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Paraneoplastic Minimal Change Disease Signaling Post-Transplant AML Relapse: Two Cases and a Literature Review
Kainat Saleem1, Sanjana Kamat2, Nigar A Khurram3
1Division of Malignant Hematology and Medical Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA.
Abstract:
Membranous nephropathy (MN) and minimal change disease (MCD) are the most common causes of nephrotic syndrome following hematopoietic stem cell transplantation (HSCT), a complication conventionally attributed to chronic graft-versus-host disease (GVHD). Paraneoplastic MCD is well described in lymphoid malignancies but is rarely reported in myeloid neoplasms. We report two cases of biopsy-confirmed MCD presenting as the initial manifestation of acute myeloid leukemia (AML) relapse following allogeneic HSCT. Both patients were White men in their sixties with relapsed/refractory AML who developed nephrotic-range proteinuria and acute kidney injury after matched unrelated donor HSCT without histologic evidence of GVHD. Renal biopsies confirmed MCD in both cases. Corticosteroid therapy was ineffective in halting renal deterioration; renal function improved only after initiation of leukemia-directed therapy, with one patient achieving dialysis independence. These cases highlight a rare paraneoplastic presentation of AML relapse. Nephrotic syndrome due to MCD may signal post-HSCT leukemia recurrence, and evaluation for AML relapse warrants consideration in steroid-refractory cases or those without concurrent GVHD. In such cases, control of the underlying malignancy, rather than escalation of immunosuppression, may be central to renal recovery.
Insights
Minimal change disease (MCD) can signal acute myeloid leukemia (AML) relapse after hematopoietic stem cell transplantation (HSCT). Kidney function improved with leukemia treatment, not immunosuppression, in these rare paraneoplastic cases.
Area of Science:
- Nephrology
- Hematology
- Oncology
Background:
- Minimal change disease (MCD) and membranous nephropathy (MN) are common causes of nephrotic syndrome post-hematopoietic stem cell transplantation (HSCT).
- Graft-versus-host disease (GVHD) is the typical cause of these renal complications.
- Paraneoplastic MCD is known in lymphoid malignancies but rare in myeloid neoplasms.
Purpose of the Study:
- To report rare cases of biopsy-confirmed MCD as the initial presentation of acute myeloid leukemia (AML) relapse post-allogeneic HSCT.
- To highlight the significance of MCD in signaling potential leukemia recurrence in HSCT patients.
Main Methods:
- Case report of two patients with relapsed/refractory AML undergoing allogeneic HSCT.
- Analysis of clinical presentation, renal biopsy findings (confirming MCD), treatment response, and outcomes.
- Evaluation of the role of leukemia-directed therapy versus immunosuppression for renal recovery.
Main Results:
- Both patients presented with nephrotic-range proteinuria and acute kidney injury post-HSCT without GVHD.
- Renal biopsies confirmed MCD.
- Corticosteroid therapy was ineffective; renal function improved only after initiating AML-directed therapy.
- One patient achieved dialysis independence.
Conclusions:
- MCD can be a rare paraneoplastic manifestation of AML relapse post-HSCT.
- Nephrotic syndrome due to MCD may indicate leukemia recurrence, especially in steroid-refractory cases or those without GVHD.
- Controlling the underlying AML is crucial for renal recovery in such scenarios, rather than increasing immunosuppression.