Lymphoma and the Kidney: A Kidney Biopsy Teaching Case.

Lymphomatous infiltration of kidney parenchyma is a frequent complication of systemic hematologic malignancies and often shows subtle clinical presentation. Diffuse large B-cell lymphoma represents the most frequent form involving the kidney, with advanced stage at diagnosis, poor outcome, and risk for central nervous system relapse if not adequately treated. Kidney biopsy can provide specific and early detection of these cases, helping in the differential diagnosis with more frequent entities. Finally, further hematologic workup (bone marrow biopsy, complete blood cell count, and positron emission tomography) can distinguish secondary involvement of the kidney from the rarer kidney-limited forms, especially in patients without a previous diagnosis of lymphoma. Making a prompt and correct diagnosis directs the management of these cases and may improve the outcome, as described in the present report.

Opportunities to improve outcomes in sickle cell disease.

Sickle cell disease represents a spectrum of inherited hemoglobin disorders. The pathophysiology involves abnormalities not just in red blood cells but also vascular endothelium, white blood cell function, coagulation, and inflammatory response. Known sequelae of sickle cell disease include invasive infections, painful episodes, acute chest syndrome, strokes, and chronic pulmonary hypertension. Preventive strategies that decrease the risk of infection are the routine use of daily antibiotics until five years of age, immunization of children with the 7-valent pneumococcal conjugate vaccine in addition to the 23-valent polysaccharide pneumococcal vaccine, annual influenza vaccination after six months of age, and meningococcal vaccination after two years of age. A significant advance in stroke prevention is the use of transcranial Doppler ultrasonography to identify asymptomatic, at-risk children who should be considered for chronic blood transfusions. Chronic transfusion therapy for primary or secondary stroke prevention requires careful surveillance for iron overload and chelation therapy. Patients with chest pain, fever, or respiratory symptoms and new pulmonary infiltrates require aggressive medical management for acute chest syndrome. Pain management still represents an important area for aggressive treatment using sickle cell disease-specific guidelines. Newer treatments include hydroxyurea therapy to decrease the frequency of painful episodes and associated comorbidities, and hematopoietic cell transplantation for a limited subset of patients. Family physicians play a crucial role in instituting evidence-based preventive care strategies, initiating timely treatment of acute illness, recognizing life-threatening episodes, and providing a medical home for multidisciplinary management.