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Birkelo BC, Koyner JL, Ostermann M, Bhatraju PK. The Road to Precision Medicine for Acute Kidney Injury. Crit Care Med 2024; 52:1127-1137. [PMID: 38869385 PMCID: PMC11250999 DOI: 10.1097/ccm.0000000000006328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVES Acute kidney injury (AKI) is a common form of organ dysfunction in the ICU. AKI is associated with adverse short- and long-term outcomes, including high mortality rates, which have not measurably improved over the past decade. This review summarizes the available literature examining the evidence of the need for precision medicine in AKI in critical illness, highlights the current evidence for heterogeneity in the field of AKI, discusses the progress made in advancing precision in AKI, and provides a roadmap for studying precision-guided care in AKI. DATA SOURCES Medical literature regarding topics relevant to precision medicine in AKI, including AKI definitions, epidemiology, and outcomes, novel AKI biomarkers, studies of electronic health records (EHRs), clinical trial design, and observational studies of kidney biopsies in patients with AKI. STUDY SELECTION English language observational studies, randomized clinical trials, reviews, professional society recommendations, and guidelines on areas related to precision medicine in AKI. DATA EXTRACTION Relevant study results, statements, and guidelines were qualitatively assessed and narratively synthesized. DATA SYNTHESIS We synthesized relevant study results, professional society recommendations, and guidelines in this discussion. CONCLUSIONS AKI is a syndrome that encompasses a wide range of underlying pathologies, and this heterogeneity has hindered the development of novel therapeutics for AKI. Wide-ranging efforts to improve precision in AKI have included the validation of novel biomarkers of AKI, leveraging EHRs for disease classification, and phenotyping of tubular secretory clearance. Ongoing efforts such as the Kidney Precision Medicine Project, identifying subphenotypes in AKI, and optimizing clinical trials and endpoints all have great promise in advancing precision medicine in AKI.
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Affiliation(s)
- Bethany C Birkelo
- Division of Nephrology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St. Thomas' Hospital, London, United Kingdom
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Kidney Research Institute, University of Washington, Seattle, WA
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Chen JJ, Lee TH, Kuo G, Yen CL, Lee CC, Chang CH, Tu KH, Chen YC, Fang JT, Hung CC, Yang CW, Chou WC, Chi CC, Tu YK, Yu Yang H. All-cause and immune checkpoint inhibitor-associated acute kidney injury in immune checkpoint inhibitor users: a meta-analysis of occurrence rate, risk factors and mortality. Clin Kidney J 2024; 17:sfad292. [PMID: 38186874 PMCID: PMC10768773 DOI: 10.1093/ckj/sfad292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Indexed: 01/09/2024] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) have been associated with acute kidney injury (AKI). However, the occurrence rate of ICI-related AKI has not been systematically examined. Additionally, exposure to proton pump inhibitors (PPIs) and non-steroidal anti-inflammatory drugs (NSAIDs) were considered as risk factors for AKI, but with inconclusive results in ICI-related AKI. Our aim was to analyse the occurrence rate of all-cause AKI and ICI-related AKI and the occurrence rates of severe AKI and dialysis-requiring AKI, and to determine whether exposure to PPIs and NSAIDs poses a risk for all-cause and ICI-related AKI. Methods This study population was adult ICI recipients. A systematic review was conducted by searching MEDLINE, Embase and PubMed through October 2023. We included prospective trials and observational studies that reported any of the following outcomes: the occurrence rate of all-cause or ICI-related AKI, the relationship between PPI or NSAID exposure and AKI development or the mortality rate in the AKI or non-AKI group. Proportional meta-analysis and pairwise meta-analysis were performed. The evidence certainty was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. Results A total of 120 studies comprising 46 417 patients were included. The occurrence rates of all-cause AKI were 7.4% (14.6% from retrospective studies and 1.2% from prospective clinical trials). The occurrence rate of ICI-related AKI was 3.2%. The use of PPIs was associated with an odds ratio (OR) of 1.77 [95% confidence interval (CI) 1.43-2.18] for all-cause AKI and an OR of 2.42 (95% CI 1.96-2.97) for ICI-related AKI. The use of NSAIDs was associated with an OR of 1.77 (95% CI 1.10-2.83) for all-cause AKI and an OR of 2.57 (95% CI 1.68-3.93) for ICI-related AKI. Conclusions Our analysis revealed that approximately 1 in 13 adult ICI recipients may experience all-cause AKI, while 1 in 33 adult ICI recipients may experience ICI-related AKI. Exposure to PPIs and NSAIDs was associated with an increased OR risk for AKI in the current meta-analysis.
