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Zhou P, Gao Y, Kong Z, Wang J, Si S, Han W, Li J, Lv Z, Wang R. Immune checkpoint inhibitors and acute kidney injury. Front Immunol 2024; 15:1353339. [PMID: 38464524 PMCID: PMC10920224 DOI: 10.3389/fimmu.2024.1353339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024] Open
Abstract
As a new type of anti-tumor immunotherapy, immune checkpoint inhibitors (ICIs) have improved the prognosis of multiple malignancies. However, renal complications are becoming more frequent. Nephrotoxicity often manifests as acute kidney injury (AKI), and the most common histopathological type is acute tubulointerstitial nephritis (ATIN). Based on previous studies of the incidence and potential risk factors for nephrotoxicity, in this review, we describe the mechanism of AKI after ICIs treatment, summarize the incidence, risk factors, and outcomes of AKI, and discuss the diagnosis and management of immune checkpoint inhibitors-associated acute kidney injury (ICI-AKI). In addition, we review the current status of ICIs rechallenge and the therapeutic strategies of ICIs applied in kidney transplant recipients. Finally, we emphasize the importance of collaboration between nephrologists and oncologists to guide the treatment of ICIs and the management of renal complications.
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Affiliation(s)
- Ping Zhou
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Ying Gao
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhijuan Kong
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Junlin Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shuxuan Si
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wei Han
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jie Li
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhimei Lv
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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2
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Zhang H, Houadj L, Wu KY, Tran SD. Diagnosing and Managing Uveitis Associated with Immune Checkpoint Inhibitors: A Review. Diagnostics (Basel) 2024; 14:336. [PMID: 38337852 PMCID: PMC10855398 DOI: 10.3390/diagnostics14030336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
This review aims to provide an understanding of the diagnostic and therapeutic challenges of uveitis associated with immune checkpoint inhibitors (ICI). In the wake of these molecules being increasingly employed as a treatment against different cancers, cases of uveitis post-ICI therapy have also been increasingly reported in the literature, warranting an extensive exploration of the clinical presentations, risk factors, and pathophysiological mechanisms of ICI-induced uveitis. This review further provides an understanding of the association between ICIs and uveitis, and assesses the efficacy of current diagnostic tools, underscoring the need for advanced techniques to enable early detection and accurate assessment. Further, it investigates the therapeutic strategies for ICI-related uveitis, weighing the benefits and limitations of existing treatment regimens, and discussing current challenges and emerging therapies in the context of their potential efficacy and side effects. Through an overview of the short-term and long-term outcomes, this article suggests recommendations and emphasizes the importance of multidisciplinary collaboration between ophthalmologists and oncologists. Finally, the review highlights promising avenues for future research and development in the field, potentially informing transformative approaches in the ocular assessment of patients under immunotherapy and the management of uveitis following ICI therapy.
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Affiliation(s)
- Huixin Zhang
- Faculty of Medicine, Laval University, Quebec, QC G1V 0A6, Canada;
| | - Lysa Houadj
- Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada;
| | - Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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3
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Moturi K, Sharma H, Hashemi-Sadraei N. Nephrotoxicity in the Age of Immune Checkpoint Inhibitors: Mechanisms, Diagnosis, and Management. Int J Mol Sci 2023; 25:414. [PMID: 38203586 PMCID: PMC10778678 DOI: 10.3390/ijms25010414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Immune checkpoint inhibitors (ICI) revolutionized cancer therapy by augmenting anti-tumor immunity via cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed death-1/programmed death-ligand 1 (PD-1/PD-L1). However, this breakthrough is accompanied by immune-related adverse effects (irAEs), including renal complications. ICI-related nephritis involves complex mechanisms like auto-reactive T cells, auto-antibodies, reactivation of drug-specific T cells, and cytokine-driven inflammation culminating in AKI. ICI-AKI typically manifests weeks to months into treatment, often with other irAEs. Timely detection relies on monitoring creatinine levels and urine characteristics. Biomarkers, like soluble interleukin-2 receptor (sIL-2R) and urine cytokine levels, provide non-invasive insights, while renal biopsy remains the gold standard for confirmation. Management of ICI-AKI requires a balance between discontinuing ICI therapy and prompt immunosuppressive intervention, typically with corticosteroids. Some cases permit ICI therapy resumption, but varying renal recovery rates highlight the importance of vigilant monitoring and effective therapy. Beyond its clinical implications, the potential of irAEs to predict positive treatment responses in certain cancers raises intriguing questions. Data on nephritis-treatment response links are limited, and ongoing research explores this complex interaction. In summary, ICI therapy's transformative impact on cancer treatment is counterbalanced by irAEs, including nephritis. Early recognition and management are vital, with ongoing research refining diagnostic and treatment strategies.
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Affiliation(s)
- Krishna Moturi
- Department of Medicine, Division of Hematology and Oncology, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM 87131, USA;
| | | | - Neda Hashemi-Sadraei
- Department of Medicine, Division of Hematology and Oncology, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM 87131, USA;
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4
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Tang J, Yang N, Pan S, Ren P, Chen M, Jin J, He Q, Zeng Y. The renal damage and mechanisms relevant to antitumoral drugs. Front Oncol 2023; 13:1331671. [PMID: 38148845 PMCID: PMC10749913 DOI: 10.3389/fonc.2023.1331671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023] Open
Abstract
Over the past few decades, significant progress has been made in the development of drugs to combat cancer. It is unfortunate that these drugs can also lead to various kidney injuries and imbalances in electrolyte levels. Nephrotoxicity caused by chemotherapy drugs can impact different parts of the kidneys, including the glomeruli, renal tubules, interstitium, or renal microvessels. Despite the existing knowledge, our understanding of the mechanisms underlying the renal damage caused by antitumoral drugs remains incomplete. In this review, we aim to provide a comprehensive overview of the specific types of kidney injury and the mechanisms responsible for the drug-mediated renal damage, and briefly discuss possible prevention and treatment measures. Sensitive blood and urine biomarkers can provide clinicians with more information about kidney injury detection and reference value for subsequent treatment options. In addition, we emphasize that both oncologists and nephrologists have a responsibility to remain vigilant against the potential nephrotoxicity of the drugs. It's crucial for experts in both fields to collaborate in early detection, monitoring and prevention of kidney damage.
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Affiliation(s)
- Jiyu Tang
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, China
| | - Nan Yang
- Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, China
- Jinzhou Medical University, Graduate School of Clinical Medicine, Jinzhou, China
| | - Shujun Pan
- School of Medicine, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Peiyao Ren
- School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Maosheng Chen
- Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, China
| | - Juan Jin
- Department of Nephrology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, China
| | - Qiang He
- Department of Nephrology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, China
| | - Yuqun Zeng
- Department of Nephrology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital), Hangzhou Medical College, Hangzhou, China
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Silvestris N, Franchina T, Gallo M, Argentiero A, Avogaro A, Cirino G, Colao A, Danesi R, Di Cianni G, D'Oronzo S, Faggiano A, Fogli S, Giuffrida D, Gori S, Marrano N, Mazzilli R, Monami M, Montagnani M, Morviducci L, Natalicchio A, Ragni A, Renzelli V, Russo A, Sciacca L, Tuveri E, Zatelli MC, Giorgino F, Cinieri S. Diabetes management in cancer patients. An Italian Association of Medical Oncology, Italian Association of Medical Diabetologists, Italian Society of Diabetology, Italian Society of Endocrinology and Italian Society of Pharmacology multidisciplinary consensus position paper. ESMO Open 2023; 8:102062. [PMID: 38070434 PMCID: PMC10714217 DOI: 10.1016/j.esmoop.2023.102062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/07/2023] [Accepted: 10/11/2023] [Indexed: 12/31/2023] Open
Abstract
Cancer management has significantly evolved in recent years, focusing on a multidisciplinary team approach to provide the best possible patient care and address the various comorbidities, toxicities, and complications that may arise during the patient's treatment journey. The co-occurrence of diabetes and cancer presents a significant challenge for health care professionals worldwide. Management of these conditions requires a holistic approach to improve patients' overall health, treatment outcomes, and quality of life, preventing diabetes complications and cancer treatment side-effects. In this article, a multidisciplinary panel of experts from different Italian scientific societies provide a critical overview of the co-management of cancer and diabetes, with an increasing focus on identifying a novel specialty field, 'diabeto-oncology', and suggest new co-management models of cancer patients with diabetes to improve their care. To better support cancer patients with diabetes and ensure high levels of coordinated care between oncologists and diabetologists, 'diabeto-oncology' could represent a new specialized field that combines specific expertise, skills, and training.
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Affiliation(s)
- N Silvestris
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina.
