Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
Wichita Nephrology Group PA, Wichita, KS.
Am J Kidney Dis. 2019 Oct;74(4):558-562. doi: 10.1053/j.ajkd.2019.02.010. Epub 2019 Apr 2.
Acute kidney injury is common in patients with cancer and may result from sepsis, obstruction, radiotherapy, chemotherapeutic agents, and nonsteroidal anti-inflammatory drugs. Rare reports of acute kidney injury due to cast nephropathy in patients with pancreatic acinar cell carcinoma have been described, but a pathogenetic link between cast nephropathy and carcinoma was not established. We report a patient with pancreatic mixed acinar-neuroendocrine carcinoma who developed severe acute kidney injury. Kidney biopsy showed cast nephropathy characterized by fractured periodic acid-Schiff-negative casts, associated with mononuclear and giant cell reaction. The patient did not have multiple myeloma and casts did not show immunoglobulin light chain restriction on immunofluorescence. Analysis using liquid chromatography-tandem mass spectrometry and immunohistochemistry identified 2 acinar cell-specific proteins, regenerating islet-derived 1α and carboxypeptidase A1, in both tubular casts and tumor cells. Thus, this case demonstrates that solid tumor-specific proteins can be nephropathic by obstructing renal tubules, resulting in acute kidney injury, a previously proposed but not characterized pathophysiologic mechanism for paraneoplastic nephropathy associated with carcinoma.
急性肾损伤在癌症患者中很常见，可能由脓毒症、梗阻、放射治疗、化疗药物和非甾体抗炎药引起。有罕见报道称胰腺腺泡细胞癌患者的肾病性 casts 病可导致急性肾损伤，但 casts 病与癌之间的发病机制联系尚未确定。我们报告了一例患有胰腺混合腺泡-神经内分泌癌的患者，其发生严重的急性肾损伤。肾活检显示特征为周期性酸-Schiff 染色阴性 casts 断裂的 casts 病，伴有单核细胞和巨细胞反应。患者没有多发性骨髓瘤，并且 casts 在免疫荧光检查中没有显示免疫球蛋白轻链受限。使用液相色谱-串联质谱和免疫组化分析在管状 casts 和肿瘤细胞中均鉴定出 2 种腺泡细胞特异性蛋白，即胰岛衍生 1α和羧肽酶 A1。因此，本例表明，通过阻塞肾小管导致急性肾损伤的实体瘤特异性蛋白可能具有肾毒性，这是一种先前提出但尚未确定的与癌相关的副肿瘤性肾病的病理生理机制。
