Immune Checkpoint Inhibitors and Immune-Related Adverse Renal Events

Safety of Immune Checkpoint Inhibitor Resumption after Interruption for Immune-Related Adverse Events, a Narrative Review

Immune checkpoint inhibitors (ICIs) have become the standard of care for several types of cancer due to their superiority in terms of survival benefits in first- and second-line treatments compared to conventional therapies, and they present a better safety profile (lower absolute number of grade 1-5 adverse events), especially if used in monotherapy. However, the pattern of ICI-related adverse events is totally different, as they are characterized by the development of specific immune-related adverse events (irAEs) that are unique in terms of the organs involved, onset patterns, and severity. The decision to resume ICI treatment after its interruption due to irAEs is challenged by the need for tumor control versus the risk of occurrence of the same or different irAEs. Studies that specifically assess this point remain scarce, heterogenous and mostly based on small samples of patients or focused only on the recurrence rate of the same irAE after ICI resumption. Moreover, patients with grade ≥3 irAEs were excluded from many of these studies. Herein, we provide a narrative review on the field of safety of ICI resumption after interruption due to irAE(s).

Management of adverse events associated with cabozantinib plus nivolumab in renal cell carcinoma: A review

Tyrosine kinase inhibitors have been successfully developed in combination with immune checkpoint inhibitors to treat advanced renal cell carcinoma (RCC), further advancing treatment. While safety profiles are generally manageable with combination regimens, overlapping adverse events (AEs) and immune-related AEs can make treatment more complex. The CheckMate 9ER study evaluated the tyrosine kinase inhibitor cabozantinib in combination with the anti-programmed cell death protein-1 antibody nivolumab in patients with previously untreated advanced RCC. Cabozantinib + nivolumab demonstrated superiority over sunitinib for progression-free survival, overall survival, and objective response rate. These outcomes supported the approval of cabozantinib + nivolumab as a first-line therapy for advanced RCC. The safety profile was manageable with prophylaxis, supportive care, dose holds and reductions for cabozantinib, and dose holds and immunosuppressive therapy for nivolumab. This review discusses the safety results of CheckMate 9ER and provides guidance on managing some of the more clinically relevant AEs with a focus on overlapping AEs, including diarrhea, elevated amylase/lipase, hepatotoxicity, dermatologic reactions, fatigue, endocrine disorders, and nephrotoxicity. We discuss AE management strategies (prophylaxis, supportive care, dose modification, and immunosuppressive therapy), and provide recommendations for identifying the causative agent of overlapping AEs and for consulting specialists about organ-specific immune-related AEs. Optimizing AE management can maintain tolerability and should be a priority with cabozantinib + nivolumab treatment.

The Role of Kidney Biopsy in Immune Checkpoint Inhibitor-Associated AKI

AKI in the setting of immune checkpoint inhibitors.Need for kidney biopsy for diagnosis of immune checkpoint inhibitors.Importance of pathology in diagnosis of immune checkpoint inhibitor-induced AKI.

OUP accepted manuscript

Cancer is the second leading cause of death in people with chronic kidney disease (CKD) after cardiovascular disease. The incidence of CKD in patients with cancer is higher than in the non-cancer population. Across various populations, CKD is associated with an elevated risk of cancer incidence and cancer death compared with people without CKD, although the risks are cancer site-specific. Higher risk of cancer is detectable in mild CKD [estimated glomerular filtration rate (eGFR) 60-89 mL/min/1.73 m2], although this risk is more obvious if sensitive markers of kidney disease are used, such as cystatin C. Independent of eGFR, albuminuria is associated with increased risk of site-specific cancer incidence and death. Here, we explore the potential mechanisms for the increased risk of cancer observed in CKD, including patient factors (shared risks such as cardiometabolic disease, obesity, smoking, diet, lifestyle and environment), disease (genetic, inflammatory and infective) and treatment factors. In particular, we discuss the ways in which renal adverse events associated with conventional chemotherapies and newer systemic anti-cancer therapies (including targeted and immunotherapies) may contribute to worse cancer outcomes in people with CKD. Finally, we review the potential benefits of acknowledging increased risk of cancer in risk prediction tools used for the management of CKD.