| | - T Franchina
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina
| | - M Gallo
- Endocrinology and Metabolic Diseases Unit, AO SS Antonio e Biagio e Cesare Arrigo of Alessandria, Alessandria
| | - A Argentiero
- Medical Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", Bari
| | - A Avogaro
- Department of Medicine, University of Padova, Padua
| | - G Cirino
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples
| | - A Colao
- Endocrinology, Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples; UNESCO Chair, Education for Health and Sustainable Development, Federico II University, Naples
| | - R Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | | | - S D'Oronzo
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari
| | - A Faggiano
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, ENETS Center of Excellence, Sapienza University of Rome, Rome
| | - S Fogli
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | - D Giuffrida
- Department of Oncology, Istituto Oncologico del Mediterraneo, Viagrande, Catania
| | - S Gori
- Oncologia Medica, IRCCS Ospedale Don Calabria-Sacro Cuore di Negrar, Verona
| | - N Marrano
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari
| | - R Mazzilli
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, ENETS Center of Excellence, Sapienza University of Rome, Rome
| | - M Monami
- Diabetology, Careggi Hospital and University of Florence, Firenze
| | - M Montagnani
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Pharmacology, Medical School, University of Bari Aldo Moro, Bari
| | - L Morviducci
- Diabetology and Nutrition Unit, Department of Medical Specialties, ASL Roma 1 - S, Spirito Hospital, Rome
| | - A Natalicchio
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari
| | - A Ragni
- Endocrinology and Metabolic Diseases Unit, AO SS Antonio e Biagio e Cesare Arrigo of Alessandria, Alessandria
| | - V Renzelli
- Diabetologist and Endocrinologist, Italian Association of Medical Diabetologists, Rome
| | - A Russo
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo
| | - L Sciacca
- Department of Clinical and Experimental Medicine, Endocrinology Section, University of Catania, Catania
| | - E Tuveri
- Diabetology, Endocrinology and Metabolic Diseases Service, ASL-Sulcis, Carbonia
| | - M C Zatelli
- Section of Endocrinology, Geriatrics, and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara
| | - F Giorgino
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari
| | - S Cinieri
- Medical Oncology Division and Breast Unit, Senatore Antonio Perrino Hospital, ASL Brindisi, Brindisi, Italy
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6
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Esposito P, Bottini A, Lecini E, Cappadona F, Piaggio M, Macciò L, Genova C, Viazzi F. Biopsy-proven acute tubulointerstitial nephritis in patients treated with immune checkpoint inhibitors: a pooled analysis of case reports. Front Oncol 2023; 13:1221135. [PMID: 37936605 PMCID: PMC10627243 DOI: 10.3389/fonc.2023.1221135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/12/2023] [Indexed: 11/09/2023] Open
Abstract
Introduction Acute kidney injury (AKI) in cancer patients receiving immune checkpoint inhibitors (ICIs) may recognize multiple causes. Here, we reviewed cases of biopsy-proven acute tubulointerstitial nephritis (ATIN) to describe the clinical characteristics and outcomes of this condition. Method We conducted a pooled analysis of clinical cases of ICI-related biopsy-proven ATIN up to 1 May 2022. We collected data on clinical characteristics, AKI, biopsy findings, laboratory examinations, and renal outcomes. Results Eighty-five patients (61.4 ± 19 years, 56 male) were evaluated. Melanoma was the most prevalent diagnosis (51%), followed by non-small cell lung cancer (30%). ICI treatment consisted of PD-1, PDL-1 (nivolumab, pembrolizumab, atezolizumab), and CTLA-4 inhibitors (i) (ipilimumab) or combination PD-1i+CTLA4i. Renal toxicity developed after a median of four cycles of therapy. Fifty-one patients (65.5%) developed the most severe form of AKI- stage 3, including five patients requiring dialysis. All the 19 patients treated with dual ICI blockade developed AKI-stage 3, compared with 29 patients out of the 60 receiving a single agent (p<0.001). Most events were managed with corticosteroids associated with ICI withdrawal. In 15 patients ICI was restarted, but in six (40%) AKI recurred. Overall, 32 patients (40%) presented a complete renal recovery, which chance was inversely associated with dual ICI blockade (OR 0.15, 95CI 0.03-0.7, p=0.01). Conclusion ICI-related ATIN may develop late after the therapy initiation, presenting as severe AKI, particularly in patients with dual ICI blockade. Although this complication may be partially reversible, concerns remain about the renal function sequelae and the possibility of restarting ICI treatment.
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Affiliation(s)
- Pasquale Esposito
- Nephrology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Annarita Bottini
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Elvina Lecini
- Department of Internal Medicine, University of Genova, Genova, Italy
| | | | - Michela Piaggio
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Lucia Macciò
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Carlo Genova
- Department of Internal Medicine, University of Genova, Genova, Italy
- UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Viazzi
- Nephrology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
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7
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Park SD, Kim MS, Han MH, Kim YJ, Jung HY, Choi JY, Cho JH, Park SH, Kim CD, Kim YL, Lim JH. Renal Sarcoidosis-like Reaction Induced by PD-1 Inhibitor Treatment in Non-Small Cell Lung Cancer: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050991. [PMID: 37241223 DOI: 10.3390/medicina59050991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023]
Abstract
Monoclonal antibodies directed against immune checkpoint proteins have been widely used to treat various cancers and have resulted in favorable clinical outcomes. Despite these beneficial properties, immune checkpoint inhibitors (ICIs) can induce side effects called immune-related adverse events, including sarcoidosis-like reactions (SLR) across multiple organs. Here, we report a case of renal SLR after ICI treatment, and we review the related literature. A 66-year-old Korean patient with non-small cell lung cancer was referred to the nephrology clinic for renal failure after the 14th pembrolizumab treatment dose. A renal biopsy revealed multiple epithelioid cell granulomas, with several lymphoid aggregates in the renal interstitium and a moderate degree of inflammatory cell infiltration in the tubulointerstitium. A moderate dose of steroid therapy was initiated, and the serum creatinine level partially recovered after four weeks of treatment. Judicious monitoring of renal SLR is, therefore, required during ICI therapy, and a timely diagnosis by renal biopsy and appropriate treatment are important.
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Affiliation(s)
- Sang-Don Park
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Mee-Seon Kim
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Man-Hoon Han
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Yong-Jin Kim
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu 41944, Republic of Korea
| | - Hee-Yeon Jung
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Jang-Hee Cho
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Sun-Hee Park
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Chan-Duck Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Yong-Lim Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Jeong-Hoon Lim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
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Capaccione KM, Valiplackal JP, Huang A, Roa T, Fruauff A, Liou C, Kim E, Khurana S, Maher M, Ma H, Ngyuen P, Mak S, Dumeer S, Lala S, D'souza B, Laifer-Narin S, Desperito E, Ruzal-Shapiro C, Salvatore MM. Checkpoint Inhibitor Immune-Related Adverse Events: A Multimodality Pictorial Review. Acad Radiol 2022; 29:1869-1884. [PMID: 35382975 DOI: 10.1016/j.acra.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 02/07/2023]
Abstract
Cancer immunotherapies are drugs that modulate the body's own immune system as an anticancer strategy. Checkpoint inhibitor immunotherapies interfere with cell surface binding proteins that function to promote self-recognition and tolerance, ultimately leading to upregulation of the immune response. Given the striking success of these agents in early trials in melanoma and lung cancer, they have now been studied in many types of cancer and have become a pillar of anticancer therapy for many tumor types. However, abundant upregulation results in a new class of side effects, known as immune-related adverse events (IRAEs). It is critical for the practicing radiologist to be able to recognize these events to best contribute to care for patients on checkpoint inhibitor immunotherapy. Here, we provide a comprehensive system-based review of immune-related adverse events and associated imaging findings. Further, we detail the best imaging modalities for each as well as describe problem solving modalities. Given that IRAEs can be subclinical before becoming clinically apparent, radiologists may be the first provider to recognize them, providing an opportunity for early treatment. Awareness of IRAEs and how to best image them will prepare radiologists to make a meaningful contribution to patient care as part of the clinical team.
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Affiliation(s)
- Kathleen M Capaccione
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032.
| | - Jacienta P Valiplackal
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Alice Huang
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Tina Roa
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Alana Fruauff
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Connie Liou
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Eleanor Kim
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Sakshi Khurana
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Mary Maher
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hong Ma
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Pamela Ngyuen
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Serena Mak
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Shifali Dumeer
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Sonali Lala
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Belinda D'souza
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Sherelle Laifer-Narin
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Elise Desperito
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Carrie Ruzal-Shapiro
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
| | - Mary M Salvatore
- Department of Radiology, Columbia University Irving Medical Center, 622 W 168(th) Street, New York, New York, 10032
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9
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Kohatsu K, Suzuki T, Takimoto M, Matsui K, Hashiguchi A, Koike J, Shirai S. Granulomatous interstitial nephritis with CTLA-4 haploinsufficiency: a case report. BMC Nephrol 2022; 23:367. [PMID: 36384506 PMCID: PMC9670605 DOI: 10.1186/s12882-022-02999-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cytotoxic T lymphocyte antigen-4 (CTLA-4) is an essential inhibitory regulator of immune activation. CTLA-4 haploinsufficiency is known to be associated with dysregulation of FOXP3+ regulatory T cells, hyperactivation of effector T cells, and lymphocytic infiltration of multiple organs. However, there have only been a few reports of renal involvement with CTLA-4. Herein, we present a case of acute granulomatous tubulointerstitial nephritis (TIN) in a patient with CTLA-4 haploinsufficiency. CASE PRESENTATION A 44-year-old man presented with a 3-week history of fever and malaise, and subsequently developed acute kidney injury (AKI) a few days after treatment with levofloxacin (LVFX). A kidney biopsy and immunohistochemical staining revealed granulomatous TIN with dominantly infiltrating CD4+ T cells. General symptoms and renal impairment showed improvement after discontinuation of LVFX and initiation of oral steroids. However, they worsened following steroid tapering. Further, a colon biopsy analysis showed similar findings to the renal tissue analysis. We suspected that granulomatous TIN was possibly associated with CTLA-4 haploinsufficiency. Therefore, the patient was transferred to another hospital for further treatment of CTLA-4 haploinsufficiency using immunosuppressive agents. CONCLUSIONS There have been few reports regarding renal involvement of CTLA-4 haploinsufficiency. In the present case, granulomatous TIN could have arisen due to instability of immune regulatory functions, such as CTLA-4 haploinsufficiency, and treatment with LVFX could have triggered immunologic activation and severe inflammation as well as renal dysfunction.
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Affiliation(s)
- Kaori Kohatsu
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Tomo Suzuki
- Department of Nephrology, Kameda Medical Center, Chiba, Japan
| | - Madoka Takimoto
- Department of Hematology, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Katsuomi Matsui
- Department of Nephrology and Hypertension, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Akinori Hashiguchi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Junki Koike
- Department of Diagnostic Pathology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Sayuri Shirai
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
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10
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Miao J, Sise ME, Herrmann SM. Immune checkpoint inhibitor related nephrotoxicity: Advances in clinicopathologic features, noninvasive approaches, and therapeutic strategy and rechallenge. FRONTIERS IN NEPHROLOGY 2022; 2:1017921. [PMID: 37674988 PMCID: PMC10479679 DOI: 10.3389/fneph.2022.1017921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/28/2022] [Indexed: 09/08/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are used increasingly to treat more than 17 cancers and have shown promising therapeutic results. However, ICI use can result in a variety of immune-related adverse events (IRAEs) which can occur in any organ, including the kidneys. Acute kidney injury (AKI) is the most common nephrotoxicity, classically related to acute interstitial nephritis. Much more diverse patterns and presentations of ICI-related kidney injury can occur, and have implications for diagnostic and therapeutic management approaches. In this review, we summarize the recently approved ICIs for cancer, the incidence and risk factors for nephrotoxicity, our current understanding of the pathophysiological mechanisms and the key clinicopathological features of ICI-related AKI, and therapeutic strategies. We also explore important knowledge that require further investigation, such as the risks/benefits of ICI rechallenge in patients who recover from an episode of ICI-related AKI, and the application of liquid biopsy and microbiome to identify noninvasive biomarkers to diagnose and predict kidney injury and guide ICI therapy.