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Affiliation(s)
- Jia-Jin Chen
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tao-Han Lee
- Nephrology Department, Chansn Hospital, Taoyuan City, Taiwan
| | - George Kuo
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chieh-Li Yen
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kun-Hua Tu
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ji-Tseng Fang
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Cheng-Chieh Hung
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Wei Yang
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Department of Hematology and Oncology, Chang Gung Memorial Hospital in Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Chi Chi
- School of Medicine, College of Medicine, Chang Gung University; Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Yu-Kang Tu
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Huang- Yu Yang
- Kidney Research Center, Nephrology Department, Chang Gung Memorial Hospital in Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Coca SG. Do Novel Biomarkers Have Utility in the Diagnosis and Prognosis of AKI? CON. KIDNEY360 2023; 4:1667-1669. [PMID: 37291706 PMCID: PMC10758505 DOI: 10.34067/kid.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Steven G Coca
- Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Plappert D, Kraft L, Amann K, Latus J. [Acute interstitial nephritis and hantavirus infection]. Dtsch Med Wochenschr 2023; 148:1525-1535. [PMID: 37949081 DOI: 10.1055/a-1950-7419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Acute interstitial nephritis (AIN) is a cause of acute kidney injury and characterized by an inflammation of the tubulointerstitial space, leading to a decline in kidney function. Multiple etiologies can cause AIN including medications, autoimmune diseases and infections. A multiplicity of drugs is associated with AIN, while antibiotics (especially beta-lactams), proton-pump inhibitors (PPI) and non-steroidal anti-inflammatory agents (NSAIDs) are the most common. The pathognomonic triad of exanthema, fever and eosinophilia is rarely present in AIN patients. Treatment of medication-associated AIN is based upon the discontinuation of the provoking drug. Glucocorticoids can be considered in severe cases.Nephropathia epidemica (NE) is a disease caused by an infection with the Puumula-virus (PUUV) in northern and central Europe. Small rodents (mostly mice) are the host of the virus accountable for a rising number of infections during spring and summer. It is causing a syndrome consisting of AIN, fever and often thrombocytopenia. There is a good chance of complete recovery of kidney function following NE.
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Stanski NL, Rodrigues CE, Strader M, Murray PT, Endre ZH, Bagshaw SM. Precision management of acute kidney injury in the intensive care unit: current state of the art. Intensive Care Med 2023; 49:1049-1061. [PMID: 37552332 DOI: 10.1007/s00134-023-07171-z] [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: 04/19/2023] [Accepted: 07/12/2023] [Indexed: 08/09/2023]
Abstract
Acute kidney injury (AKI) is a prototypical example of a common syndrome in critical illness defined by consensus. The consensus definition for AKI, traditionally defined using only serum creatinine and urine output, was needed to standardize the description for epidemiology and to harmonize eligibility for clinical trials. However, AKI is not a simple disease, but rather a complex and multi-factorial syndrome characterized by a wide spectrum of pathobiology. AKI is now recognized to be comprised of numerous sub-phenotypes that can be discriminated through shared features such as etiology, prognosis, or common pathobiological mechanisms of injury and damage. The characterization of sub-phenotypes can serve to enable prognostic enrichment (i.e., identify subsets of patients more likely to share an outcome of interest) and predictive enrichment (identify subsets of patients more likely to respond favorably to a given therapy). Existing and emerging biomarkers will aid in discriminating sub-phenotypes of AKI, facilitate expansion of diagnostic criteria, and be leveraged to realize personalized approaches to management, particularly for recognizing treatment-responsive mechanisms (i.e., endotypes) and targets for intervention (i.e., treatable traits). Specific biomarkers (e.g., serum renin; olfactomedin 4 (OLFM4); interleukin (IL)-9) may further enable identification of pathobiological mechanisms to serve as treatment targets. However, even non-specific biomarkers of kidney injury (e.g., neutrophil gelatinase-associated lipocalin, NGAL; [tissue inhibitor of metalloproteinases 2, TIMP2]·[insulin like growth factor binding protein 7, IGFBP7]; kidney injury molecule 1, KIM-1) can direct greater precision management for specific sub-phenotypes of AKI. This review will summarize these evolving concepts and recent innovations in precision medicine approaches to the syndrome of AKI in critical illness, along with providing examples of how they can be leveraged to guide patient care.
