Profitable remedy of non-Hodgkin’s lymphoma with rituximab and dose-adjusted CHOP remedy in a affected person with concomitant end-stage renal illness requiring haemodialysis
NDT Plus. 2011 Jun; 4(3): 186–189.
Though malignancy is a deadly complication of end-stage renal illness (ESRD) requiring haemodialysis, profitable remedy of haematological malignancies has been hardly ever reported. We describe the case of a 64-year-old man who introduced with non-Hodgkin’s lymphoma (NHL; scientific stage, IVB) concomitant with ESRD. Earlier than chemotherapy, haemodialysis was initiated, and one course of dose-adjusted CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) remedy adopted by eight programs of rituximab remedy had been administered in response to the efficiency standing and diploma of organ dysfunction. Consequently, the affected person was illness free for 27 months. Thus, rituximab plus CHOP mixture remedy was efficient for NHL concomitant with ESRD.
Key phrases: end-stage renal illness, haemodialysis, non-Hodgkin’s lymphoma, rituximab and dose-adjusted CHOP remedy
Coronary heart failure, an infection, malignancy and cerebrovascular illness have been reported to be life-threatening and deadly issues in sufferers with end-stage renal illness (ESRD) who’re present process haemodialysis . Though most malignant tumours originate from the gastrointestinal tract (abdomen and colon), kidneys, lungs and thyroid, haematological malignancies reminiscent of lymphomas have been hardly ever reported . Just a few earlier research have reported that in sufferers present process haemodialysis, non-Hodgkin’s lymphoma (NHL) was efficiently handled with rituximab mixture remedy [2–4].
The present first-line remedy really helpful for NHL is rituximab plus CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) . Rituximab is a chimeric human/mouse anti-CD20 monoclonal antibody that’s efficient in sufferers with CD20+ B-cell lymphoma .
Right here, we report the case of a affected person with NHL and ESRD who was efficiently handled with a mixture remedy of rituximab and CHOP; haemodialysis was initiated at analysis and maintained thereafter.
A 64-year-old man presenting with a painful tumour of the best orbita was referred to a regional hospital on 22 February 2007. He had been recognized with diabetes mellitus when he was 50 years previous, and coronary artery bypass graft surgical procedure for 3-vessel coronary illness had been carried out on 20 October 2006. On admission, the affected person was normotensive (blood stress, 146/62 mmHg; coronary heart fee, 72 beats/min). Bodily examination revealed tumours of the best orbita, left cervical lymph nodes and proper inguinal lymph nodes. The laboratory findings are summarized in .
|Protein||+++||PT (s)||111.4 s||CRP||1.62 mg/dL|
|Sugar||+||APTT (s)||34.3 s||HTLV-I||destructive|
|Occult Blood||+||Fib||367.5 mg/dL||sIL-2R||61200 IU/I|
|pH||5.5||FDP||3.6 mg/dL||HbA1C||8.4 %|
|Peripheral cell rely||Serum Chemistry T.Bil||0.23 mg/dL|
|WBC||12.3 ×103/μL||AST||18 IU/L|
|SEG||74.5 %||LDH||996 IU/L|
|LYMPH||9.0 %||γ -GTP||17 IU/L|
|MONO||13.0 %||Na||138 mEq /dL|
|EOSIN||1.0 %||Glu||201 mg/dL|
|BASO||0.0 %||Ok||4.87 mEq /dL|
|Abnormally||0.0 %||Cl||106 mEq /dL|
|RBC||264 ×104/μL||Ca||7.9 mg/dL|
|Hb||7.4 g/dL||BUN||66.8 mg/dL|
|Hct||23.4 %||Cr||7.4 mg/dL|
|MCV||90.0 fL||UA||9.9 mg/dL|
|MCH||28.5 pg||Ferritin||690 ng/mL|
|PLT||13.6 ×104/μL||TP||6.3 g/dL|
|Ret||1.2 %||ALB||4.3 g/dL|
A fluorodeoxyglucose-positron emission tomography/computed tomography scan confirmed extranodal lesions in the best orbita, lung and testis in addition to the cervical, thoracic, stomach and inguinal lymph nodes (). Histological evaluation of lymph node specimens confirmed diffuse growth and infiltration of irregular lymphoid cells (). Stream cytometric and immunohistochemical evaluation of the lymph node specimens revealed that the floor marker was constructive for CD19, CD20, CD25, MUM1, bcl2 and λ chain (). On the premise of all these findings, we lastly recognized NHL [diffuse large B-cell lymphoma; clinical stage (CS) IVB]. The affected person was categorised as a high-risk affected person in response to the worldwide prognostic index (IPI) for NHL  due to the next findings: age > 60 years, CS > III, efficiency standing > 2, variety of extranodal lesions > 2 and lactate dehydrogenase ranges > regular.
Previous to chemotherapy, haemodialysis was initiated due to ESRD. Subsequently, we administered an adjusted dose of CHOP (25 mg/m2 doxorubicin on Day 1, 1.4 mg/m2 vincristine on Day 1, 375 mg/m2 cyclophosphamide on Day 1 and 60 mg/m2 prednisolone for five days) to regulate the exercise of NHL (). After present process one course of CHOP with haemodialysis, the affected person attained full response (CR) with decision of systemic lymphadenopathy and extranodal lesions. A psoas haematoma developed throughout chemotherapy. When the psoas haematoma occurred, as a result of administration of warfarin towards atrial fibrillation, we modified the anticoagulant agent from warfarin to heparin throughout haemodialysis with out development of psoas haematoma. Purple blood cell focus (RCC) transfusions have been crucial when first chemotherapy of CHOP remedy was carried out due to the mixture of chemotherapy and haemodialysis that may trigger blood spoiling at each session.