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Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Meghan E. Sise
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, United States
| | - Sandra M. Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
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11
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Immune checkpoint inhibitors and kidney disease. Curr Opin Nephrol Hypertens 2022; 31:449-455. [PMID: 35894279 DOI: 10.1097/mnh.0000000000000805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICIs) have changed the landscape of cancer treatment. However, use of ICIs can be limited by inflammatory toxicities referred to as immune-related adverse events (irAEs). ICI-associated acute kidney injury (ICI-associated AKI) affects 3-5% of ICI users. RECENT FINDINGS With the rapidly growing indication of ICI, knowledge of ICI-associated kidney toxicity has also expanded from case series to large multicentre cohort studies. In this review, we discuss the clinical features, risk factors, clinicopathological correlations and prognosis of ICI-associated AKI from the most recent rigorously conducted retrospective cohort studies. We also discuss recent advances in diagnostic biomarker investigation, treatment and the unique challenge faced in the kidney transplant population. SUMMARY With more comprehensive understanding of the clinical features and risk factors, ICI-associated AKI is commonly diagnosed clinically, especially given the inherent challenges performing a kidney biopsy in the cancer population; however, this highlights the urgent need for improved noninvasive diagnostic biomarkers to aid diagnosis and prognosis. Prospective studies are needed to better define the optimal treatment of ICI-associated AKI and to minimize the risk of graft loss in patients with kidney transplant who require ICIs.
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12
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Anderson MA, Khauli MA, Furtado F, Pourvaziri A, Catalano O. Immunotherapy-related renal toxicity causes reversible renal enlargement. Abdom Radiol (NY) 2022; 47:3301-3307. [PMID: 35776145 DOI: 10.1007/s00261-022-03594-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/11/2022] [Accepted: 06/14/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE Prior case reports have noted an increase in renal size and perinephric stranding accompanying immunotherapy-related renal toxicity due to checkpoint-inhibitor therapy. The purpose of this investigation was to systematically evaluate if immunotherapy-related renal toxicity affects renal size and possible associated imaging findings. METHODS This retrospective multi-hospital study included 25 patients (13 men), mean age 67 years (range 46-83) who received immune-checkpoint inhibitors for cancer treatment, developed biopsy-proven immunotherapy-related nephritis, and who also had abdominal imaging before, during, and after nephritis was diagnosed. Long axis renal diameter, renal corticomedullary differentiation/enhancement and perinephric stranding were evaluated by two readers at three timepoints: (1) prior to checkpoint inhibitor therapy (baseline), (2) after biopsy-proven immunotherapy-related nephritis (post-treatment), and (3) following renal function recovery (follow-up). Intraclass correlation coefficient and Cohen's Kappa were calculated to quantify agreement. Logistic regression analysis was implemented to measure the association between each timepoint and imaging features. RESULTS Reader agreement on kidney measurements was excellent (ICC = 0.87). There was an increase in renal size between baseline and post-treatment (p = 0.001), followed by a decrease between post-treatment to follow-up (p < 0.001). Agreement was perfect for abnormal renal corticomedullary differentiation/enhancement (Kappa = 1, p < 0.001) and almost perfect for perinephric stranding (Kappa = 0.97, p < 0.001). Neither post-treatment nor follow-up imaging findings were significantly associated with these findings compared to the baseline (p = 0.2-0.6). CONCLUSION Immunotherapy-related renal toxicity was associated with an increase in renal size coincident with acute renal dysfunction.
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Affiliation(s)
- Mark A Anderson
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White Building, Room 270, Boston, MA, 02114, USA.
| | - Mark A Khauli
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White Building, Room 270, Boston, MA, 02114, USA
| | - Felipe Furtado
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White Building, Room 270, Boston, MA, 02114, USA
| | - Ali Pourvaziri
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White Building, Room 270, Boston, MA, 02114, USA
| | - Onofrio Catalano
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White Building, Room 270, Boston, MA, 02114, USA
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13
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Kanbay M, Copur S, Siriopol D, Yildiz AB, Berkkan M, Popa R, Hasbal NB, Ortiz A, Perazella MA. The association of acute kidney injury on outcomes in cancer patients receiving immune checkpoint inhibitor therapy: a systematic review and meta-analysis. Clin Kidney J 2022; 16:817-826. [PMID: 37151409 PMCID: PMC10157786 DOI: 10.1093/ckj/sfac194] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Immune checkpoint inhibitors (ICPIs) are a novel therapeutic approach to cancer treatment that has changed the landscape of cancer therapy but also has some considerable drawbacks. Acute kidney injury (AKI) is one of these potential complications that may have effects on patient outcomes. In this review, we assessed the effect of AKI on mortality outcomes in cancer patients receiving this immunotherapy.
Materials and methods
We performed a systematic review and meta-analysis of prospective, retrospective, randomized, and non-randomized studies, which examined the effects of AKI in cancer patients receiving immune checkpoint inhibitors. We searched through PubMed, Medline, Web of Science, Scopus, and Cochrane Library databases.
Results
7 studies were included in the final analysis, with a total number of patients of 761. Overall, the risk of death was higher in patients that developed AKI during ICPI treatment (HR 1.42, 95% CI 1.05 to 1.92, P = 0.02; heterogeneity χ2 = 11.68, I2 = 66%, P = 0.02) compared to patients that did not develop AKI. In addition, there was a trend to a better survival in those with less severe AKI patients compared to those with more severe AKI (HR 1.35, 95% CI 0.99 to 1.83, P = 0.05). Lastly, it was seen that patients with persistent kidney dysfunction (non-recovery) had an increased risk for all-cause mortality (HR 2.93, 95% CI 1.41 to 6.08, P = 0.004; heterogeneity χ2 = 0.53, I2 = 0%, P = 0.47).
Conclusions
Development of AKI in patients with cancer receiving immune checkpoint inhibitors is associated with increased risk of mortality.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Section of Nephrology, Koc University School of Medicine , Istanbul , Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine , Istanbul , Turkey
| | - Dimitrie Siriopol
- Department of Nephrology, “Saint John the New” County Hospital , Suceava , Romania
| | | | - Metehan Berkkan
- Department of Medicine, Koc University School of Medicine , Istanbul , Turkey
| | - Raluca Popa
- Department of Nephrology, “Saint John the New” County Hospital , Suceava , Romania
| | - Nuri Baris Hasbal
- Department of Medicine, Section of Nephrology, Koc University School of Medicine , Istanbul , Turkey
| | - Alberto Ortiz
- Department of Medicine, Universidad Autonoma de Madrid and IIS-Fundacion Jimenez Diaz , Madrid , Spain
| | - Mark A Perazella
- Department of Internal Medicine Section of Nephrology, Yale University School of Medicine , CT, USA
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14
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Adverse Renal Effects of Anticancer Immunotherapy: A Review. Cancers (Basel) 2022; 14:cancers14174086. [PMID: 36077623 PMCID: PMC9454552 DOI: 10.3390/cancers14174086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The immune system has a natural ability to work against cancer cells; however, in many cases this ability is insufficient, and cancers develop methods enabling them to escape from the supervision of immune cells. Novel therapeutic methods used in neoplastic diseases are based on encouraging immune cells to fight against cancer. In some cases, boosted by this approach, the immune system may damage not only tumor cells, but also other cells, tissues and organs in the human body. Kidney involvement, for example, is directly dangerous for patients’ health and may have an impact on human body homeostasis and the excretion of xenobiotics. However, renal function impairment in patients treated with immunotherapy is thought to be relatively rare but may be severe. Knowledge of early diagnosis and proper management are essential for physicians utilizing immunotherapy in daily clinical practice. Abstract Modern oncological therapy utilizes various types of immunotherapy. Immune checkpoint inhibitors (ICIs), chimeric antigen receptor T cells (CAR-T) therapy, cancer vaccines, tumor-targeting monoclonal antibodies (TT-mAbs), bispecific antibodies and cytokine therapy improve patients’ outcomes. However, stimulation of the immune system, beneficial in terms of fighting against cancer, generates the risk of harm to other cells in a patient’s body. Kidney damage belongs to the relatively rare adverse events (AEs). Best described, but still, superficially, are renal AEs in patients treated with ICIs. International guidelines issued by the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) cover the management of immune-related adverse events (irAEs) during ICI therapy. There are fewer data concerning real occurrence and possible presentations of renal adverse drug reactions of other immunotherapeutic methods. This implies the need for the collection of safety data during ongoing clinical trials and in the real-life world to characterize the hazard related to the use of new immunotherapies and management of irAEs.
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15
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Immune Checkpoint Inhibitors’ Associated Renal Toxicity: A Series of 12 Cases. J Clin Med 2022; 11:jcm11164786. [PMID: 36013025 PMCID: PMC9409791 DOI: 10.3390/jcm11164786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/16/2022] Open
Abstract
We present a series of twelve patients, bearing a wide range of solid malignancies, who received either PD-L1 or a combination of PD-L1 and CTLA-4 inhibitors. Following immunotherapy administration, they exhibited the clinical signs indicative of renal toxicity, including increased serum creatinine levels, proteinuria, nephrotic syndrome and/or hematuria. All patients underwent renal biopsy. Results: All cases demonstrated some degree of interstitial inflammation and tubular injury, while in five patients, glomerular alterations consistent with a specific glomerulopathy were also observed: secondary “lupus-like” membranous glomerulopathy in two cases and membranoproliferative glomerulonephritis, IgA glomerulonephritis and secondary AA amyloidosis in each of the remaining three patients. The two patients with “lupus-like” nephritis and the one with amyloidosis experienced nephrotic syndrome, while their creatinine was within normal range. In the remaining nine cases, deterioration of renal function was the main manifestation. Conclusion: Our findings harmonize with bibliographical data that identify tubulointerstitial nephritis as the most frequent histological lesion related to ICIs administration. The preferential involvement of tubulointerstitial tissue could be associated with the reported higher expression levels of PD-L1 on tubular epithelial cells, compared to glomeruli. On the other hand, glomerular involvement is probably a consequence of a systemic immune system reconstruction, induced by immune-checkpoints inhibition.
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16
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Gosangi B, McIntosh L, Keraliya A, Irugu DVK, Baheti A, Khandelwal A, Thomas R, Braschi-Amirfarzan M. Imaging features of toxicities associated with immune checkpoint inhibitors. Eur J Radiol Open 2022; 9:100434. [PMID: 35967881 PMCID: PMC9372737 DOI: 10.1016/j.ejro.2022.100434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/16/2022] [Accepted: 07/28/2022] [Indexed: 12/11/2022] Open
Abstract
The past decade has witnessed a change in landscape of cancer management with the advent of precision oncology. Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment and have played an important role in improving patient survival. While the patients are living longer, treatment with ICIs are sometimes associated with adverse effects, some of which could be fatal. Radiologists can play a crucial role by early identification of some of these adverse effects during restaging scans. Our paper focuses on the imaging features of commonly occurring ICI toxicities based on organ system.
