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Herrmann SM, Alexander MP, Romero MF, Zand L. Renal Tubular Acidosis and Immune Checkpoint Inhibitor Therapy: An Immune-Related Adverse Event of PD-1 Inhibitor-A Report of 3 Cases. Kidney Med 2020; 2:657-662. [PMID: 33089143 PMCID: PMC7568062 DOI: 10.1016/j.xkme.2020.05.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Sandra M Herrmann
- Divisions of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Michael F Romero
- Divisions of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | - Ladan Zand
- Divisions of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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202
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Ong SC, Mannon RB. Use of Checkpoint Inhibitors in a Kidney Transplant Recipient with Metastatic Cancer. Clin J Am Soc Nephrol 2020; 15:1190-1192. [PMID: 32205320 PMCID: PMC7409757 DOI: 10.2215/cjn.15941219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Song Ching Ong
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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203
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Herrmann SM, Perazella MA. Immune Checkpoint Inhibitors and Immune-Related Adverse Renal Events. Kidney Int Rep 2020; 5:1139-1148. [PMID: 32775813 PMCID: PMC7403510 DOI: 10.1016/j.ekir.2020.04.018] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 02/06/2023] Open
Abstract
Renal toxicities have been increasingly recognized as complications of the immune checkpoint inhibitors (ICIs). Recent studies have outlined the incidence and potential risk factors for nephrotoxicity. For clinicians, the key question is how to manage patients who develop these adverse renal effects. This is of paramount importance to providers as ICI use for cancer therapy becomes more widespread and nephrotoxicity increasingly develops. As clinicians encounter ICI-associated nephrotoxicity, an appropriate approach to management is required to facilitate the best outcomes in patients with cancer. Importantly, ICI rechallenge in patients who developed ICI-related acute kidney injury (AKI) is unclear and represents a conundrum for providers. Clinicians struggle with the "if, when, and how to" questions related to ICI rechallenge in this subset of patients. In addition, ICI use in the transplant population raises concerns for promoting acute rejection when treating cancer in these patients. We herein review current information on these various topics.
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Affiliation(s)
- Sandra M. Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark A. Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
- Veterans Affairs Medical Center, West Haven, Connecticut, USA
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204
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ANCA-associated pauci-immune necrotizing glomerulonephritis during the treatment with pembrolizumab. Virchows Arch 2020; 478:801-804. [PMID: 32691143 DOI: 10.1007/s00428-020-02882-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023]
Abstract
Cancer immunotherapy is rapidly changing the treatment paradigm in oncology, and immune checkpoint inhibitors (ICPIs) have been used successfully in a variety of cancer types. Specific side effects termed immune-related adverse events (irAEs) have now been described in various organ systems, including the kidney. Renal complications have rarely been reported compared with other irAEs and mostly consist of acute interstitial nephritis. Only rare cases of ICPI-related glomerulonephritis have been described. Herein, we report the case of an adult patient treated with pembrolizumab (anti-PD-1) for squamous cell carcinoma (SCC), who developed infectious enterocolitis, and ANCA-related with diffuse necrotizing crescentic glomerulonephritis, both conditions potentially linked to treatment with pembrolizumab.
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205
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Incidence and Clinical Features of Immune-Related Acute Kidney Injury in Patients Receiving Programmed Cell Death Ligand-1 Inhibitors. Kidney Int Rep 2020; 5:1700-1705. [PMID: 33102962 PMCID: PMC7569697 DOI: 10.1016/j.ekir.2020.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/21/2020] [Accepted: 07/14/2020] [Indexed: 01/14/2023] Open
Abstract
Background Programmed cell death receptor ligand 1 (PD-L1) inhibitors are immune checkpoint inhibitors (ICIs) with a side effect profile that may differ from other classes of ICIs such as those directed against cytotoxic T-lymphocyte−associated protein 4 (CTLA-4) and programmed cell death 1 receptor (PD-1). Being the more recently approved class of checkpoint inhibitors, there are no studies investigating the frequency, etiology and predictors of acute kidney injury (AKI) in patients receiving PD-L1 inhibitors. Methods This was a retrospective cohort study of patients who received PD-L1 inhibitors during 2017 to 2018 in our healthcare system. AKI was defined by a ≥1.5-fold rise in serum creatinine from baseline. The etiology of all cases of sustained AKI (lasting >48 hours) and clinical course were determined by review of electronic health records. Results The final analysis included 599 patients. Within 12 months of ICI initiation, 104 patients (17%) experienced AKI, and 36 (6%) experienced sustained AKI; however, only 5 (<1%) experienced suspected PD-L1–related AKI. The PD-L1–related AKI occurred a median of 99 days after starting therapy. All patients concurrently received another medication known to cause acute interstitial nephritis (proton pump inhibitors, nonsteroidal anti-inflammatory drugs, or antibiotics) at the time of the suspected PDL1-related AKI. Conclusion Although AKI is common in patients receiving PD-L1 therapy, the incidence of suspected PD-L1–related AKI is low (<1%) and may be less common when compared to other classes of ICIs. This cohort provides further validation that other drugs associated with acute interstitial nephritis may be involved in the pathogenesis of ICI-related AKI.
