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Case 6
Presented by: V. Nickeleit and M. Latour
Clinical History
The patient is a 71 year-old woman with a history of smoking and “chronic pulmonary disease”. Aged 62 at an outside institution she underwent a left nephrectomy for a renal cell carcinoma (clear cell type) and subsequently presented at age 68 with “advanced” abdominal metastases (jejunum, mesentery, one mesenteric lymph node). Surgical intervention resulted in incomplete tumor resection. No additional therapeutic intervention was tried (i.e. no chemotherapy and no radiation) until at age 69 when treatment with “Sunitinib” (Sutent/SU11248), a tyrosine kinase inhibitor with receptor inhibition of VEGFR and PDGFR was initiated. At this time renal function tests of the right kidney were within normal limits and the patient’s blood pressure was well controlled. The treatment was given in cycles, each cycle consisting of 28 days followed by 15 days without medication. Altogether 10 cycles were administered that resulted in complete tumor regression the next year. However, under Sunitinib therapy, in particular during the 28 days of the treatment cycles with Sunitinib administration, the patient rapidly developed severe hypertension requiring additional antihypertensive therapy with multiple drugs (Hydralazine, Clonidine, Spironolactone, Metropolol and Toxazosin). The same year she presented with new onset severe nephrotic syndrome including anasarca and pleural effusions. Proteinuria (3.4gm/24 hours) was associated with mild renal dysfunction, i.e. an increase in serum creatinine up to 1.5mg/dl. The urine sediment was bland and all serologic work-ups including ANA and ANCA tests were within normal limits. There was no evidence of an infection. A diagnostic renal biopsy was performed in order to determine the cause of the proteinuria.
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GLOMERULOPATHY WITH CAPILLARY INJURY, ENDOTHELIOSIS, AND SEGMENTAL SCLEROSIS
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28.12.2007 |
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