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Key Words
- AIP, acute interstitial pneumonitis
- ARDS, acute respiratory distress syndrome
- CTCAE, Common Terminology Criteria for Adverse Events
- CTLA-4 inhibitor, Cytotoxic T-lymphocyte antigen- 4 inhibitor
- Colitis
- FDA, Food and Drug Administration
- Hepatitis
- ICI, Immune check point inhibitor
- Immune check point inhibitors toxicity
- LGE, late Gadolinium enhancement
- NSCLC, non-small cell lung cancer
- NSIP, non-specific interstitial pneumonia
- OP, organizing pneumonia
- PD-1 inhibitor, programmed cell death-1 inhibitor
- PD-L1 inhibitor, programmed cell death ligand-1 inhibitor
- PFS, progression free survival
- Pancreatitis
- Pneumonitis
- RRP, radiation recall pneumonitis
- irAE, immune-related adverse event
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Affiliation(s)
- Babina Gosangi
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Lacey McIntosh
- Department of Radiology, University of Massachusetts, Worcester, MA, USA
| | - Abhishek Keraliya
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Richard Thomas
- Department of Radiology, Lahey Health System, Burlington, MA, USA
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17
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Moss EM, Perazella MA. The role of kidney biopsy in immune checkpoint inhibitor nephrotoxicity. Front Med (Lausanne) 2022; 9:964335. [PMID: 36035427 PMCID: PMC9399765 DOI: 10.3389/fmed.2022.964335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/25/2022] [Indexed: 11/21/2022] Open
Abstract
Immune checkpoint inhibitors, medications that boost host immune response to tumor cells, are now at the forefront of anti-cancer therapy. While efficacious in the treatment of patients with advanced cancer, immune checkpoint inhibitors can lead to serious autoimmune side effects involving any organ in the body. Immune checkpoint inhibitor nephrotoxicity is an increasingly recognized cause of acute kidney injury in patients with cancer. This review discusses the clinical and histopathologic diagnosis of immune checkpoint inhibitor nephrotoxicity, highlighting the need for more reliable non-invasive diagnostic testing. We focus on the controversy surrounding the role of kidney biopsy in diagnosis and management of suspected immune checkpoint inhibitor toxicity with inclination toward pursuing kidney biopsy in certain outlined circumstances. Finally, we briefly discuss treatment of immune checkpoint inhibitor nephrotoxicity and the decision to re-challenge immunotherapy in patients who experience these adverse events.
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Affiliation(s)
- Emily M. Moss
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
- *Correspondence: Emily M. Moss
| | - Mark A. Perazella
- Division of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
- Veterans Affairs Connecticut Healthcare System, Veterans Health Administration, West Haven, CT, United States
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18
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Sun G, Liu H, Shi X, Tan P, Tang W, Chen X, Sun G, Yang W, Kong X, Zheng Z, Cao H, Shao G. Treatment of patients with cancer using PD‑1/PD‑L1 antibodies: Adverse effects and management strategies (Review). Int J Oncol 2022; 60:74. [PMID: 35485291 PMCID: PMC9084612 DOI: 10.3892/ijo.2022.5364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/14/2022] [Indexed: 12/12/2022] Open
Abstract
In 2020, there were an estimated 19.3 million new cancer cases and close to 10 million cancer deaths worldwide. Cancer remains one of the leading causes of death. In recent years, with the continuous improvement of our understanding of tumor immunotherapy, immunotherapeutics, such as immune checkpoint inhibitors, have gradually become a hot spot for tumor treatment. Amongst these, programmed cell death protein 1/programmed cell death protein ligand 1 (PD-1/PD-L1) related inhibitors, such as nivolumab and pembrolizumab, atezolizumab, avelumab and durvalumab have been shown to exhibit a high level of efficacy in several types of tumors. It has been confirmed that these inhibitors play an important role in the anti-tumor process, significantly improving the survival rate of patients and delaying the progress of the underlying cancer. However, its method of therapeutic interference and potential for damaging the immune system has caused concern regarding its suitability. As these adverse effects are caused by an immune response to endogenous tissues, they are designated as immune-related adverse events (irAEs). In this review, the typical irAEs reported in recent years and the management strategies adopted are highlighted, to serve as a reference in assessing the clinical response to these adverse reactions.
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Affiliation(s)
- Guangshun Sun
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Hanyuan Liu
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Xuesong Shi
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Pengyu Tan
- Department of Food Science and Engineering, Nanjing Xiaozhuang University, Nanjing, Jiangsu 211166, P.R. China
| | - Weiwei Tang
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Xin Chen
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Guoqiang Sun
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Weijun Yang
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Xiangyi Kong
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Zhiying Zheng
- Hepatobiliary/Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Living Donor Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu 215005, P.R. China
| | - Hongyong Cao
- Department of General Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
| | - Guoqiang Shao
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210001, P.R. China
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19
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Gerard AO, Barbosa S, Parassol N, Andreani M, Merino D, Cremoni M, Laurain A, Pinel S, Bourneau-Martin D, Rocher F, Esnault VLM, Borchiellini D, Sicard A, Drici MD. Risk factors associated with immune checkpoint inhibitor-induced acute kidney injury compared to other immune-related adverse events: a case-control study. Clin Kidney J 2022; 15:1881-1887. [PMID: 36158153 PMCID: PMC9494514 DOI: 10.1093/ckj/sfac109] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Indexed: 11/27/2022] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) foster anti-cancer immune responses. Their efficacy comes at the cost of immune-related adverse events (IRAEs). The latter affects various organs, including kidneys, mostly as acute tubulointerstitial nephritis, the pathophysiology of which remains unclear. We conducted a multicentre case–control study to compare the characteristics of patients with renal IRAEs (ICI-AKI) with those of patients diagnosed with other IRAEs. Methods We queried the French pharmacovigilance database for all adverse events involving ICIs. Reports were classified as ICI-AKI or extrarenal IRAE. For each ICI-AKI report, four reports of extrarenal IRAEs were randomly included (control group, 4:1 ratio). Variables showing an association with a P < 0.05 were included as covariates in a multivariate analysis. Results Therefore, 167 ICI-AKI reports were compared with 668 extrarenal IRAEs. At least one concomitant extrarenal IRAE was mentioned in 44.3% of ICI-AKI reports. Patients with ICI-AKI were significantly older than patients with extrarenal IRAEs (69.1 versus 64.6 years; P = 0.0135), and chronic kidney disease was significantly more prevalent (12.0% versus 3.3%; P = 0.0125). Patients with ICI-AKI were significantly more likely to be treated with fluindione [adjusted odds ratio (OR) 6.53, 95% confidence interval (95% CI) 2.21–19.31; P = 0.0007], a non-steroidal anti-inflammatory drug (NSAID, OR 3.18, 95% CI 1.07–9.4; P = 0.0368) or a proton-pump inhibitor (PPI, OR 2.18, 95% CI 1.42–3.34; P = 0.0004). Conclusion This study is limited by a lack of data, preventing confirmation of numerous reports therefore not included in the analysis. We are unable to draw definite pathophysiological conclusions from our data. Nonetheless, we suggest that ICIs may be a ‘second-hit’ that precipitates acute kidney injury caused by another concomitant drug (fluindione, NSAID or PPI).
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Affiliation(s)
- Alexandre O Gerard
- Department of Nephrology-Dialysis-Transplantation, University Hospital Centre of Nice, Nice, France
- Department of Pharmacology and Pharmacovigilance Centre of Nice, University Hospital Centre of Nice, Nice, France
| | - Susana Barbosa
- Institute of Molecular and Cellular Pharmacology (IPMC), UMR 7275, CNRS, University Côte d'Azur, Valbonne, France
| | - Nadège Parassol
- Department of Pharmacology and Pharmacovigilance Centre of Nice, University Hospital Centre of Nice, Nice, France
| | - Marine Andreani
- Department of Nephrology-Dialysis-Transplantation, University Hospital Centre of Nice, Nice, France
| | - Diane Merino
- Department of Pharmacology and Pharmacovigilance Centre of Nice, University Hospital Centre of Nice, Nice, France
| | - Marion Cremoni
- Department of Nephrology-Dialysis-Transplantation, University Hospital Centre of Nice, Nice, France
| | - Audrey Laurain
- Department of Nephrology-Dialysis-Transplantation, University Hospital Centre of Nice, Nice, France
| | - Sylvine Pinel
- Pharmacovigilance Center of Paris - Fernand Widal, Assistance Publique - Hôpitaux de Paris, Paris, France
| | | | - Fanny Rocher
- Department of Pharmacology and Pharmacovigilance Centre of Nice, University Hospital Centre of Nice, Nice, France
| | - Vincent L M Esnault
- Department of Nephrology-Dialysis-Transplantation, University Hospital Centre of Nice, Nice, France
| | - Delphine Borchiellini
- Department of Medical Oncology, Centre Antoine Lacassagne, University Côte d'Azur, Nice, France
| | - Antoine Sicard
- Department of Nephrology-Dialysis-Transplantation, University Hospital Centre of Nice, Nice, France
- Laboratory of Molecular Physio Medicine (LP2M), UMR 7370, CNRS, University Côte d'Azur, Nice, France
- Clinical Research Unit of University Côte d'Azur (UR2CA), University Côte d'Azur, Nice France
| | - Milou-Daniel Drici
- Department of Pharmacology and Pharmacovigilance Centre of Nice, University Hospital Centre of Nice, Nice, France
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20
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Khauli MA, An TJ, Anderson MA. Imaging Findings in Immunotherapy-related Renal Toxicity. J Immunother 2022; 45:162-166. [PMID: 34670254 DOI: 10.1097/cji.0000000000000398] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/20/2021] [Indexed: 11/26/2022]
Abstract
Immunotherapy-related adverse events (irAEs) associated with immune-checkpoint inhibitors can affect nearly any organ system including commonly the luminal gastrointestinal tract, hepatobiliary system, lungs, endocrine glands, and skin, many of which have described imaging manifestations. In patients without clinically suspected irAEs, imaging findings may be the first indication of an abnormality that prompts further workup to facilitate early detection and initiation of appropriate treatment, such as therapy discontinuation or corticosteroid therapy. While some irAEs have well described imaging correlates, such as pneumonitis, hypophysitis, and colitis, others are not well described, such as nephritis. We report 2 cases of irAE nephritis associated with PD-1 inhibitor therapy and their imaging features.