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206
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Piscitani L, Sirolli V, Di Liberato L, Morroni M, Bonomini M. Nephrotoxicity Associated with Novel Anticancer Agents (Aflibercept, Dasatinib, Nivolumab): Case Series and Nephrological Considerations. Int J Mol Sci 2020; 21:E4878. [PMID: 32664269 PMCID: PMC7402330 DOI: 10.3390/ijms21144878] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022] Open
Abstract
Cancer patients have an incidence of about 60% kidney disease development and are at elevated risk of acute renal damage. Kidney disease in these patients is frequently associated with nephrotoxicity from the ongoing oncological treatment. New anticancer therapeutic strategies, such as targeted therapies and immunotherapies, offer substantial benefits in the treatment of many neoplasms. However, their use is associated with significant nephrotoxicity, which qualitatively differs from that seen with traditional cytotoxic chemotherapy, while the underlying mechanisms are complex and still to be clearly defined. Nephrologists need to be knowledgeable about the array of such renal toxicities for effective collaboration with the oncologist in the prevention and management of kidney involvement. Renal adverse effects may range from asymptomatic proteinuria to renal failure, and their prompt identification and timely treatment is essential for optimal and safe care of the patient. In this article, after presenting clinical cases we discuss the differing renal toxicity of three novel anticancer agents (aflibercept, dasatinib, and nivolumab) and possible measures to counter it.
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Affiliation(s)
- Luca Piscitani
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.P.); (V.S.); (L.D.L.)
| | - Vittorio Sirolli
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.P.); (V.S.); (L.D.L.)
| | - Lorenzo Di Liberato
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.P.); (V.S.); (L.D.L.)
| | - Manrico Morroni
- Department of Experimental and Clinical Medicine-Neuroscience and Cell Biology, School of Medicine, Università Politecnica delle Marche, Via Tronto 10/A, 60126 Ancona, Italy;
| | - Mario Bonomini
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.P.); (V.S.); (L.D.L.)
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207
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Vaughan E, Connolly E, Hui M, Chadban S. Minimal change disease in a patient receiving checkpoint inhibition: Another possible manifestation of kidney autoimmunity? Cancer Rep (Hoboken) 2020; 3:e1250. [PMID: 33085845 DOI: 10.1002/cnr2.1250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Nivolumab has been associated with immune-related adverse events, including nephritis, with acute interstitial nephritis being the most commonly reported renal manifestation. CASE We describe the first case to our knowledge of minimal change disease with nephrotic syndrome associated with the PD-1 checkpoint inhibitor, Nivolumab. Minimal change disease has been reported with other immune checkpoint inhibitors; however, this is the first reported case with Nivolumab. We report development of nephrotic syndrome with acute kidney injury in a 57-year-old man, 1 month after commencement of Nivolumab for metastatic squamous cell carcinoma of the tongue. Minimal change disease was confirmed by renal biopsy. Management with corticosteroids and cessation of Nivolumab failed to improve kidney function or nephrosis. CONCLUSION This case adds to current literature identifying minimal change as an additional complication of immune checkpoint inhibitor-associated acute kidney injury. Given the increasing use of immune checkpoint inhibitors for a range of malignancies, nephrologists, oncologist and generalists should be aware of the spectrum of kidney pathologies associated with their use.