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Affiliation(s)
- Natalja L Stanski
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Camila E Rodrigues
- Department of Nephrology, Prince of Wales Clinical School, UNSW Medicine, Sydney, NSW, Australia
- Nephrology Department, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Michael Strader
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
| | - Patrick T Murray
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
| | - Zoltan H Endre
- Department of Nephrology, Prince of Wales Clinical School, UNSW Medicine, Sydney, NSW, Australia
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, 2-124 Clinical Sciences Building, 8440-112 ST NW, Edmonton, AB, T6G 2B7, Canada.
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Canney M, Clark EG, Hiremath S. Biomarkers in acute kidney injury: On the cusp of a new era? J Clin Invest 2023; 133:e171431. [PMID: 37395275 DOI: 10.1172/jci171431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
The field of nephrology has been slow in moving beyond the utilization of creatinine as an indicator for chronic kidney disease and acute kidney injury (AKI). Early diagnosis and establishment of etiology, in particular, are important for treatment of AKI. In the setting of hospital-acquired AKI, tubular injury is more common, but acute interstitial nephritis (AIN) has a more treatable etiology. However, it is likely that AIN is under- or misdiagnosed due to current strategies that largely rely on clinical gestalt. In this issue of the JCI, Moledina and colleagues made an elegant case for the chemokine called C-X-C motif ligand 9 (CXCL9) as a biomarker of AIN. The authors used urine proteomics and tissue transcriptomics in patients with and without AIN to identify CXCL9 as a promising, noninvasive, diagnostic biomarker of AIN. These results have clinical implications that should catalyze future research and clinical trials in this space.
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Affiliation(s)
- Mark Canney
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Moledina DG, Obeid W, Smith RN, Rosales I, Sise ME, Moeckel G, Kashgarian M, Kuperman M, Campbell KN, Lefferts S, Meliambro K, Bitzer M, Perazella MA, Luciano RL, Pober JS, Cantley LG, Colvin RB, Wilson FP, Parikh CR. Identification and validation of urinary CXCL9 as a biomarker for diagnosis of acute interstitial nephritis. J Clin Invest 2023; 133:e168950. [PMID: 37395276 PMCID: PMC10313360 DOI: 10.1172/jci168950] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/14/2023] [Indexed: 07/04/2023] Open
Abstract
BackgroundAcute tubulointerstitial nephritis (AIN) is one of the few causes of acute kidney injury with diagnosis-specific treatment options. However, due to the need to obtain a kidney biopsy for histological confirmation, AIN diagnosis can be delayed, missed, or incorrectly assumed. Here, we identify and validate urinary CXCL9, an IFN-γ-induced chemokine involved in lymphocyte chemotaxis, as a diagnostic biomarker for AIN.MethodsIn a prospectively enrolled cohort with pathologist-adjudicated histological diagnoses, termed the discovery cohort, we tested the association of 180 immune proteins measured by an aptamer-based assay with AIN and validated the top protein, CXCL9, using sandwich immunoassay. We externally validated these findings in 2 cohorts with biopsy-confirmed diagnoses, termed the validation cohorts, and examined mRNA expression differences in kidney tissue from patients with AIN and individuals in the control group.ResultsIn aptamer-based assay, urinary CXCL9 was 7.6-fold higher in patients with AIN than in individuals in the control group (P = 1.23 × 10-5). Urinary CXCL9 measured by sandwich immunoassay was associated with AIN in the discovery cohort (n = 204; 15% AIN) independently of currently available clinical tests for AIN (adjusted odds ratio for highest versus lowest quartile: 6.0 [1.8-20]). Similar findings were noted in external validation cohorts, where CXCL9 had an AUC of 0.94 (0.86-1.00) for AIN diagnosis. CXCL9 mRNA expression was 3.9-fold higher in kidney tissue from patients with AIN (n = 19) compared with individuals in the control group (n = 52; P = 5.8 × 10-6).ConclusionWe identified CXCL9 as a diagnostic biomarker for AIN using aptamer-based urine proteomics, confirmed this association using sandwich immunoassays in discovery and external validation cohorts, and observed higher expression of this protein in kidney biopsies from patients with AIN.FundingThis study was supported by National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) awards K23DK117065 (DGM), K08DK113281 (KM), R01DK128087 (DGM), R01DK126815 (DGM and LGC), R01DK126477 (KNC), UH3DK114866 (CRP, DGM, and FPW), R01DK130839 (MES), and P30DK079310 (the Yale O'Brien Center). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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Affiliation(s)