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Affiliation(s)
| | | | - Mark A Anderson
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA
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21
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Abdelrahim M, Abudayyeh A. Renal Toxicity. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1342:389-397. [PMID: 34972976 DOI: 10.1007/978-3-030-79308-1_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
With the increasing use of immunotherapy, there has been an associated increased survival in many cancers but has also resulted in unregulated organ-specific toxicities. In this review, we will discuss the renal toxicities associated with a checkpoint inhibitor (CPI) from the typical acute tubulointerstitial nephritis to glomerulonephritis and their proposed mechanisms and treatments. We also discuss the use of CPI and reactivation of preexisting autoimmune disease with a focus on renal cell cancer in setting of chronic kidney disease (CKD). Transplant rejection in setting of CPI use has been further evaluated with single-center and multicenter retrospective studies, and available data will be presented in this chapter.
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Affiliation(s)
- Maen Abdelrahim
- Institute of Academic Medicine and Weill Cornell Medical College, Houston Methodist Cancer Center, Houston Methodist Cancer Center, Houston, TX, USA
| | - Ala Abudayyeh
- Division of Internal Medicine, Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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22
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Kelly-Goss MR, Badran YR, Dougan M. Update on Immune Checkpoint Inhibitor Enterocolitis. Curr Gastroenterol Rep 2022; 24:171-181. [PMID: 36264425 PMCID: PMC9583048 DOI: 10.1007/s11894-022-00852-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI) therapy revolutionized the treatment of multiple solid and hematologic malignancies. Yet, with it came profound inflammatory toxicities that mimic autoimmune diseases, termed immune-related adverse events (irAEs). Prominent among these is gastrointestinal inflammation, including a spectrum of gastritis, enteritis, and colitis. Here we synthesize an approach to immune checkpoint related enterocolitis (irEC) - including diagnostics and therapeutics - underpinned by new insights into the mechanism behind these phenomena. RECENT FINDINGS This review presents updated insights on how to approach irEC, including novel approaches to selective immunosuppressive therapy, the role of fecal microbiota transplant, and the underlying cellular mechanisms of irEC. This review provides an update on irEC diagnosis and therapy, with considerations of new therapies and special patient populations. The field of gastrointestinal irAEs requires additional investigation, which will ultimately provide the tools required for patients to continue to receive life-saving ICI therapy.
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Affiliation(s)
- Molly R. Kelly-Goss
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114 USA ,Harvard Medical School, Boston, MA 02115 USA
| | - Yousef R. Badran
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114 USA ,Harvard Medical School, Boston, MA 02115 USA ,Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114 USA
| | - Michael Dougan
- Harvard Medical School, Boston, MA 02115 USA ,Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114 USA
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23
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Elsherif SB, Anderson M, Chaudhry AA, Kumar SP, Gopireddy DR, Lall C, Bhosale PR. Response criteria for immunotherapy and the radiologic patterns of immune-related adverse events. Eur J Radiol 2021; 146:110062. [PMID: 34890935 DOI: 10.1016/j.ejrad.2021.110062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/11/2021] [Accepted: 11/18/2021] [Indexed: 12/11/2022]
Abstract
Immunotherapy has revolutionized clinical outcomes in both early-stage and advanced-stage malignancies. Immunotherapy has improved patient survival in both solid and hematologic disorders with the potential added benefit of less toxicity compared to conventional cytotoxic chemotherapy. Imaging plays a fundamental role in monitoring treatment response and assessment of immune-related adverse events, e.g. pneumonitis, colitis, etc. Familiarity with the current strategies of immune-related response evaluation and their limitations is essential for radiologists to guide clinicians with their treatment decisions. Radiologists should be aware of the wide spectrum of immune-related adverse events and their various radiological features as well as the patterns of treatment response associated with immunotherapies.
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Affiliation(s)
- Sherif B Elsherif
- The Department of Radiology, The University of Florida College of Medicine, Jacksonville, FL, USA.
| | - Marcus Anderson
- The Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ammar A Chaudhry
- The Department of Diagnostic Radiology, City of Hope National Cancer Center, Los Angeles, CA, USA
| | - Sindhu P Kumar
- The Department of Radiology, The University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dheeraj R Gopireddy
- The Department of Radiology, The University of Florida College of Medicine, Jacksonville, FL, USA
| | - Chandana Lall
- The Department of Radiology, The University of Florida College of Medicine, Jacksonville, FL, USA
| | - Priya R Bhosale
- The Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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Abstract
Hematologic malignancies are a broad category of cancers arising from the lymphoid and myeloid cell lines. The 2016 World Health Organization classification system incorporated molecular markers as part of the diagnostic criteria and includes more than 100 subtypes. This article focuses on the subtypes for which imaging with positron emission tomography/computed tomography (PET/CT) has become an integral component of the patient's evaluation, that is, lymphoma and multiple myeloma. Leukemia and histiocytic and dendritic cell neoplasms are also discussed as these indications for PET/CT are less common, but increasingly seen in clinic.
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25
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Pediatric onco-nephrology: time to spread the word : Part I: early kidney involvement in children with malignancy. Pediatr Nephrol 2021; 36:2227-2255. [PMID: 33245421 DOI: 10.1007/s00467-020-04800-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/28/2020] [Accepted: 09/25/2020] [Indexed: 12/29/2022]
Abstract
Onco-nephrology has been a growing field within the adult nephrology scope of practice. Even though pediatric nephrologists have been increasingly involved in the care of children with different forms of malignancy, there has not been an emphasis on developing special expertise in this area. The fast pace of discovery in this field, including the development of new therapy protocols with their own kidney side effects and the introduction of the CD19-targeted chimeric antigen receptor T cell (CAR-T) therapy, has introduced new challenges for general pediatric nephrologists because of the unique effects of these treatments on the kidney. Moreover, with the improved outcomes in children receiving cancer therapy come an increased number of survivors at risk for chronic kidney disease related to both their cancer diagnosis and therapy. Therefore, it is time for pediatric onco-nephrology to take its spot on the expanding subspecialties map in pediatric nephrology.
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26
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Kamyshova ES, Bobkova IN, Sekacheva MI. Kidney injury associated with antitumor therapy: focus on the adverse events of modern immuno-oncological drugs. TERAPEVT ARKH 2021; 93:649-660. [DOI: 10.26442/00403660.2021.06.200860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022]
Abstract
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.
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27
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The Mechanism of Drug Nephrotoxicity and the Methods for Preventing Kidney Damage. Int J Mol Sci 2021; 22:ijms22116109. [PMID: 34204029 PMCID: PMC8201165 DOI: 10.3390/ijms22116109] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is a global health challenge of vast proportions, as approx. 13.3% of people worldwide are affected annually. The pathophysiology of AKI is very complex, but its main causes are sepsis, ischemia, and nephrotoxicity. Nephrotoxicity is mainly associated with the use of drugs. Drug-induced AKI accounts for 19-26% of all hospitalized cases. Drug-induced nephrotoxicity develops according to one of the three mechanisms: (1) proximal tubular injury and acute tubular necrosis (ATN) (a dose-dependent mechanism), where the cause is related to apical contact with drugs or their metabolites, the transport of drugs and their metabolites from the apical surface, and the secretion of drugs from the basolateral surface into the tubular lumen; (2) tubular obstruction by crystals or casts containing drugs and their metabolites (a dose-dependent mechanism); (3) interstitial nephritis induced by drugs and their metabolites (a dose-independent mechanism). In this article, the mechanisms of the individual types of injury will be described. Specific groups of drugs will be linked to specific injuries. Additionally, the risk factors for the development of AKI and the methods for preventing and/or treating the condition will be discussed.
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28
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Brahmer JR, Abu-Sbeih H, Ascierto PA, Brufsky J, Cappelli LC, Cortazar FB, Gerber DE, Hamad L, Hansen E, Johnson DB, Lacouture ME, Masters GA, Naidoo J, Nanni M, Perales MA, Puzanov I, Santomasso BD, Shanbhag SP, Sharma R, Skondra D, Sosman JA, Turner M, Ernstoff MS. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse events. J Immunother Cancer 2021; 9:e002435. [PMID: 34172516 PMCID: PMC8237720 DOI: 10.1136/jitc-2021-002435] [Citation(s) in RCA: 287] [Impact Index Per Article: 95.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are the standard of care for the treatment of several cancers. While these immunotherapies have improved patient outcomes in many clinical settings, they bring accompanying risks of toxicity, specifically immune-related adverse events (irAEs). There is a need for clear, effective guidelines for the management of irAEs during ICI treatment, motivating the Society for Immunotherapy of Cancer (SITC) to convene an expert panel to develop a clinical practice guideline. The panel discussed the recognition and management of single and combination ICI irAEs and ultimately developed evidence- and consensus-based recommendations to assist medical professionals in clinical decision-making and to improve outcomes for patients.
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Affiliation(s)
- Julie R Brahmer
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Hamzah Abu-Sbeih
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Paolo Antonio Ascierto
- Unit of Melanoma Cancer Immunotherapy and Innovative Therapy, National Tumour Institute IRCCS Fondazione 'G. Pascale', Napoli, Italy
| | - Jill Brufsky
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura C Cappelli
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frank B Cortazar
- Massachusetts General Hospital, Boston, Massachusetts, USA
- New York Nephrology Vasculitis and Glomerular Center, Albany, New York, USA
| | - David E Gerber
- Department of Hematology and Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lamya Hamad
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Eric Hansen
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Mario E Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory A Masters
- Department of Medicine, Helen F. Graham Cancer Center, Newark, Delaware, USA
| | - Jarushka Naidoo
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
- Department of Oncology, Beaumont Hospital Dublin, The Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Michele Nanni
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Bianca D Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Satish P Shanbhag
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Cancer Specialist of North Florida, Fleming Island, Florida, USA
| | - Rajeev Sharma
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Dimitra Skondra
- Department of Ophthalmology and Visual Science, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jeffrey A Sosman
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Medical Center, Chicago, Illinois, USA
| | - Michelle Turner
- Department of Oncology and the Thoracic Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Marc S Ernstoff
- Division of Cancer Treatment & Diagnosis, National Cancer Institute, Rockville, Maryland, USA
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29
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Noto-Kadou-Kaza B, Desbuissons G, Isnard CB. Association of Acute Interstitial Nephritis with Nivolumab in Renal Cell Carcinoma: A Case Report. Indian J Nephrol 2021; 31:303-306. [PMID: 34376950 PMCID: PMC8330651 DOI: 10.4103/ijn.ijn_62_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/30/2020] [Accepted: 05/10/2020] [Indexed: 11/04/2022] Open
Abstract
Recently, a number of innovative anticancer agents such us the programmed death 1 (PD-1) immune checkpoint inhibitors have been developed. Nevertheless, this type of immunotherapy may be associated with immune-related adverse events whose pathophysiology is considered similar to those found in autoimmune diseases such as nephritis. We report the case of a 71-year-old female with metastatic renal carcinoma who underwent nephrectomy. After three lines of other chemotherapies (VEGF and mTOR inhibitors), the patient was treated by nivolumab (3 mg/kg) for 4 months and developed acute kidney injury 16 weeks after initiating this immunotherapy. Kidney biopsy displayed a diffuse extensive interstitial inflammation associated with moderate interstitial edema. The discontinuation of nivolumab and the administration of prednisone (at 1 mg/kg and tapered over 3 months) was an effective treatment of the interstitial edema and led to the recovery of the kidney function.
