs were reported.Conclusions:In this first real-world experience in Indian patients, ibrutinib demonstrated therapeutic efficacy in relapsed/refractory CLL (with/without del17p) and MCL. Safety results were consistent with the current known profile of ibrutinib.

We describe a patient with non-Hodgkin's lymphoma who developed a lupus anticoagulant (LA) detectable by activated partial thromboplastin time (APTT), dilute Russell's viper venom time (DRVVT) and kaolin clotting time (KCT). IgM anticardiolipin antibodies (ACA) were elevated. At a later admission, and following treatment for the lymphoma, routine coagulation screening showed an elevated prothrombin time (PT) without correction in mixing tests using a recombinant thromboplastin. Routine APTT was below the reference range and ACA levels were normal. Raw data for one-stage factor assays demonstrated the presence of an inhibitor. Analysis for LA was undertaken by DRVVT, KCT, activated seven lupus anticoagulant assay, Taipan snake venom time, platelet neutralisation procedures (PNP), Ecarin time and PT using rabbit brain thromboplastin. The results revealed a LA capable of prolonging the clotting times of the PNPs and PT using recombinant thromboplastin, but that was corrected using Ecarin venom, modified PNP and brain thromboplastin. The antibody also demonstrated the lupus anticoagulant co-factor effect. The factor VIII: C was markedly raised which may have masked the LA in the APTT. The changing laboratory profile over time demonstrates the effects of LA heterogeneity and variations in sensitivity and specificity of assays for the detection of antiphospholipid antibodies.

Patients with multiple myeloma are at high risk of thrombosis. Treatment with Lenalidomide increases this risk with venous thrombo embolic events (very common, ≥ 1/10) and myocardial infarction and stroke being common (≥ 1/100 to < 1/10) adverse events. Lenalidomide treatment often continues until disease progression or intolerance. Anticoagulation with oral vitamin K antagonists such as warfarin is often challenging in this patient group due to erratic INRs, frequent need for blood tests and multiple interactions with myeloma therapy. Prolonged treatment with low molecular weight heparin results in injection site tenderness besides cutaneous bruising. There is no published data exploring role of newer anticoagulants as anti thrombotic agents in multiple myeloma on Lenalidomide therapy. Rivaroxaban, an oral anti Xa inhibitor, is a newer anticoagulant which does not require INR monitoring and is licensed for thromboprophylaxis in atrial fibrillation and treatment of deep vein thrombosis / pulmonary embolism. This is a retrospective non randomised observational study which looked at cohort of myeloma patients at high risk of thrombosis and included patients on Lenalidomide. Follow up duration varied from 3 to 12 months. The cohort consisted of 7 patients, age range 53 to 86 years; 3 males, 4 females; dosage range 10 mg to 20 mg (guided by indication and adjusted for renal function). Indication for anti thrombotic treatment included: Deep Vein Thrombosis (n = 1), recurrent DVT (3), recurrent Pulmonary Embolism (2) and Atrial fibrillation (2). One patient had both recurrent DVT & PE. Of 7 patients, 5 were on treatment with Lenalidomide. Rivaroxaban was intended to continue long term whilst thromboembolic risks persisted. Rivaroxaban was well tolerated with only a single episode of minor bleed (oral mucosal) which resolved spontaneously. No new thromboembolic events were reported on treatment. All patients were able to continue on anti myeloma therapy (see table 1). These data indicate that Rivaroxaban is an effective and well tolerated anti thrombotic agent in patients on Lenalidomide therapy and in multiple myeloma thus providing an option to prolonged treatment with subcutaneous low molecular weight heparin or oral vitamin K antagonists. Abstract 5095. TableNoAgeSexDiagnosisIndicationeGFR / Platelet countSignificant organ impairmentRivaroxaban DosagePlanned duration of treatmentBleeding Complications175MMyelomaDVT LenalidomideN/NNone20 mgUntil progression on LenalidomideNone265FMyelomaBil PEN / 51None10 mgLong termNone386MMyelomaAF Lenalidomide33 / NNone15 mgLong term (dose as per renal fn)Minor bleeding oral mucosal – single episode481FMyelomaRecurrent DVT35 / NSingle kidney Prev stroke15 mgLong term (dose as per renal fn)None553FMyelomaRec DVT /PE LenalidomideN / NNone20 mgLong termNone668MMyelomaRec DVT PS 3 to 4 For LenN / NEnd stage COPD20 mgLong term Review as per organ impairmentNone777FMyelomaSSS /A F/PPMLenalidomideN / NNone20 mgLong termNone Disclosures No relevant conflicts of interest to declare.

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