Identifying Potential Diagnostic Genes for Diabetic Nephropathy Based on Hypoxia and Immune Status

Background

The prognosis of diabetic nephropathy is poor, and early diagnosis of diabetic nephropathy is challenging. Fortunately, searching for DN-specific markers based on machine algorithms can facilitate diagnosis.

Methods

xCell model and CIBERSORT algorithm were used to analyze the relationship between immune cells and DN, and WGCNA analysis was used to evaluate the regulatory relationship between hypoxia gene and DN-related immune cells. Lasso regression and ROC regression were used to detect the ability of core genes to diagnose DN, the PPI network of core genes with high diagnostic ability was constructed, and the interaction between core genes was discussed.

Results

There were 519 differentially expressed genes in renal tubules and 493 differentially expressed genes in glomeruli. Immune and hypoxia responses are involved in the regulation of renal glomerulus and renal tubules. We found that there are 16 hypoxia-related genes involved in the regulation of hypoxia response. Seventeen hypoxia-related genes in renal tubules are involved in regulating hypoxia response on the proteasome signal pathway. Lasso and ROC regression were used to screen anoxic core genes. Further, we found that TGFBR3, APOLD1, CPEB1, and KDR are important in diagnosing DN glomerulopathy, respectively, PSMB8, PSMB9, RHOA, VCAM1, and CDKN1B, which have high specificity for renal tubulopathy in DN.

Conclusion

Hypoxia and immune reactions are involved in the progression of DN. T cells are the central immune response cells. TGFBR3, APOLD1, CPEB1, and KDR have higher diagnostic accuracy in the diagnosis of DN. PSMB8, PSMB9, RHOA, VCAM1, and CDKN1B have higher diagnostic accuracy in DN diagnosis.

Kidney Injury in Patients Treated with Immune Checkpoint Inhibitors Does Not Meet KDIGO-AKI Criteria

Kidney injury in patients treated with immune checkpoint inhibitors develops gradually and often does not meet the Kidney Disease Improving Global Outcomes criteria for AKI.Proper classification of kidney injury could prevent the development of CKD and improve continued oncologic treatment.

Durable response after immunotherapy discontinuation for delayed and severe immune-related adverse events: a case report

Recent studies have shown that immune-related adverse events (irAEs), occurring even after the discontinuation of immune checkpoint inhibitors (ICIs), may be associated with favorable disease outcomes, particularly in patients with melanoma and lung cancer. However, a few clinical cases have been described on the correlation between irAEs and ICIs efficacy in renal cell carcinoma (RCC) patients. This study reports the clinical case of a metastatic RCC patient who has experienced severe immune-related renal toxicity after 19 months of nivolumab use. Despite immunotherapy discontinuation, the patient has maintained clinical benefit and disease progression-free for 3 years. We examined the correlation between the occurrence and the severity of irAEs, treatment discontinuation and clinical benefits. The evidence on ICI retreatment following ICI discontinuation due to irAEs was also reviewed.

Acute Diffuse Renal Tubulopathy in a Patient With Lung Cancer: A Case Report

Immune checkpoints inhibitors (ICPIs), as either a frontline or adjuvant therapy, showed favorable outcomes among diverse malignancies. Immune-related adverse events (IRAEs) are increasingly encountered, but the kidneys are rarely affected. A 67-year-old man with stage IV squamous cell carcinoma of the lung presented with acute kidney injury and hypercalcemia secondary to bone metastasis. After an aggressive saline infusion and subcutaneous denosumab 60mg administration, his renal function and serum calcium level were recovered on day 4. Due to his intolerance to chemotherapy, immunotherapy with a monoclonal antibody targeting programmed cell death protein-1 (PD-1), pembrolizumab 2mg/kg, was used on day 4. On day 11, polyuria, non-albumin dominant proteinuria, and severe deficiencies of electrolytes (potassium 2.5 mmol/L, calcium 5.5 mg/dL, magnesium 1.3 mg/dL, and phosphate 1.5 mg/dL) along with concomitant renal wasting were developed acutely. Except for postponing the next pembrolizumab, prednisolone at 1 mg/kg/day was given on day 13. On day 27, his polyuria subsided and urine protein loss resolved. Serum levels of potassium, phosphate, calcium, and magnesium all returned within the reference range. This case highlighted that renal IRAEs, even though uncommon, could be severe and potentially life-threatening if left unrecognized and untreated. Early recognition of renal IRAEs and prompt withdrawal of ICPIs may result in lower renal morbidity.