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Affiliation(s)
- Befa Noto-Kadou-Kaza
- Department of Nephrology, Pitie-Salpetriere, 47-80 Boulevard de l'Hôpital, 75013, Paris, France
| | - Geoffroy Desbuissons
- Department of Nephrology, Pitie-Salpetriere, 47-80 Boulevard de l'Hôpital, 75013, Paris, France
| | - Corinne Bagnis Isnard
- Department of Nephrology, Pitie-Salpetriere, 47-80 Boulevard de l'Hôpital, 75013, Paris, France
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30
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Nasser NJ, Gorenberg M, Agbarya A. First line Immunotherapy for Non-Small Cell Lung Cancer. Pharmaceuticals (Basel) 2020; 13:ph13110373. [PMID: 33171686 PMCID: PMC7695295 DOI: 10.3390/ph13110373] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/19/2022] Open
Abstract
Immunotherapy for non-small cell lung cancer (NSCLC) is incorporated increasingly in first line treatments protocols. Multiple phase 3 studies have tested different medications targeting programmed death receptor 1 (PD-1), programmed death-ligand 1 (PD-L1), cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), with or without chemotherapy. The inclusion criteria differ between the various clinical trials, including the cut-off levels of PD-L1 expression on tumor cells, and the tumor histology (squamous or non-squamous). Patients with tumor expression levels of PD-L1 ≥ 50% are candidates for treatment with single agent Pembrolizumab or Atezolizumab. Patients with PD-L1 < 50% are candidates for immunotherapy with pembrolizumab as a single agent if PL-1 > 1%; immunotherapy doublet, Nivolumab and Ipilimumab, or single agent immunotherapy combined with chemotherapy. Here we review phase 3 clinical trials utilizing immunotherapy in the first line for treatment of NSCLC, including Pembrolizumab in KEYNOTE-024, KEYNOTE-042, KEYNOTE-189 and KEYNOTE-407; Nivolumab and Ipilimumab in CHECKMATE-227 and CHECKMATE 9LA; and Atezolizumab in IMpower110, IMpower130 and IMpower150.
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Affiliation(s)
- Nicola J. Nasser
- Department of Radiation Oncology, University of Maryland School of Medicine, Maryland Proton Treatment Center, Baltimore, MD 21201, USA
- Correspondence: or
| | - Miguel Gorenberg
- Department of Nuclear Medicine, Bnai Zion Medical Center; the Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 31048, Israel;
| | - Abed Agbarya
- Institute of Oncology, Bnai Zion Medical Center, Haifa 31048, Israel;
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31
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Franzin R, Netti GS, Spadaccino F, Porta C, Gesualdo L, Stallone G, Castellano G, Ranieri E. The Use of Immune Checkpoint Inhibitors in Oncology and the Occurrence of AKI: Where Do We Stand? Front Immunol 2020; 11:574271. [PMID: 33162990 PMCID: PMC7580288 DOI: 10.3389/fimmu.2020.574271] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a novel class of immunotherapy drugs that have improved the treatment of a broad spectrum of cancers as metastatic melanoma, non-small lung cancer or renal cell carcinoma. These humanized monoclonal antibodies target inhibitory receptors (e.g. CTLA-4, PD-1, LAG-3, TIM-3) and ligands (PD-L1) expressed on T lymphocytes, antigen presenting cells and tumor cells and elicit an anti-tumor response by stimulating immune system. Nevertheless, the improved overall survival is complicated by the manifestation of Immune-related Adverse Effects (irAEs). During treatment with ICIs, the most common adverse kidney effect is represented by the development of acute kidney injury (AKI) with the acute tubulointerstitial nephritis as recurrent histological feature. The mechanisms involved in ICIs-induced AKI include the re-activation of effector T cells previously stimulated by nephrotoxic drugs (i.e. by antibiotics), the loss of tolerance versus self-renal antigens, the increased PD-L1 expression by tubular cells or the establishment of a pro-inflammatory milieu with the release of self-reactive antibodies. For renal transplant recipient treated with ICIs, the increased incidence of rejection is a serious concern. Therefore, the combination of ICIs with mTOR inhibitors represents an emerging strategy. Finally, it is relevant to anticipate which patients under ICIs would experience severe irAEs and from a kidney perspective, to predict patients with higher risk of AKI. Here, we provide a detailed overview of ICIs-related nephrotoxicity and the recently described multicenter studies. Several factors have been reported as biomarkers of ICIs-irAEs, in this review we speculate on potential biomarkers for ICIs-associated AKI.
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Affiliation(s)
- Rossana Franzin
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giuseppe Stefano Netti
- Clinical Pathology, Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Federica Spadaccino
- Clinical Pathology, Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Camillo Porta
- Oncology, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Elena Ranieri
- Clinical Pathology, Center of Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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32
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Pourvaziri A, Parakh A, Biondetti P, Sahani D, Kambadakone A. Abdominal CT manifestations of adverse events to immunotherapy: a primer for radiologists. Abdom Radiol (NY) 2020; 45:2624-2636. [PMID: 32451672 DOI: 10.1007/s00261-020-02531-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Immunotherapy is a rapidly growing field within oncology and is being increasingly used in the management of several malignancies. Due to their unique mechanism of action on the immune system and neoplastic cells, the response pattern and adverse events of this novel therapy are distinct from conventional systemic therapies. Accordingly, the imaging appearances following immunotherapy including adverse events are unique and at times perplexing. Imaging is integral to management of patients on immunotherapeutic agents and a thorough understanding of its mechanism, response patterns and adverse events is crucial for precise interpretation of imaging studies. This review provides a description of the mechanism of action of current immunotherapeutic agents and the organ-wise description of their side effects.
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Affiliation(s)
- Ali Pourvaziri
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Anushri Parakh
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Pierpaolo Biondetti
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA
| | - Dushyant Sahani
- Department of Radiology, University of Washington, UWMC Radiology RR218, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Avinash Kambadakone
- Division of Abdominal Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA, 02114, USA.
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33
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Wang LY, Wang JN, Diao ZL, Guan YM, Liu WH. Acute Kidney Injury in Oncology Patients. J Cancer 2020; 11:4700-4708. [PMID: 32626516 PMCID: PMC7330685 DOI: 10.7150/jca.45382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/11/2020] [Indexed: 12/17/2022] Open
Abstract
With rapid progress in cancer diagnosis and treatment in the last two decades, outcomes in oncological patients have improved significantly. However, the incidence of acute kidney injury (AKI) in this population has also increased significantly. AKI complicates many aspects of patients' care and adversely affects their prognoses; thus, accurately diagnosing the risk factors for AKI ensures appropriate management. AKI may be caused by pre-renal, intrinsic renal, and post-renal reasons, as well as for combined reasons. This review summarizes the potential etiologies of AKI according to the three classifications. For each underlying cause of AKI, the cancer itself and/or cancer treatment may contribute to a patient developing AKI. Therefore, we present disease- and treatment-related factors for each cause category, with special focus on immune checkpoint inhibitors, which are being used increasingly more often. It is important for nephrology services to be knowledgeable to provide the best level of care.
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Affiliation(s)
- Li-Yan Wang
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jia-Ni Wang
- National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zong-Li Diao
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yi-Ming Guan
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wen-Hu Liu
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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34
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Kähler KC, Hassel JC, Heinzerling L, Loquai C, Thoms KM, Ugurel S, Zimmer L, Gutzmer R. Side effect management during immune checkpoint blockade using CTLA-4 and PD-1 antibodies for metastatic melanoma - an update. J Dtsch Dermatol Ges 2020; 18:582-609. [PMID: 32489011 DOI: 10.1111/ddg.14128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
CTLA-4 and PD-1 play a key role in tumor-induced downregulation of lymphocytic immune responses. Immune checkpoint inhibitors have been shown to alter the immune response to various cancer types. Anti-CTLA-4 and anti-PD-1 antibodies affect the interaction between tumor, antigen-presenting cells and T lymphocytes. Clinical studies of the anti-CTLA-4 antibody ipilimumab and the anti-PD-1 antibodies nivolumab and pembrolizumab have provided evidence of their positive effects on overall survival in melanoma patients. Combined treatment using ipilimumab and nivolumab has been shown to achieve five-year survival rates of 52 %. Such enhancement of the immune response is inevitably associated with adverse events. Knowledge of the spectrum of side effects is essential, both in terms of prevention and management. Adverse events include colitis, dermatitis, hypophysitis, thyroiditis, hepatitis and other, less common autoimmune phenomena. In recent years, considerable progress has been made in the detection and treatment of the aforementioned immune-related adverse events. However, early diagnosis of rare neurological or cardiac side effects, which may be associated with increased mortality, frequently pose a challenge. The present update highlights our current understanding as well as new insights into the spectrum of side effects associated with checkpoint inhibitors and their management.
