Gross Hematuria Leading to a Diagnosis of Chronic Lymphocytic Leukemia

Introduction: Renal involvement is common in chronic lymphocytic lymphoma (CLL) but is under-diagnosed and usually involves renal infiltration or urinary tract obstruction. Glomerular injuries are uncommon in CLL, but when they occur, patients’ usually present with nephrotic syndrome. We report a newly diagnosed CLL patient, presenting with AKI, hematuria and anti-GBM-like disease. Case Description: A 74-year-old female presented with one month of gross hematuria and an AKI. She did not have any rash, arthralgia, weight loss or fever, no new medications or NSAID use. Medical history included well balanced hypertension. Physical exam was unremarkable. Urinary sediment showed numerous dysmorphic RBC’s and several RBC casts (figure 1). Creatinine was 2.0 mg/dL (baseline values 0.8 mg/dL two years prior). Work-up demonstrated a urinary albumin-creatinine ratio of 68 mg/g and a urinary protein-creatinine ratio of 530 mg/g, a positive anti-nuclear antibody test (ANA) and Anti RNP, normal C3 and C4 levels and negative cryoglobulin, anti-GBM and ANCA antibodies. Work up was also positive for serum IgM kappa paraprotein. Serum free light chain values were with a kappa of 79.2, lambda of 57.1, leading to a ratio of 1.39. Renal ultrasound demonstrated several septated cysts and was otherwise unremarkable. Non-contrast CT scan demonstrated splenomegaly of 15 cm and bilateral inguinal lymphadenopathy up to 1.5 cm. A kidney biopsy demonstrated a single fibrotic crescent with no other significant signs of proliferation. A lymphocytic infiltration was also demonstrated in the sample. Immunofluorescence was positive for IgG and IgM in a linear pattern (figure 1). Bone marrow and inguinal lymph node biopsies demonstrated findings consistent with CLL. Discussion: Our patient presented with an AKI, hematuria, dysmorphic RBCs and red cell casts and seemingly non-glomerular proteinuria, but diagnosed with a rare glomerular injury, suspected to be due to CLL. To our knowledge this is the first description of CLL presenting with anti-GBM-like disease.