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Affiliation(s)
- Erin Vaughan
- Renal Department, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Elizabeth Connolly
- Medical Oncology Department, Chris O Brien Lifehouse, University of Sydney, Sydney, New South Wales, Australia
| | - Mun Hui
- Medical Oncology Department, Chris O Brien Lifehouse, University of Sydney, Sydney, New South Wales, Australia
| | - Steven Chadban
- Renal Department, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
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208
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Hu R, Chen M, Xu Y, Wang M, Zheng K, Li X. Renal immune-related adverse events of immune checkpoint inhibitor. Asia Pac J Clin Oncol 2020; 16:305-311. [PMID: 32573099 DOI: 10.1111/ajco.13387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/13/2020] [Indexed: 12/11/2022]
Abstract
The status of immune checkpoint inhibitors (ICPIs) is raising in the treatment of malignancy for their effectiveness. The ICPIs therapy takes the risk of off-target toxicity because of immune system overactivation, including renal toxicity. It was declared that the renal toxicity was rare. However, with the increasing experience of ICPIs therapy, the renal immune-relate adverse events of ICPIs were reported more and their management was launching an enthusiastic discussion nowadays. In this review, we focused on the mechanism of ICPIs related renal irAEs (immune-related adverse events), the clinical and pathological manifestation of different forms of renal injury, and management strategies when the renal irAEs happened. Good management of irAEs might need help from Multi-Disciplinary Treatment and could promote a better clinical practice on ICPIs.
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Affiliation(s)
- Rongrong Hu
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Minjiang Chen
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Xu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Mengzhao Wang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ke Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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209
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Heybeli C, Canaslan K, Oktan MA, Yıldız S, Arda HÜ, Çavdar C, Çelik A, Gökmen N, Cömert B. Acute kidney injury following colistin treatment in critically-ill patients: may glucocorticoids protect? J Chemother 2020; 33:85-94. [PMID: 32500843 DOI: 10.1080/1120009x.2020.1770027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Nephrotoxicity following colistin administration is common and factors alleviating nephrotoxicity are yet to be determined. We retrospectively evaluated outcomes of subjects who were treated with colistin (n = 133) and with antibiotics other than colistin (control, n = 133) in intensive care units. Acute kidney injury (AKI) occurred in 69.2% and 29.3% of patients in colistin and control groups, respectively (p < 0.001). In the colistin group, glucocorticoid exposure was more common in subjects who did not develop AKI (p < 0.001). This was not the case in the control group. In the colistin cohort, older age (per 10 years, odds ratio [OR] 1.41, 95% CI 1.05-1.91; p = 0.025), PPI use (OR 3.30, 95% CI 1.18-9.23; p = 0.023) and furosemide treatment (OR 2.66, 95% CI 1.01-6.98; p = 0.047) were independently associated with the development of AKI while glucocorticoid treatment (OR 0.23, 95% CI 0.10-0.53; p = 0.001) was independently associated with reduced risk of AKI. Mortality was observed in 74 patients in the colistin cohort (55.6%). A higher APACHE-II score (OR 1.17, 95% CI 1.08-1.26; p < 0.001) was independently associated with mortality while a higher serum albumin level (per 1 g/dL increase, OR 0.20, 95% CI 0.070-0.60; p = 0.004) was associated with a lower risk of mortality. In conclusion, glucocorticoid exposure is associated with a lower risk of AKI caused by colistin therapy in critically-ill patients. Prospective studies are needed to confirm these findings and determine the optimal type, dose and duration of glucocorticoid therapy.