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Affiliation(s)
- Katharina C Kähler
- Department of Dermatology, Venereology and Allergology, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jessica C Hassel
- Department of Dermatology and National Center for Tumor Diseases, University Medical Center, Heidelberg, Germany
| | - Lucie Heinzerling
- Department of Dermatology, University Medical Center, Erlangen, Germany
| | - Carmen Loquai
- Department of Dermatology, University Medical Center, Mainz, Germany
| | - Kai-Martin Thoms
- Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Medical Center, Essen, Germany
| | - Lisa Zimmer
- Department of Dermatology, Venereology and Allergology, University Medical Center, Essen, Germany
| | - Ralf Gutzmer
- Department of Dermatology, Venereology and Allergology, Skin Cancer Center, Hanover Medical School, Hanover, Germany
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35
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Kähler KC, Hassel JC, Heinzerling L, Loquai C, Thoms K, Ugurel S, Zimmer L, Gutzmer R. Nebenwirkungsmanagement bei Immun‐Checkpoint‐Blockade durch CTLA‐4‐ und PD‐1‐Antikörper beim metastasierten Melanom – ein Update. J Dtsch Dermatol Ges 2020; 18:582-609. [DOI: 10.1111/ddg.14128_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Katharina C. Kähler
- Klinik für Dermatologie Venerologie und Allergologie Universitätsklinikum Schleswig‐Holstein Campus Kiel
| | - Jessica C. Hassel
- Hautklinik und Nationales Centrum für Tumorerkrankungen Universitätsklinikum Heidelberg
| | | | | | - Kai‐Martin Thoms
- Klinik für Dermatologie Venerologie und Allergologie Universitätsmedizin Göttingen
| | - Selma Ugurel
- Klinik für Dermatologie Venerologie und Allergologie Universitätsklinikum Essen
| | - Lisa Zimmer
- Klinik für Dermatologie Venerologie und Allergologie Universitätsklinikum Essen
| | - Ralf Gutzmer
- Klinik für Dermatologie Allergologie und Venerologie Hauttumorzentrum Hannover Medizinische Hochschule Hannover
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Parthymos I, Liamis G, Dounousi E, Pentheroudakis G, Mauri D, Zarkavelis G, Florentin M. Metabolic consequences of immune checkpoint inhibitors: A new challenge in clinical practice. Crit Rev Oncol Hematol 2020; 151:102979. [PMID: 32480349 DOI: 10.1016/j.critrevonc.2020.102979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 02/29/2020] [Accepted: 05/03/2020] [Indexed: 12/13/2022] Open
Abstract
Treatment of oncologic patients has progressed greatly the last few years with the development of immune checkpoint inhibitors (ICPIs). These drugs are associated with the immune system and, thus, may cause side effects of immune origin, the so called immune related adverse events (irAEs). Immune related AEs may actually affect all organs and systems and frequently resemble clinical entities commonly encountered in clinical practice. As ICPIs have improved both quality of life and life expectancy, clinicians of various specialties may need to deal with irAEs in their everyday practice. Therefore, they should be able to recognize them timely and treat them accordingly. Herein, we review the pathophysiology, clinical manifestations and treatment of irAEs.
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Affiliation(s)
- Ioannis Parthymos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Evangelia Dounousi
- Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Pentheroudakis
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - Davide Mauri
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - George Zarkavelis
- Department of Medical Oncology, University Hospital of Ioannina, Ioannina, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), Ioannina, Greece
| | - Matilda Florentin
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece.
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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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Abstract
Programed death-ligand 1 (PD-L1, B7-H1, CD274) is a coinhibitory molecule that plays a vital role in the pathogenesis of both neoplastic and nonneoplastic diseases. However, the role of PD-L1 in primary and secondary renal diseases remains to be clarified. Previous studies have shown that both intracellular and intercellular PD-L1 participate in renal diseases via complex mechanisms. PD-L1 plays a dual role in lupus nephritis and has a protective effect in renal ischemia reperfusion injury and nephrotoxic nephritis but not in proliferative immune complex glomerulonephritis. PD-L1 supplementation, anti-PD-L1 antibodies, and D-peptide antagonists have promising application prospects in the treatment of renal diseases. In this review, we summarize the available data published on PD-L1 in renal diseases for the first time.
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Affiliation(s)
- Yi Wei
- Department of Nephrology, The Sixth affiliated hospital, Sun Yat-sen University, Guangzhou, China
| | - Zongpei Jiang
- Department of Nephrology, The Sixth affiliated hospital, Sun Yat-sen University, Guangzhou, China
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39
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Choi J, Lee SY. Clinical Characteristics and Treatment of Immune-Related Adverse Events of Immune Checkpoint Inhibitors. Immune Netw 2020; 20:e9. [PMID: 32158597 PMCID: PMC7049586 DOI: 10.4110/in.2020.20.e9] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have been changing the paradigm of cancer treatment. However, immune-related adverse effects (irAEs) have also increased with the exponential increase in the use of ICIs. ICIs can break up the immunologic homeostasis and reduce T-cell tolerance. Therefore, inhibition of immune checkpoint can lead to the activation of autoreactive T-cells, resulting in various irAEs similar to autoimmune diseases. Gastrointestinal toxicity, endocrine toxicity, and dermatologic toxicity are common side effects. Neurotoxicity, cardiotoxicity, and pulmonary toxicity are relatively rare but can be fatal. ICI-related gastrointestinal toxicity, dermatologic toxicity, and hypophysitis are more common with anti- CTLA-4 agents. ICI-related pulmonary toxicity, thyroid dysfunction, and myasthenia gravis are more common with PD-1/PD-L1 inhibitors. Treatment with systemic steroids is the principal strategy against irAEs. The use of immune-modulatory agents should be considered in case of no response to the steroid therapy. Treatment under the supervision of multidisciplinary specialists is also essential, because the symptoms and treatments of irAEs could involve many organs. Thus, this review focuses on the mechanism, clinical presentation, incidence, and treatment of various irAEs.
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Affiliation(s)
- Juwhan Choi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea
| | - Sung Yong Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul 08308, Korea
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40
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Toxicités rénales des inhibiteurs des points de contrôle de l’auto-immunité. Nephrol Ther 2020; 16:19-26. [DOI: 10.1016/j.nephro.2019.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/31/2019] [Indexed: 12/29/2022]
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41
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The renal adverse effects of cancer immunotherapy. J Nephrol 2020; 33:467-481. [PMID: 31912436 DOI: 10.1007/s40620-019-00691-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/21/2019] [Indexed: 12/14/2022]
Abstract
Over the past decade, the development and clinical use of immunotherapy agents has increased exponentially. As clinical experience builds with these agents so too does our understanding of the associated adverse effects. In particular, the effects of immunotherapy on the kidneys, individual nephrons, and kidney function remain less well described than the adverse effects on barrier organ systems such as the gastrointestinal tract and skin. However, phase IV post-marketing surveillance and clinical case studies together with basic research has begun to reveal mechanisms by which immunotherapy mediates renal adverse effects. This work may lead to improvements in treatment guidelines and therapy. These advances are particularly important as post-cancer survival increases leaving patients to cope with the consequences of not only the cancer, but the short- and long-term adverse effects of treatment. Here we discuss the major renal adverse effects encountered with individual immunotherapeutic agents, putative mechanisms, their current management, and how cancer survivorship programs can help patients who have been treated with immunotherapy.
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42
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43
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Izzedine H. [Renal toxicities of targeted therapies in oncology]. Nephrol Ther 2019; 16:1-8. [PMID: 31818703 DOI: 10.1016/j.nephro.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/23/2019] [Indexed: 02/01/2023]
Abstract
The advent of new molecules oncology including targeted therapies, has resulted in improved patient survival over standard chemotherapy. The renal toxicities of these anticancer agents are more and more recognized and vary according to the targeted therapeutic target. This article reviews the renal toxicity associated with targeted anticancer therapies directed against Epidermal growth factor receptor, Human epidermal growth factor-2, B-rapidly accelerated fibrosarcoma, Mitogen-activated protein kinase, Anaplastic lymphoma kinase, Programmed cell death-1/programmed cell death ligand-1, Cytotoxic T lymphocyte antigen-4 and Vascular endothelial growth factor/receptor. The early diagnosis and management of these renal adverse events is essential for the clinician who cares for such patients.
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Affiliation(s)
- Hassan Izzedine
- Ramsay GDS, service de néphrologie, hôpital privé des Peupliers, 8, place de l'Abbé-Henocque, 75013 Paris, France.
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44
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Spiers L, Coupe N, Payne M. Toxicities associated with checkpoint inhibitors-an overview. Rheumatology (Oxford) 2019; 58:vii7-vii16. [PMID: 31816085 PMCID: PMC6900917 DOI: 10.1093/rheumatology/kez418] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/30/2019] [Indexed: 12/14/2022] Open
Abstract
Immunotherapy has an increasing role in the management of cancer, both in metastatic disease and as an adjuvant therapy. However, sensitization of the immune system with checkpoint inhibitors comes with a unique side effect profile. Full appreciation of this can take some time to emerge as some adverse events are rare, or can be subtle and potentially overlooked. Clinician awareness of these side effects can be particularly important in patients with pre-existing autoimmune conditions. Here we describe common symptoms and diagnostic strategies for organ-specific side effects of anti-CTLA-4 and anti-PD-1/PD-L1 immunotherapy agents.
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Affiliation(s)
- Laura Spiers
- Department of Oncology, Churchill Hospital, Oxford University Hospitals Foundation Trust, Oxford, UK
| | - Nicholas Coupe
- Department of Oncology, Churchill Hospital, Oxford University Hospitals Foundation Trust, Oxford, UK
| | - Miranda Payne
- Department of Oncology, Churchill Hospital, Oxford University Hospitals Foundation Trust, Oxford, UK
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45
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Simeone E, Grimaldi AM, Festino L, Trojaniello C, Vitale MG, Vanella V, Palla M, Ascierto PA. Immunotherapy in metastatic melanoma: a novel scenario of new toxicities and their management. Melanoma Manag 2019; 6:MMT30. [PMID: 31871619 PMCID: PMC6920742 DOI: 10.2217/mmt-2019-0005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Checkpoint inhibitors can cause an imbalance in immune tolerance that may clinically manifest as immune-related adverse events (irAEs). These events may involve many organs and tissues, including the skin, gastrointestinal (GI) tract, liver, endocrine system, kidneys, central nervous system (CNS), eyes and lungs. The incidence of irAEs appears to be lower with anti-programmed death antigen-1/programmed death antigen-ligand-1 agents than with the anti-cytotoxic T-lymphocyte-associated protein-4 antibody ipilimumab. Combined immunotherapy does not appear to be associated with novel safety signals compared with monotherapy, but more organs may be involved. Increased experience and the use of algorithms for the most common irAEs have resulted in severe toxicity and related deaths being reduced. However, continuous vigilance, especially regarding less common events, is needed to better characterize the wide spectrum of clinical manifestations.