Is Rechallenge Appropriate in Patients that Develop Immune Checkpoint Inhibitor-Associated AKI?: PRO

This is an Early Access article. Please select the PDF button, above, to view it. Be sure to also read the CON: 10.34067/KID.0003902021 and the COMMENTARY 10.34067/KID.0005592021

Renal Complications Related to Checkpoint Inhibitors: Diagnostic and Therapeutic Strategies

Immune checkpoint inhibitors (ICI) targeting CTLA-4 and the PD-1/PD-L1 axis have unprecedentedly improved global prognosis in several types of cancers. However, they are associated with the occurrence of immune-related adverse events. Despite their low incidence, renal complications can interfere with the oncologic strategy. The breaking of peripheral tolerance and the emergence of auto- or drug-reactive T-cells are the main pathophysiological hypotheses to explain renal complications after ICI exposure. ICIs can induce a large spectrum of renal symptoms with variable severity (from isolated electrolyte disorders to dialysis-dependent acute kidney injury (AKI)) and presentation (acute tubule-interstitial nephritis in >90% of cases and a minority of glomerular diseases). In this review, the current trends in diagnosis and treatment strategies are summarized. The diagnosis of ICI-related renal complications requires special steps to avoid confounding factors, identify known risk factors (lower baseline estimated glomerular filtration rate, proton pump inhibitor use, and combination ICI therapy), and prove ICI causality, even after long-term exposure (weeks to months). A kidney biopsy should be performed as soon as possible. The treatment strategies rely on ICI discontinuation as well as co-medications, corticosteroids for 2 months, and tailored immunosuppressive drugs when renal response is not achieved.

Immune checkpoint inhibitors: current status

The use of immune checkpoint inhibitors (ICIs) is growing rapidly in oncology and palliative care clinicians and other generalists will increasingly see patients who are receiving, or who have received ICI. For optimal care, it is important that clinicians have a basic understanding of the unique nature of ICI as anticancer treatments, including patterns of response, potential issues with concurrent corticosteroid use and the wide range of possible immune-related adverse effects (IrAEs). This paper, informed by a recent literature search, provides a succinct yet comprehensive overview of ICI, with a particular focus on IrAE, highlighting that some are potentially life-threatening and/or can develop a long time, sometimes years, after even a short course of an ICI.

Kidney injury associated with antitumor therapy: focus on the adverse events of modern immuno-oncological drugs

Immune checkpoint inhibitors (ICIs), including cytotoxic T-lymphocyte associated antigen 4 (CTLA-4) and programmed death protein 1 (PD-1) or its ligand (PD-L1), are a new generation of immuno-oncological drugs that to date have demonstrated efficacy in a number of malignancies. The mechanism of ICT inhibitors action consist in the potentiation of the immune response by eliminating the tumor cells inhibitory effect on the T-lymphocytes activation. However, excessive immune system activation can cause the development of a special class of immune-related adverse events (irAEs) involved a wide variety of organs and systems, including the kidneys. Despite the fact that immuno-mediated kidney injury caused by ICI therapy develops quite rarely, it can be serious and determine the patient's prognosis, which necessitates early diagnosis and timely start of treatment. In this regard, awareness of the manifestations of ICI-associated renal irAEs is particularly relevant not only for oncologists and for nephrologists, but for doctors of other specialties. In this review, we elucidated the main variants of immuno-mediated kidney injury caused by ICI therapy, discussed possible predictors and mechanisms of their development, and considers the general principles of diagnosis and management of patients according to the severity of irAEs.

