Correspondence

Case 4-2002: Cancer-Associated Obstruction and Glomerular Damage

N Engl J Med 2002; 346:1751-1752May 30, 2002

Article

To the Editor:

Case 4-2002 (Jan. 31 issue) described a 75-year-old man with acute renal failure five months after cystoprostatectomy and urethrectomy for carcinoma.1 Recently, we cared for a 52-year-old woman who had acute renal failure after surgery for an obstructing transitional-cell carcinoma of the bladder. The follow-up serum creatinine concentration was 1.5 mg per deciliter. Two months after surgery, she presented with acute oliguric renal failure. No obstruction was present, and hemodialysis was initiated. Findings on a biopsy of the kidney were consistent with the presence of anti–glomerular basement membrane antibody disease: light microscopy revealed an acute necrotizing, crescentic glomerulonephritis, and immunofluorescence was strongly positive for linear deposition of IgG in the glomerular basement membrane. Hemoptysis later developed, and treatment with plasmapheresis, corticosteroids, and cyclophosphamide was begun. The titer of anti–glomerular basement membrane was 191 U per milliliter before therapy, as assessed by enzyme-linked immunosorbent assay. Hemoptysis resolved, but there was no recovery of renal function.

These case reports suggest that obstructions associated with cancer may result in glomerular damage, triggering anti–glomerular basement membrane disease. Of interest in this regard are three reports of patients in whom anti–glomerular basement membrane disease developed after lithotripsy.2-4

Alfredo Blas, III, M.D.
Rita McGill, M.D.
Stephen Sandroni, M.D.
Allegheny General Hospital, Pittsburgh, PA 15212
sandroni@pol.net

4 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 4-2002). N Engl J Med 2002;346:353-360
   Full Text | Web of Science | Medline

2. 2

   Guerin V, Rabian C, Noel LH, et al. Anti-glomerular-basement-membrane disease after lithotripsy. Lancet 1990;335:856-857
   CrossRef | Web of Science | Medline

3. 3

   Umekawa T, Kohri K, Iguchi M, Yoshioka K, Kurita T. Glomerular-basement-membrane antibody disease and extracorporeal shock wave lithotripsy. Lancet 1993;341:556-556
   CrossRef | Web of Science | Medline

4. 4

   Xenocostas A, Jothy S, Collins B, Loertscher R, Levy M. Anti-glomerular basement membrane glomerulonephritis after extracorporeal shock wave lithotripsy. Am J Kidney Dis 1999;33:128-132
   CrossRef | Web of Science | Medline