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Affiliation(s)
- Cihan Heybeli
- Department of Internal Medicine, Division of Nephrology, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Kübra Canaslan
- Department of Internal Medicine, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Mehmet Ası Oktan
- Department of Internal Medicine, Division of Nephrology, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Serkan Yıldız
- Department of Internal Medicine, Division of Nephrology, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Hayri Üstün Arda
- Department of Internal Medicine, Division of Nephrology, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Caner Çavdar
- Department of Internal Medicine, Division of Nephrology, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Ali Çelik
- Department of Internal Medicine, Division of Nephrology, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Necati Gökmen
- Department of Anesthesiology and Reanimation, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Bilgin Cömert
- Department of Internal Medicine, Division of Intensive Care Medicine, Dokuz Eylül University School of Medicine, Izmir, Turkey
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210
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Immune Check Point Inhibitor-Associated Endothelialitis. Kidney Int Rep 2020; 5:1371-1374. [PMID: 32775844 PMCID: PMC7403552 DOI: 10.1016/j.ekir.2020.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 11/23/2022] Open
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211
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Trager MH, Coley SM, Dube G, Khan S, Ingham M, Samie FH, Geskin LJ, McDonnell D, Brouder D, Saenger Y, Carvajal R. Combination checkpoint blockade for metastatic cutaneous malignancies in kidney transplant recipients. J Immunother Cancer 2020; 8:e000908. [PMID: 32503950 PMCID: PMC7279669 DOI: 10.1136/jitc-2020-000908] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Immune checkpoint blockade has emerged as a highly effective treatment for patients with metastatic melanoma and cutaneous squamous cell carcinoma. Nivolumab blocks the interactions between programmed cell death protein 1 and programmed death ligand 1 allowing for activation of a latent immune response against the malignancy. Ipilimumab binds to and blocks cytotoxic T-lymphocyte-associated protein 4, alleviating the negative regulation of T-cell activation that is mediated by that checkpoint. Combination therapy with nivolumab and ipilimumab is associated with longer overall survival at 5 years compared with nivolumab monotherapy. Solid organ transplant recipients have a significantly higher risk of malignancies compared with the general population. There is limited data surrounding the efficacy of combination immunotherapy in solid organ transplant recipients, as these patients were excluded from seminal trials due to risk of organ rejection. CASE PRESENTATIONS Here we present four cases of combination immunotherapy in kidney transplant recipients. Three patients had metastatic melanoma, and one patient had metastatic cutaneous squamous cell carcinoma. Two patients had radiographic responses from immunotherapy, one patient had stable disease, and one patient had disease progression. Only one patient had biopsy-proven rejection. At last follow-up, three patients had functioning grafts, though one required hemodialysis after treatment, and one patient succumbed to disease, but graft function remained intact throughout her course. CONCLUSIONS These cases describe the use of ipilimumab and nivolumab combination immunotherapy for cutaneous malignancies in kidney transplant recipients. They highlight the potential to preserve kidney graft function while effectively treating the disease. TRIAL REGISTRATION NUMBER NCT03816332.
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Affiliation(s)
- Megan H Trager
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York, USA
| | - Shana M Coley
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University Irving Medical Center, New York, New York, USA
| | - Geoffrey Dube
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Shaheer Khan
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew Ingham
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Faramarz H Samie
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York, USA
| | - Larisa J Geskin
- Department of Dermatology, Columbia University Irving Medical Center, New York, New York, USA
| | - Diana McDonnell
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Yvonne Saenger
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Richard Carvajal
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, New York, USA
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212