- Dennis G. Moledina
- Section of Nephrology, Department of Internal Medicine and
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Wassim Obeid
- Division of Nephrology, Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Rex N. Smith
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
- Immunopathology Research Laboratory and
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
- Immunopathology Research Laboratory and
| | - Meghan E. Sise
- Section of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gilbert Moeckel
- Section of Renal Pathology, Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Kashgarian
- Section of Renal Pathology, Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Kirk N. Campbell
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Lefferts
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kristin Meliambro
- Division of Nephrology, Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Markus Bitzer
- Section of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Jordan S. Pober
- Department of Pathology and
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Robert B. Colvin
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
- Immunopathology Research Laboratory and
| | - F. Perry Wilson
- Section of Nephrology, Department of Internal Medicine and
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chirag R. Parikh
- Division of Nephrology, Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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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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Melchinger H, Calderon-Gutierrez F, Obeid W, Xu L, Shaw MM, Luciano RL, Kuperman M, Moeckel GW, Kashgarian M, Wilson FP, Parikh CR, Moledina DG. Urine Uromodulin as a Biomarker of Kidney Tubulointerstitial Fibrosis. Clin J Am Soc Nephrol 2022; 17:1284-1292. [PMID: 35948365 PMCID: PMC9625093 DOI: 10.2215/cjn.04360422] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/15/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Uromodulin, produced exclusively in the kidney's thick ascending limb, is a biomarker of kidney tubular health. However, the relationship between urine uromodulin and histologic changes in the kidney tubulointerstitium has not been characterized. In this study, we test the association of urine uromodulin with kidney histologic findings in humans and mice. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We investigated the independent association of urine uromodulin measured at the time of kidney biopsy with histologic features in 364 participants at two academic medical centers from 2015 to 2018 using multivariable linear regression models. This relationship was further examined by comparison of uromodulin staining in murine models of kidney fibrosis and repair. RESULTS We found urine uromodulin to be correlated with serum creatinine (rho=-0.43; P<0.001), bicarbonate (0.20; P<0.001), and hemoglobin (0.11; P=0.03) at the time of biopsy but not with urine albumin (-0.07; P=0.34). Multivariable models controlling for prebiopsy GFR, serum creatinine at biopsy, and urine albumin showed higher uromodulin to be associated with lower severity of interstitial fibrosis/tubular atrophy and glomerulosclerosis (interstitial fibrosis/tubular atrophy: -3.5% [95% confidence intervals, -5.7% to -1.2%] and glomerulosclerosis: -3.3% [95% confidence intervals, -5.9% to -0.6%] per two-fold difference in uromodulin). However, when both interstitial fibrosis/tubular atrophy and glomerulosclerosis were included in multivariable analysis, only interstitial fibrosis/tubular atrophy was independently associated with uromodulin (interstitial fibrosis/tubular atrophy: -2.5% [95% confidence intervals, -4.6% to -0.4%] and glomerulosclerosis: -0.9% [95% confidence intervals, -3.4% to 1.5%] per two-fold difference in uromodulin). In mouse kidneys, uromodulin staining was found to be lower in the fibrotic model than in normal or repaired models. CONCLUSIONS Higher urine uromodulin is independently associated with lower tubulointerstitial fibrosis in both human kidney biopsies and a mouse model of fibrosis. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_08_10_CJN04360422.mp3.