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Affiliation(s)
- Ester Simeone
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Antonio M Grimaldi
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Lucia Festino
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Claudia Trojaniello
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Maria G Vitale
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Vito Vanella
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Marco Palla
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
| | - Paolo A Ascierto
- Unit of Melanoma, Cancer Immunotherapy & Innovative Therapies Unit - Istituto Nazionale Tumori Fondazione 'G. Pascale,' IRCCS, 80131, Napoli, Italy
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46
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Qiu W, Zheng K, Wang H, Si X, Zhang X, Li X, Zhang L. [Clinical Diagnosis and Treatment Recommendation of Immune-related Adverse Renal Events Related to Immune Checkpoint Inhibitor]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2019; 22:645-648. [PMID: 31650947 PMCID: PMC6817426 DOI: 10.3779/j.issn.1009-3419.2019.10.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
免疫检查点抑制剂(immuno-checkpoint inhibitors, ICIs)正越来越多地应用于临床肿瘤治疗,显著改善了患者预后。T细胞过度活化及相关信号通路的激活,可能引起药物相关的免疫相关不良反应(immune-related adverse effects, irAEs)。其中肾脏免疫相关不良反应相对罕见,但也存在严重甚至致命的副作用。本文分析ICIs免疫相关肾损伤的发病率、临床表现及肾脏病理表现,着重讨论诊断和治疗原则。因存在诸多继发因素须与ICIs免疫相关肾损伤相鉴别,必要时应行肾活检以决定重要药物的治疗决策。
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Affiliation(s)
- Wei Qiu
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ke Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hanping Wang
- Department of Respirology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiaoyan Si
- Department of Respirology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiaotong Zhang
- Department of Respirology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Li Zhang
- Department of Respirology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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47
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Lemoine M, Dilly B, Curie A, Hébert V, Laurent C, Hanoy M, Grangé S, Guerrot D, François A, Bertrand D. Ipilimumab-induced renal granulomatous arteritis: a case report. BMC Nephrol 2019; 20:366. [PMID: 31604452 PMCID: PMC6788031 DOI: 10.1186/s12882-019-1552-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 09/06/2019] [Indexed: 12/13/2022] Open
Abstract
Background Immune Checkpoint Inhibitors (ICPIs) are promising new drugs in treatment of advanced tumours targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4) and programmed cell death protein-1 (PD1) or its ligand (PDL-1). Ipilimumab is a monoclonal antibody targeting the CTLA-4 receptor used in treatment of metastatic melanoma. By increasing activity of the immune system, ICPIs lead to immune-related adverse events, such as dermatitis, colitis or hepatitis. ICPIs-related kidney adverse events are rare and acute tubulointerstitial nephritis with or without granuloma have mainly been reported. Case presentation We report a case of acute kidney injury in a patient with melanoma treated by ipilimumab. Kidney biopsy revealed acute interlobular and juxtaglomerular granulomatous arteritis, which has not yet been reported in patients treated by ICPIs. Kidney function partially recovered after ipilimumab discontinuation and oral prednisone. Unfortunately, the patient died a few months later from progression of his melanoma. Conclusion This case highlights a new mechanism of acute kidney injury related to ICPIs and supports the interest of kidney biopsy in case of ICPIs related acute renal failure.
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Affiliation(s)
- Mathilde Lemoine
- Nephrology department, Rouen University Hospital, 147 avenue du Maréchal Juin 76230 Bois Guillaume, Rouen, France.
| | - Baptiste Dilly
- Nephrology department, Rouen University Hospital, 147 avenue du Maréchal Juin 76230 Bois Guillaume, Rouen, France
| | - Alexandre Curie
- Nephrology department, Rouen University Hospital, 147 avenue du Maréchal Juin 76230 Bois Guillaume, Rouen, France
| | - Vivien Hébert
- Dermatology department, Rouen University Hospital, Rouen, France
| | - Charlotte Laurent
- Nephrology department, Rouen University Hospital, 147 avenue du Maréchal Juin 76230 Bois Guillaume, Rouen, France
| | - Mélanie Hanoy
- Nephrology department, Rouen University Hospital, 147 avenue du Maréchal Juin 76230 Bois Guillaume, Rouen, France
| | - Steven Grangé
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, France
| | - Dominique Guerrot
- Nephrology department, Rouen University Hospital, 147 avenue du Maréchal Juin 76230 Bois Guillaume, Rouen, France.,INSERM U1096, Rouen University Medical School, Rouen, France
| | - Arnaud François
- Pathology department, Rouen University Hospital, Rouen, France
| | - Dominique Bertrand
- Nephrology department, Rouen University Hospital, 147 avenue du Maréchal Juin 76230 Bois Guillaume, Rouen, France
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48
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Del Rivero J, Cordes LM, Klubo-Gwiezdzinska J, Madan RA, Nieman LK, Gulley JL. Endocrine-Related Adverse Events Related to Immune Checkpoint Inhibitors: Proposed Algorithms for Management. Oncologist 2019; 25:290-300. [PMID: 32297436 DOI: 10.1634/theoncologist.2018-0470] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/15/2019] [Indexed: 12/16/2022] Open
Abstract
Immune checkpoint inhibitors have proven to be effective for various advanced neoplasia. Immune-related adverse events (irAEs) as a result of increased T cell activation are unique and potentially life-threating toxicities associated with the use of immune checkpoint inhibitors. Multiple endocrine irAEs, including primary hyperthyroidism and hypothyroidism, thyroiditis, primary adrenal insufficiency, type 1 diabetes mellitus, and hypophysitis, have been reported with the use of various immune checkpoint inhibitors. In some cases, these irAEs can lead to discontinuation of treatment. Here we propose for the general oncologist algorithms for managing endocrine irAEs to aid in the clinical care of patients receiving immunotherapy. KEY POINTS: There is a relative high risk of endocrine immune-related adverse events (irAEs) during therapy with checkpoint inhibitors, particularly when combination therapy is implemented. Patients treated with anti-CTLA-4 antibodies have an increased risk of hypophysitis, whereas patients treated with anti-PD-1/PD-L1 antibodies have a higher risk of primary thyroid dysfunction. Rarely, patients develop T1DM and central diabetes insipidus, and hypoparathyroidism is a rare occurrence. A growing clinical understanding of endocrine irAEs has led to effective treatment strategies with hormone replacement.
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Affiliation(s)
- Jaydira Del Rivero
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa M Cordes
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Joanna Klubo-Gwiezdzinska
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Ravi A Madan
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lynnette K Nieman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - James L Gulley
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Kaur A, Doberstein T, Amberker RR, Garje R, Field EH, Singh N. Immune-related adverse events in cancer patients treated with immune checkpoint inhibitors: A single-center experience. Medicine (Baltimore) 2019; 98:e17348. [PMID: 31593084 PMCID: PMC6799752 DOI: 10.1097/md.0000000000017348] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) like cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA4) and programmed death cell protein 1 (anti-PD1) have revolutionized cancer treatment. As ICI use becomes widespread, more immune-related adverse events (irAE's) are being reported. Our aim was to investigate the frequency and nature of new irAE's as well as report the frequency of flare-ups of pre-existing autoimmune conditions occurring after ICI therapy.We performed a retrospective chart review of all patients treated for cancer with anti-PD1 or anti-CTLA4 or combination therapy at our tertiary care center from January 2014 to April 2016. Demographic data, cancer type and stage, irAE's (new immune disorders and disease flares of pre-existing autoimmune disorders on ICI therapy), and drug treatment information were extracted.We identified 220 patients treated with ICI therapy during the study period out of which 27% (60/220) developed irAE's. 11% in anti-CTLA4 group and 16% among anti-PD1 treated patients developed irAE's. IrAE's resulted in discontinuation of cancer therapy in 28% of those who developed irAE's. 21.4% had a flare of their autoimmune disease but only 1 required discontinuation of immunotherapy.IrAE's are an important emerging clinical disease entity for specialists to be aware of. Our study shows that ICI's can be safely used in patients with pre-existing autoimmune conditions with close monitoring. However, there is still a large unmet need to have a better understanding of how to systematically evaluate and manage patients with irAE's as well as for identifying the predictors of irAE's.
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Affiliation(s)
- Aneet Kaur
- Division of Immunology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | | | | | - Elizabeth Hirak Field
- Division of Immunology, University of Iowa and Clinics and Iowa City VA Medical Center
| | - Namrata Singh
- Division of Immunology, University of Iowa Hospitals and Clinics and Iowa City VA Medical Center, Iowa City, IA
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50
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Marco T, Anna P, Annalisa T, Francesco M, Stefania SL, Stella D, Michele R, Marco T, Loreto G, Franco S. The mechanisms of acute interstitial nephritis in the era of immune checkpoint inhibitors in melanoma. Ther Adv Med Oncol 2019; 11:1758835919875549. [PMID: 31579108 PMCID: PMC6759704 DOI: 10.1177/1758835919875549] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
Treatment with immune checkpoint inhibitors (ICIs) has improved the prognosis of patients with a number of types of cancer, but the frequent development of immune-related adverse effects (irAEs) can worsen the outcome. The most common irAEs involve the gastrointestinal, cutaneous, and endocrine systems, but nephrotoxicity, resulting from damage to the tubule-interstitial compartment, may occur in some patients. The early phases of acute interstitial nephritis (AIN) are characterized by systemic symptoms that indicate a poor clinical state as well as a mild deterioration of renal function. Tubular injury is due to a direct effect mediated by cytotoxic CD8+ T cells, which sustain the local production of pro-inflammatory cytokines that progressively impair renal function. The treatment of AIN is mainly based on high-dose steroids, which in most instances leads to the recovery of renal function. However, the premature discontinuation of ICI therapy may prevent the impact of treatment on the clinical progression of the malignancy. Adequately addressing irAEs requires a standardized therapy that is based on the results of large clinical trials.
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Affiliation(s)
- Tucci Marco
- DIMO, Department of Biomedical Sciences and Clinical Oncology, University of Bari 'Aldo Moro', Section of Internal Medicine and Oncology, P.za Giulio Cesare, 11 - 70124 BARI, Italy
| | - Passarelli Anna
- DIMO, Department of Biomedical Sciences and Clinical Oncology, University of Bari, 'Aldo Moro' Italy
| | - Todisco Annalisa
- DIMO, Department of Biomedical Sciences and Clinical Oncology, University of Bari, 'Aldo Moro' Italy
| | - Mannavola Francesco
- DIMO, Department of Biomedical Sciences and Clinical Oncology, University of Bari, 'Aldo Moro' Italy
| | - Stucci Luigia Stefania
- DIMO, Department of Biomedical Sciences and Clinical Oncology, University of Bari, 'Aldo Moro' Italy
| | - D'Oronzo Stella
- DIMO, Department of Biomedical Sciences and Clinical Oncology, University of Bari, 'Aldo Moro' Italy
| | - Rossini Michele
- DETO, Department of Emergency and Organ Transplantation, University of Bari, 'Aldo Moro' Italy
| | - Taurisano Marco
- DETO, Department of Emergency and Organ Transplantation, University of Bari, 'Aldo Moro' Italy
| | - Gesualdo Loreto
- DETO, Department of Emergency and Organ Transplantation, University of Bari, 'Aldo Moro' Italy
| | - Silvestris Franco
- DIMO, Department of Biomedical Sciences and Clinical Oncology, University of Bari, 'Aldo Moro' Italy
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