Though the affected person was at excessive threat for survival in response to IPI, we chosen rituximab chemotherapy as a result of the affected person confirmed slight enchancment in efficiency standing from 3 to 2 regardless of remedy and rehabilitation.
Subsequently, the affected person was administered 375 mg/m2 rituximab each week as a result of rituximab just isn’t eradicated by haemodialysis . Rituximab was administered at a dose of 375 mg/m2 with sodium chloride with none overhydratation issues. After the administration of chemotherapy, the affected person was nonetheless capable of urinate with haemodialysis.
When the exercise of NHL was below management, we established a blood entry web site for everlasting haemodialysis. As well as, we administered 4 programs of rituximab each month. Nevertheless a significant concern with rituximab is the danger of extreme bacterial, fungal an infection and the event of progressive multifocal leukoencephalopathy, there have been no main adversarial occasions besides psoas haematoma in our case. RCC transfusions haven’t been crucial when solely rituximab remedy was administered. A monitoring of the B cells within the peripheral blood was not carried out throughout chemotherapy.
The affected person maintained CR and didn’t require additional remedy for NHL through the 27 months.
In line with a report of the Japanese Society for Dialysis Remedy, the deadly issues in ESRD sufferers present process haemodialysis are coronary heart failure, an infection and malignancy, accounting for 23.9, 20.8 and 9.4% deaths, respectively, among the many 25 224 dialysis sufferers who died in 2009 . Though most malignant tumours originate from the gastrointestinal tract (abdomen and colon), kidneys, lungs and thyroid, haematological malignancies reminiscent of lymphomas have hardly ever been reported . Maisonneuve et al.  reported that the incidence of NHL in sufferers present process dialysis was 0.5–2 instances greater than that in wholesome folks. Though the incidence of malignancy tends to be excessive in sufferers present process haemodialysis, it isn’t clear whether or not haemodialysis itself will increase the incidence of malignancy [1, 7, 8].
Rituximab plus CHOP mixture remedy has been established because the first-line remedy for NHL . To this point, ESRD sufferers present process haemodialysis haven’t been efficiently handled for NHL due to the insufficiency within the drug dose brought on by renal insufficiency and due to the danger of an infection below immunocompetent situations. The suitable dosage and course of therapeutic brokers for NHL concomitant with ESRD requiring haemodialysis haven’t but been established. Just a few earlier research have reported that NHL concomitant with ESRD requiring haemodialysis was efficiently handled with chemotherapy (). Therapy with a fractionated dose of rituximab or dose-adjusted CHOP remedy reminiscent of half-dose cyclophosphamide and doxorubicin was discovered to be efficient [2–4]. In our case, we modified the dose of CHOP and administered a half dose of cyclophosphamide and doxorubicin and a full dose of vincristine and prednisolone with out rituximab as a result of the efficiency standing of our affected person was 3 and the danger of tumour lysis syndrome was excessive. Throughout chemotherapy, psoas haematoma was the one complication noticed in our affected person due to the administration with warfarin. Jillella et al.  reported that rituximab was not eradicated by way of haemodialysis. Our affected person was administered 4 programs of rituximab weekly and month-to-month to realize a superb final result. Nevertheless a significant concern with rituximab is the danger of extreme bacterial, fungal an infection and the event of progressive multifocal leukoencephalopathy, there have been no main adversarial occasions besides psoas haematoma in our case.
|Reference (yr)||Age||Intercourse||Prognosis||Scientific stage||Therapy||Power renal failure on dialysis||Facet impact||Response|
|Jillella et al. (2002)||54||Male||Follicular lymphoma (Grade 1)||III||Rituximab 375 mg/m2, 4 course||Haemodialysis (3 instances per week)||Tumour lysis syndrome||CR|
|Feldmann et al. (2007)||70||Male||Diffuse massive B-cell lymphoma||III||Rituximab (375 mg/m2) +CHOP 6 course (first course/second course: CPA, ADR, 50% dose) (3 course full dose)||Haemodialysis (3 instances per week)||Hyperglycaemia||PR|
|Niscola et al. (2009)||70||Feminine||Splenic marginal zone lymphoma||IV||Rituximab 375 mg/m2, 6 course. Chlormbucil (6 mg/m2, Days 1–10). 6 course||Haemodialysis (n.d.)||–||CR|
|Current case||66||Male||Diffuse massive B-cell lymphoma||IVB||CHOP 1course, rituximab 375 mg/m2, 8 course||Haemodialysis (3 instances per week)||Psoas haematoma||CR, alive|
To the perfect of our data, that is the primary report of a affected person who acquired rituximab plus dose-adjusted CHOP remedy for NHL concomitant with ESRD requiring haemodialysis, whereby haemodialysis was initiated at preliminary analysis. Our findings present that adjusting the dose of the drug and modifying remedy in response to the efficiency standing, diploma of organ dysfunction and prognosis is protected, environment friendly and possible.
In conclusion, the findings in our case prompt that rituximab plus dose-adjusted CHOP together with haemodialysis is efficient for treating NHL concomitant with ESRD. A randomized potential examine on sufferers present process haemodialysis is required to additional perceive the incidence, histology, indications for remedy, therapeutic technique and dosage and programs of chemotherapy for NHL in ESRD sufferers present process haemodialysis.
Battle of curiosity assertion. None declared.