[Side effects of immune checkpoint inhibitor treatment of urological tumors]

Immune checkpoint inhibitors (ICI) are currently routinely used for the treatment of advanced or metastatic urothelial and renal cell carcinomas. Furthermore, several clinical trials are currently investigating their role in adjuvant and neoadjuvant settings as well as in high-risk non-muscle-invasive bladder cancer. As a result, urologists are increasingly confronted with patients who are currently receiving, have recently received or will receive ICI treatment. Care is often interdisciplinary, with urologists playing a central role. Therefore, a profound understanding of immune-mediated adverse events and their differential diagnoses with respect to side effects of other medications in combination treatment are therefore extremely important. This article focusses on the prevention, early diagnosis and clinical management of the most relevant immune-related side effects derived from the new VEGFR-TKI/ICI combinations.

Renal toxicity of targeted therapies for renal cell carcinoma in patients with normal and impaired kidney function

The introduction of novel targeted therapies during the last 2 decades has led to a significant improvement in patients' clinical outcomes with renal cell carcinoma. However, this improvement came at the price of a whole new spectrum of adverse events, including renal toxicity. Systemic treatment of patients with kidney neoplasms who often present with impairment of kidney function, even prior to treatment, poses an increasing diagnostic and therapeutic challenge for clinicians. Common lifestyle-related comorbidities, i.e., hypertension and diabetes, may contribute to further impairment of kidney function. The lack of official guidelines and the exclusion of patients with reduced kidney function from the clinical trials of recently approved drugs complicate the issue even further. Early detection and correct management of renal toxic effects are crucial to preserve kidney function and ensure the optimal administration of life-prolonging therapies. This review presents detailed information on the renal toxicities of three groups of drugs commonly used in renal cell carcinoma treatment: tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors, and immune checkpoint inhibitors. We outline the incidence and underlying mechanisms of renal adverse effects with a focus on patients on renal replacement therapy, as well as present suggestions for their management.

Organ-specific Adverse Events of Immune Checkpoint Inhibitor Therapy, with Special Reference to Endocrinopathies

Immune checkpoint inhibitors are potent and promising immunotherapeutic agents that are increasingly used for the management of various types of advanced cancers. The widespread approval of this group of drugs simultaneously revealed immune-related adverse events as unique side-effects. Endocrinopathies are one of the most common immune-related adverse events. The precise pathogenic mechanisms for these endocrinopathies are still unclear. Though few of the endocrinopathies are reversible, calling for only symptom control, most are irreversible, requiring multiple long-term hormone replacement therapies. However, in contrast to other organ-specific immune-related adverse events, patients with endocrinopathies can continue their immune checkpoint therapy, provided the hormone replacement therapy is adequate and the symptoms are controlled. Though patients who have developed immune-related adverse events demonstrate superior antitumor activity and overall survival, due to the high morbidity associated with the immune-related adverse events, researchers are trying to uncouple the antitumour activity associated with immune checkpoint inhibitor therapy from the immune-related adverse events, to preserve antitumour activity without adverse events.

Biomarkers, Clinical Features, and Rechallenge for Immune Checkpoint Inhibitor Renal Immune-Related Adverse Events

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are effective in treating several cancers; however, acute kidney injury (AKI) can occur as part as an immune-related adverse event (iRAE). Biomarkers at the time of AKI diagnosis may help determine whether they are ICI- related and guide therapeutic strategies.

METHODS

In this retrospective study, we reviewed patients with cancer treated with ICI therapy between 2014 and 2020 who developed AKI (defined as a ≥1.5-fold increase in serum creatinine [SCr]) that was attributed to ICI (ICI-AKI) and compared them with an adjudicated non-ICI-AKI group. Clinical and laboratory features, including SCr, serum C-reactive protein (CRP), and urine retinol binding protein/urine creatinine (uRBP/Cr) levels at AKI event were evaluated.

RESULTS

There were 37 patients with ICI-AKI and 13 non-ICI-AKI referents in the cohort for analysis. At time of AKI, SCr, CRP, and uRBP/Cr were significantly higher in the ICI-AKI compared with the non-ICI-AKI patients (median [interquartile range (IQR)] SCr 2.0 [1.7, 2.9] vs. 1.5 [1.3, 1.6] mg/dl, serum CRP 54.0 [33.7, 90.0] vs. 3.5 [3.0, 7.9] mg/l, and uRBP/Cr 1927 [1174, 46,522] vs. 233 [127, 989] μg/g Cr, respectively, P < 0.05 for all). Compared with the referent group, time from ICI initiation to AKI was shorter in the ICI-AKI patients. Among the ICI-AKI group, complete renal recovery occurred in 39% of patients by 3 months; rechallenge occurred in 16 (43%) of patients, of whom 3 (19%) had recurrence of AKI.