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Meraz-Muñoz A, Amir E, Ng P, Avila-Casado C, Ragobar C, Chan C, Kim J, Wald R, Kitchlu A. Acute kidney injury associated with immune checkpoint inhibitor therapy: incidence, risk factors and outcomes. J Immunother Cancer 2020; 8:e000467. [PMID: 32601079 PMCID: PMC7326260 DOI: 10.1136/jitc-2019-000467] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICPi) are a novel and promising anti-cancer therapy. There are limited data on the incidence, risk factors and outcomes of acute kidney injury (AKI) in patients receiving ICPi. METHODS We conducted a cohort study of patients receiving ICPi at our center between 2010 and 2017 via electronic health record. The primary outcome was AKI (increase of >50% from baseline serum creatinine (sCr)). Risk factors for AKI were assessed using logistic regression. Survival among those with and without AKI was compared using the Kaplan-Meier method. RESULTS Among 309 patients on ICPi, 51 (16.5%) developed AKI (Kidney Disease Improving Global Outcomes (KDIGO) stages 1: 53%, 2: 22%, 3: 25%). AKI was associated with other immune-related adverse events (IRAE) (OR 3.2, 95% CI 1.6 to 6; p<0.001), hypertension (OR 4.3, 95% CI 1.8 to 6.1; p<0.001) and cerebrovascular disease (OR 9.2; 95% CI 2.1 to 40; p<0.001). Baseline sCr, cancer, and ICPi type was not associated with AKI. Use of angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (OR 2.9; 95% CI 1.5 to 5.7; p=0.002), diuretics (OR 4.3; 95% CI 1.9 to 9.8; p<0.001), and corticosteroid treatment (OR 1.9; 95% CI 1.1 to 3.6; p=0.03) were associated with AKI. In the multivariable analysis, AKI was associated only with other IRAE (OR 2.82; 95% CI 1.45 to 5.48; p=0.002) and hypertension (OR 2.96; 95% CI 1.33 to 6.59; p=0.008). AKI was not associated with increased risk of mortality (HR 1.1; 95% CI: 0.8 to 1.6; p=0.67). ICPi nephrotoxicity was attributed via biopsy or nephrologist assessment in 12 patients (six interstitial nephritis, two membranous nephropathy, two minimal change disease, and two thrombotic microangiopathy). Subsequent doses of ICPi were administered to 12 patients with prior AKI, with one (8.3%) having recurrent AKI. CONCLUSION AKI is a common complication in patients receiving ICPi treatment. The development of other IRAE and previous diagnosis of hypertension were associated with increased AKI risk. AKI was not associated with worse survival. Distinguishing kidney IRAE from other causes of AKI will present a frequent challenge to oncology and nephrology practitioners. Kidney biopsy should be considered to characterize kidney lesions and guide potential therapy.
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Affiliation(s)
- Alejandro Meraz-Muñoz
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Eitan Amir
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Toronto, Ontario, Canada
| | - Pamela Ng
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Carmen Avila-Casado
- Department of Pathology, University Health Network, Toronto, Ontario, Canada
| | - Claire Ragobar
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Christopher Chan
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Joseph Kim
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Ron Wald
- Department of Medicine, Division of Nephrology, Unity Health, Toronto, Ontario, Canada
| | - Abhijat Kitchlu
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
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213
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Draibe JB, García-Carro C, Martinez-Valenzuela L, Agraz I, Fulladosa X, Bolufer M, Tango A, Torras J, Soler MJ. Acute tubulointerstitial nephritis induced by checkpoint inhibitors versus classical acute tubulointerstitial nephritis: are they the same disease? Clin Kidney J 2020; 14:884-890. [PMID: 33777371 PMCID: PMC7986364 DOI: 10.1093/ckj/sfaa027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/01/2020] [Indexed: 12/28/2022] Open
Abstract
Background The incidence of acute tubulointerstitial nephritis (ATIN) related to drugs has dramatically increased over recent years. A new subtype of ATIN, apparently different from classical drug-related ATIN, has emerged that has been related to the administration of immune checkpoint inhibitors (ICIs). We investigated these differences between ICI-related ATIN (ICI ATIN) and non-ICI-related ATIN in terms of clinical features, response to treatment with steroids and the evolution of kidney function. Methods A total of 47 patients diagnosed with ATIN from two centres were recruited. Of these, 13 patients presented with ATIN during ICI treatment and 34 were diagnosed with ATIN attributed to other drugs. The main demographic, clinical and analytical variables such as gender, age and current medication were recorded. The type of malignancy, oncological treatment, ICI dose and presence of extrarenal immune-related adverse events were also reviewed. Renal biopsy diagnosis, time to drug withdrawal and ATIN-specific treatment, as well as laboratory data during follow-up, were also studied. Results Patients diagnosed with ICI ATIN presented with lower creatinine (ICI ATIN 3.8 ± 1.03 versus classical ATIN 5.98 ± 4.15 mg/dL, P = 0.007) at diagnosis and higher urinary leucocyte counts (ICI ATIN 263.2 ± 418.04 versus classical ATIN 133.55 ± 284.62, P = 0.048) compared with patients with non-ICI-related ATIN. Time from initiation of the culprit drug to ATIN diagnosis was longer in patients with ICI ATIN than in those with classical ATIN (197.07 ± 184.99 versus 114.4 ± 352.16 days, P = 0.006). In addition, during follow-up, the slope of decreasing creatinine over time was lower for ICI ATIN compared with non-ICI-related ATIN. Conclusions In this study, we analysed differences between ICI ATIN and classical ATIN. We found that patients with ICI ATIN presented with a larger latency period after culprit drug initiation, milder acute kidney injury and slower creatinine amelioration compared with those with classical ATIN. These results may, in part, be ascribed to potential differences in the pathological mechanisms involved in ATIN development, suggesting that ICI and classical ATIN may be different diseases with similar renal histologies.