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Affiliation(s)
- Hannah Melchinger
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Frida Calderon-Gutierrez
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Wassim Obeid
- Division of Nephrology, Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Leyuan Xu
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Melissa M. Shaw
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Randy L. Luciano
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael Kuperman
- Division of Nephropathology, Arkana Laboratories, Little Rock, Arkansas
| | - Gilbert W. Moeckel
- Section of Renal Pathology, Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Michael Kashgarian
- Section of Renal Pathology, Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - F. Perry Wilson
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Chirag R. Parikh
- Division of Nephrology, Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dennis G. Moledina
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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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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Baker ML, Yamamoto Y, Perazella MA, Dizman N, Shirali AC, Hafez N, Weinstein J, Simonov M, Testani JM, Kluger HM, Cantley LG, Parikh CR, Wilson FP, Moledina DG. Mortality after acute kidney injury and acute interstitial nephritis in patients prescribed immune checkpoint inhibitor therapy. J Immunother Cancer 2022; 10:e004421. [PMID: 35354588 PMCID: PMC8968986 DOI: 10.1136/jitc-2021-004421] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND In patients receiving immune checkpoint inhibitor (ICI) therapy, acute kidney injury (AKI) is common, and can occur either from kidney injury unrelated to ICI use or from immune activation resulting in acute interstitial nephritis (AIN). In this study, we test the hypothesis that occurrence of AIN indicates a favorable treatment response to ICI therapy and therefore among patients who develop AKI while on ICI therapy, those with AIN will demonstrate greater survival compared with others with AKI. METHODS In this observational cohort study, we included participants initiated on ICI therapy between 2013 and 2019. We tested the independent association of AKI and estimated AIN (eAIN) with mortality up to 1 year after therapy initiation as compared with those without AKI using time-varying Cox proportional hazard models controlling for demographics, comorbidities, cancer type, stage, and therapy, and baseline laboratory values. We defined eAIN as those with a predicted probability of AIN >90th percentile derived from a recently validated diagnostic model. RESULTS Of 2207 patients initiated on ICIs, 617 (28%) died at 1 year and 549 (25%) developed AKI. AKI was independently associated with higher mortality (adjusted HR, 2.28 (95% CI 1.90 to 2.72)). Those AKI patients with eAIN had more severe AKI as reflected by a higher peak serum creatinine (3.3 (IQR 2.1-6.1) vs 1.4 (1.2-1.9) mg/dL, p<0.001) but exhibited lower mortality than those without eAIN in univariable analysis (HR 0.43 (95% CI 0.21 to 0.89)) and after adjusting for demographics, comorbidities, and cancer type and severity (adjusted HR 0.44 (95% CI 0.21 to 0.93)). CONCLUSION In patients treated with ICI, mortality was higher in those with AKI unrelated to ICI but lower in those where the underlying etiology was AIN. Future studies could evaluate the association of biopsy-proven or biomarker-proven AIN with mortality in those receiving ICI therapy.
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Affiliation(s)
- Megan L Baker
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Yu Yamamoto
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mark A Perazella
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Nazli Dizman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anushree C Shirali
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Navid Hafez
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jason Weinstein
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michael Simonov
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Harriet M Kluger
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lloyd G Cantley
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - F Perry Wilson
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Dennis G Moledina
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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