CONCLUSION

Our findings suggest that serum CRP and uRBP/Cr may help to differentiate AKI due to ICI from other causes.

Fatal Adverse Events Associated With Immune Checkpoint Inhibitors in Non-small Cell Lung Cancer: A Systematic Review and Meta-Analysis

Background: Immune checkpoint inhibitors (ICIs) have previously been reported to have a promising potential in terms of the improvement of outcomes in non–small cell lung cancer (NSCLC). Fatal adverse events (FAEs) of ICIs are relatively uncommon, and the incidence and risk in NSCLC remain unclear. In the present study, we conducted a systematic review and meta-analysis to evaluate the risk of FAEs in NSCLC patients administered with ICIs.

Methods: Potentially relevant studies were identified in PubMed, EMBASE, and Cochrane library database from inception to September 16, 2020. The systematic review and meta-analysis included randomized controlled trials that reported treatment-related FAEs in NSCLC. The pooled incidence and risk ratios (RRs) were calculated to evaluate prospective risk.

Results: Twenty clinical trials that included a total of 13,483 patients were selected for the meta-analysis. The overall incidence of FAEs was 0.65% [95% confidence interval (CI) = 0.31–1.07, I² = 50.2%] in ICI monotherapy, 1.17% (95% CI = 0.74–1.69, I² = 56.3%) in chemotherapy, and 2.01% (95% CI = 1.42–2.69, I² = 5.9%) in the combination therapy (ICI and chemotherapy). ICI monotherapy was associated with lower incidence of FAEs caused by blood system disorders (RR = 0.23, 95% CI = 0.07–0.73, P = 0.013, I² = 0%) and infectious diseases (RR = 0.29, 95% CI = 0.13–0.63, P = 0.002, I² = 0%). The incidence of pneumonitis significantly increased in immunotherapy (RR = 5.72, 95% CI = 1.14–28.80, P = 0.03, I² = 0%).

Conclusions: The results of the present study demonstrate that ICI monotherapy decreases the risk of FAEs, whereas the combined regimens with chemotherapy have the opposite tendency as compared to conventional chemotherapy. While the patients who received chemotherapy suffered the risks of death mainly from myelosuppression and infection, those who received immunotherapy were mainly threatened by immune-related pneumonitis.

Childhood Cancer and the Risk of ESKD

BACKGROUND

Increasing cancer incidence among children alongside improved treatments has resulted in a growing number of pediatric cancer survivors. Despite childhood cancer survivors' exposure to various factors that compromise kidney function, few studies have investigated the association between childhood cancer and future kidney disease.

METHODS

To assess the risk of ESKD among childhood cancer survivors, we conducted a nationwide, population-based, retrospective cohort study that encompassed all Israeli adolescents evaluated for mandatory military service from 1967 to 1997. After obtaining detailed histories, we divided the cohort into three groups: participants without a history of tumors, those with a history of a benign tumor (nonmalignant tumor with functional impairment), and those with a history of malignancy (excluding kidney cancer). This database was linked to the Israeli ESKD registry to identify incident ESKD cases. We used Cox proportional hazards models to estimate the hazard ratio (HR) of ESKD.

RESULTS

Of the 1,468,600 participants in the cohort, 1,444,345 had no history of tumors, 23,282 had a history of a benign tumor, and 973 had a history of malignancy. During a mean follow-up of 30.3 years, 2416 (0.2%) participants without a history of tumors developed ESKD. Although a history of benign tumors was not associated with an increased ESKD risk, participants with a history of malignancy exhibited a substantially elevated risk for ESKD compared with participants lacking a history of tumors, after controlling for age, sex, enrollment period, and paternal origin (adjusted HR, 3.2; 95% confidence interval, 1.3 to 7.7).