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Affiliation(s)
- Juliana B Draibe
- Nephrology Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
| | - Clara García-Carro
- Nephrology Research Group, Vall d'Hebron Research Institute, Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Irene Agraz
- Nephrology Research Group, Vall d'Hebron Research Institute, Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Fulladosa
- Nephrology Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
| | - Monica Bolufer
- Nephrology Research Group, Vall d'Hebron Research Institute, Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ariel Tango
- Nephrology Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
| | - Joan Torras
- Nephrology Department, Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain.,Red de Investigación Renal (REDINREN), Instituto Carlos III, FEDER, Madrid, Spain.,Clinical Sciences Department, Barcelona University, Barcelona, Spain
| | - María José Soler
- Nephrology Research Group, Vall d'Hebron Research Institute, Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Red de Investigación Renal (REDINREN), Instituto Carlos III, FEDER, Madrid, Spain
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214
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Braun GS, Kirschner M, Rübben A, Wahl RU, Amann K, Benesova K, Leipe J. [Side effects of novel cancer immunotherapies]. DER NEPHROLOGE 2020; 15:191-204. [PMID: 32351619 PMCID: PMC7189634 DOI: 10.1007/s11560-020-00424-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Systemic treatment with immune checkpoint inhibitors (ICI) has revolutionized the treatment of hematological and oncological diseases in recent years. The mechanism of action hinges on enhancing the natural ability of the immune system to eliminate malignant cells. The most important substances in this arena include inhibitors of PD‑1, PD-L1 and CTLA‑4. As a consequence, the spectrum of treatment-associated adverse reactions is shifting away from classical cytotoxic effects (e.g. pancytopenia and polyneuropathy) towards novel entities of immune-mediated complex diseases. These so-called immune-related adverse events (irAEs) can involve any organ system and mimic known classical autoimmune conditions. Timely recognition of irAEs is the key for rapid initiation of a suitable treatment and is especially challenging in the clinical routine as it requires an intensive interdisciplinary management. Nephrologists are particularly confronted with this kind of problem due to the highly interdisciplinary nature of their work. This article summarizes the broad spectrum of currently known renal and more frequently occuring non-renal forms of irAEs and aims to prime the reader on diagnostic and therapeutic options.
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Affiliation(s)
- G. S. Braun
- Klinik für Nieren- und Hochdruckkrankheiten, rheumatologische und immunologische Erkrankungen (Medizinische Klinik II), Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - M. Kirschner
- Klinik für Hämatologie, Onkologie, Hämostaseologie und Stammzelltransplantation (Medizinische Klinik IV), Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - A. Rübben
- Klinik für Dermatologie und Allergologie – Hautklinik, Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - R. U. Wahl
- Klinik für Dermatologie und Allergologie – Hautklinik, Uniklinik der RWTH Aachen, Aachen, Deutschland
| | - K. Amann
- Institut für Pathologie, Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - K. Benesova
- Sektion Rheumatologie, Innere Medizin V, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - J. Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim, Deutschland
- Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, München, Deutschland
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215
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Perazella MA. Kidney Biopsy Should Be Performed to Document the Cause of Immune Checkpoint Inhibitor-Associated Acute Kidney Injury: Commentary. KIDNEY360 2020; 1:166-168. [PMID: 35378019 DOI: 10.34067/kid.0001072019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Mark A Perazella
- Department of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut; and.,Section of Nephrology, Veterans Affairs Connecticut Medical Center, West Haven, Connecticut
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216
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Gutgarts V, Glezerman IG. Kidney Biopsy Should Be Performed to Document the Cause of Immune Checkpoint Inhibitor-Associated Acute Kidney Injury: CON. KIDNEY360 2020; 1:162-165. [PMID: 35368625 DOI: 10.34067/kid.0000132020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Victoria Gutgarts
- Weill Cornell Medical College, New York, New York; and.,Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ilya G Glezerman
- Weill Cornell Medical College, New York, New York; and.,Memorial Sloan Kettering Cancer Center, New York, New York
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