Acute renal failure secondary to severe type I cryoglobulinemia following rituximab therapy for Waldenström’s macroglobulinemia

Abstract

Waldenström's macroglobulinemia is rare lymphoproliferative disorder characterized by the presence of a monoclonal IgM paraproteinemia. Cryoglobulinemia is a common sequela of Waldenström's macroglobulinemia present in 8-18% of the patients. Cryoglobulinemia has also been described as occurring after treatment with rituximab. In the previous report, the cryoglobulinemia was a transient phenomenon and did not carry any adverse effect. We present a case of an 80-year-old male with Waldenström's macroglobulinemia in whom the rituximab-induced cryoglobulinemia resulted in acute renal failure and a vasculitic rash. Cryoglobulins level reached a peak of 63%. The patient was successfully treated with plasmapheresis, chlorambucil and prednisone, with near-complete recovery of renal function. As this case illustrates, the rituximab-induced cryoglobulin is not always benign. Pre- and post-treatment monitoring of the cryoglobulin level is advised in these patients.

A case of acute renal failure of multiple myeloma due to monoclonal type I cryoglobulinemia with thrombotic microangiopathy

“…As for ARF in type I CG, a few cases of both Waldenström's macroglobulinemia and angioimmunoblastic T cell lymphoma containing monoclonal IgM cryoglobulin have been documented [6,7]. Moreover, it is well known that monoclonal IgM in Waldenström's macroglobulinemia per se causes thrombosis, even if cryoglobulin is negative [8].…”

“…However, ARF in type I CG is a rare entity [6,7] and, furthermore, ARF with thrombotic microangiopathy (TMA) (excluding the druginduced type and anti-phospholipid antibody syndrome) has not yet been described.…”

Tubulointerstitial Nephritis Caused by Peritubular Capillaritis Accompanied by Cryoglobulinemia

“…Renal involvement is often seen, and MPGN, a typical renal lesion in HCV infection, is sometimes found in patients with cryoglobulinemic vasculitis (11). Although relatively rare, other glomerular lesions such as crescent formation, fibrinoid necrosis, and intraluminal thrombi could also be found (14)(15)(16). In addition, tubulointerstitial nephritis with cryoglobulinemia has also been reported (12).…”

Recovery of Kidney Function by Rituximab-based Therapy in a Patient with Waldenström's Macroglobulinemia-related Nephropathy Presenting Cast Nephropathy and Interstitial Lymphocytic Infiltration

“…Izzedine et al reported ischemic acute tubular necrosis caused by IgM 'flare' (15). In addition, although rituximab has been used as a treatment for cryoglobulinemia, one study reported elevation of cryoglobulinemia in a WM patient after rituximab therapy caused acute renal failure (16). The authors advised monitoring of pre-and posttreatment of the cryoglobulin level.…”