CONCLUSIONS

Childhood cancer is associated with an increased risk for ESKD, suggesting the need for tighter and longer nephrological follow-up.

Variable Expression of Programmed Cell Death Protein 1-Ligand 1 in Kidneys Independent of Immune Checkpoint Inhibition

Context

Due to recent advantages in cancer therapy, immune checkpoint inhibitors (ICIs) are new classes of drugs targeting programmed cell death protein 1 (PD-1) or its ligand programmed cell death protein 1-ligand 1 (PD-L1) used in many cancer therapies. Acute interstitial nephritis (AIN) is a potential and deleterious immune-related adverse events (irAE) in the kidney observed in patients receiving ICIs and the most common biopsy-proven diagnosis in patients who develop acute kidney injury (AKI). Based on previous reports, AIN in patients receiving ICIs is associated with tubular positivity for PD-L1, implicating that PD-L1 positivity reflects susceptibility to develop renal complications with these agents. It remains unclear if PD-L1 positivity is acquired specifically during ICI therapy or expressed independently in the kidney.

Methods

PD-L1 was analyzed in experimental mouse models of ischemia-reperfusion injury (IRI), folic acid-induced nephropathy (FAN), unilateral ureteral obstruction (UUO), and nephrotoxic serum nephritis (NTN) by immunostaining, SDS-PAGE, and subsequent immunoblotting. In addition, we included a total number of 87 human kidney samples (six renal biopsies with AIN related to ICI therapy, 13 nephrectomy control kidneys, and 68 ICI-naïve renal biopsies with various underlying kidney diseases to describe PD-L1 expression.

Results

We here report distinct PD-L1 expression in renal compartments in multiple murine models of kidney injury and human cases with various underlying kidney diseases, including ICI-related AIN and renal pathologies independent of ICI therapy. PD-L1 is frequently expressed in various renal pathologies independent of ICI therapy and could potentially be a pre-requisit for susceptibility to develop AKI and deleterious immune-related AIN. In addition, we provide evidence that tubular PD-L1 positivity in the kidney is associated with detection of urinary PD-L1⁺ tubular epithelial cells.

Conclusion

Our study implicates that PD-L1 is frequently expressed in various renal pathologies independent of ICI therapy and could potentially be a pre-requisit for susceptibility to develop AKI and deleterious immune-related AIN. Because non-invasive detection of PD-L1⁺ cells in corresponding urine samples correlates with intrarenal PD-L1 positivity, it is attractive to speculate that further non-invasive detection of PD-L1⁺ cells may identify patients at risk for ICI-related AIN.

Organ-specific Adverse Events of Immune Checkpoint Inhibitor Therapy, with Special Reference to Endocrinopathies

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Immune evasion in renal cell carcinoma: biology, clinical translation, future directions

Targeted therapies and immune checkpoint inhibitors have advanced the treatment landscape of Renal Cell Carcinoma (RCC) over the last decade. While checkpoint inhibitors have demonstrated survival benefit and are currently approved in the front-line and second-line settings, primary and secondary resistance is common. A comprehensive understanding of the mechanisms of immune evasion in RCC is therefore critical to the development of effective combination treatment strategies. This article reviews the current understanding of the different, yet coordinated, mechanisms adopted by RCC cells to evade immune killing; summarizes various aspects of clinical translation thus far, including the currently registered RCC clinical trials exploring agents in combination with checkpoint inhibitors; and provides perspectives on the current landscape and future directions for the field.

Renal Tubular Acidosis and Immune Checkpoint Inhibitor Therapy: An Immune-Related Adverse Event of PD-1 Inhibitor-A Report of 3 Cases

The main cause of acute kidney injury in patients receiving immune checkpoint inhibitors (ICIs) is acute interstitial nephritis. However, as their use continues to increase, other kidney manifestations are being described. We report 3 cases of patients treated with ICIs who developed predominantly electrolyte disorders secondary to renal tubular acidosis as an immune-related adverse event and discuss the potential mechanism. Nongap acidosis in combination with hypokalemia should raise suspicion for distal renal tubular acidosis in patients treated with ICIs.