Adverse kidney effects of epidermal growth factor receptor inhibitors

Nivolumab-induced pneumonitis and cardiopathy in a patient with relapsed Hodgkin's lymphoma

INTRODUCTION

Nivolumab, the monoclonal antibody inhibitor of programmed cell death protein 1, enhances the T-cell response, including anti-tumour responses, by blocking the attachment of programmed death-ligand 1 and programmed death-ligand 2 ligands to the programmed cell death protein 1 receptor, which in turn leads to a reduction in tumour growth. Nivolumab has been approved in relapsed or refractory classic Hodgkin's lymphoma after autologous transplantation of haematopoietic stem cell and treatment with brentuximab as monotherapy.

CASE REPORT

We herewith report a case of 65-year-old woman who developed an interstitial pneumonitis and a global cardiac hypokinesis following a treatment with Nivolumab for a refractory Hodgkin's Lymphoma. Nivolumab was administered as the fifth line of therapy. Some concomitant patient treatments include drug with known autoimmune toxicities. Although the patient had a persistent complete remission following the sixth infusion, it was discontinued as she developed dyspnea of NYHA stage IV and orthopnea. The chest tomography revealed a bilateral micronodular pattern of organizing pneumonia with bilateral pleural effusion. The forced expiratory volume was decreased to 50%. In parallel her transthoracic echocardiography revealed a global hypokinesis with a left ventricular ejection fraction of 20%.

MANAGEMENT AND OUTCOME

The patient was treated with empiric antibiotics although the microbial assessments were negative. She was also treated with beta-blocker and angiotensin-converting enzyme inhibitors. The cardiac magnetic resonance imaging performed after 4 months confirmed the hypokinetic cardiopathy with an ejection fraction of 48%. The patient had a significant clinical improvement. The tomography emission positron scan conducted 8 months after interruption of Nivolumab showed complete remission with some moderate activation of residual lesion basal posterior lobe of left lung field.

DISCUSSION

Early and effective diagnosis of immune-related adverse events through the search for predictive biomarkers like drug factors and individual risk factors will allow targeted surveillance leading to a better tolerance.

Structural insights into conformational stability and binding of thiazolo-[2,3-b] quinazolinone derivatives with EGFR-TKD and in-vitro study

Heterocyclic molecules are well-known drugs against various diseases including cancer. Many tyrosine kinase inhibitors including erlotinib, osimertinib, and sunitinib were developed and approved but caused adverse effects among treated patients. Which prevents them from being used as cancer therapeutics. In this study, we strategically developed heterocyclic thiazolo-[2,3-b]quinazolinone derivatives by an organic synthesis approach. These synthesized molecules were assessed against the epidermal growth factor receptor tyrosine kinase domain (EGFR-TKD) by in silico methods. Molecular docking simulations unravel derivative 17 showed better binding energy scores and followed Absorption, Distribution, Metabolism, Excretion, and Toxicity (ADMET) properties. The binding affinity displayed by synthetic congener and reference molecule erlotinib was found to be -8.26 ± 0.0033 kcal/mol and -7.54 ± 0.1411 kcal/mol with the kinase domain. Further, molecular dynamic simulations were conducted thrice to validate the molecular docking study and achieved significant results. Both synthetic derivative and reference molecule attained stability in the active site of the TKD. The synthetic congener and erlotinib showed free energy binding (ΔGbind) -102.975 ± 3.714 kJ/mol and -130.378 ± 0.355 kJ/mol computed by Molecular Mechanics Poison Boltzmann Surface Area (MM-PBSA) method. In addition, the motions of each sampled system including the Apo complex were determined by the principal component analysis and Gibbs energy landscape analysis. The in-vitro apoptosis study was performed using MCF-7 and H-1299 cancer cell lines. However, thiazolo-[2,3-]-quinazoline derivative 17 showed fair anti-proliferative activity against MCF-7 and H-1299. Further, the in-vivo study is necessary to determine the effectivity of the potent anti-proliferative, non-toxic molecule against TKD.

Molecular Mechanisms and Biomarkers Associated with Chemotherapy-Induced AKI

Acute kidney injury (AKI) is a life-threatening condition characterized by a rapid and transient decrease in kidney function. AKI is part of an array of conditions collectively defined as acute kidney diseases (AKD). In AKD, persistent kidney damage and dysfunction lead to chronic kidney disease (CKD) over time. A variety of insults can trigger AKI; however, chemotherapy-associated nephrotoxicity is increasingly recognized as a significant side effect of chemotherapy. New biomarkers are urgently needed to identify patients at high risk of developing chemotherapy-associated nephrotoxicity and subsequent AKI. However, a lack of understanding of cellular mechanisms that trigger chemotherapy-related nephrotoxicity has hindered the identification of effective biomarkers to date. In this review, we aim to (1) describe the known and potential mechanisms related to chemotherapy-induced AKI; (2) summarize the available biomarkers for early AKI detection, and (3) raise awareness of chemotherapy-induced AKI.

Renal Safety Profile of EGFR Targeted Therapies: A Study from VigiBase® the WHO Global Database of Individual Case Safety Reports

Kidney EGFR expression together with reported cases of glomerular diseases in the context of anti-EGFR drug administration raise concerns about the renal safety profile of these drugs. This issue is addressed in a case/non-case study carried out on VigiBase®, the WHO global database of individual case safety reports (ICRS). Disproportionality analysis of renal adverse effects related to the selected anti-EGFR drugs, erlotinib, gefitinib, afatinib, osimertinib, cetuximab and panitumumab, was assessed using the reporting odds ratio (ROR). Nine hundred and eighty-nine ICRSs were included. A signal of disproportionate reporting (SDR) was found for afatinib (ROR = 2.70; 95% CI [2.22-3.29]) and erlotinib (ROR = 1.73; 95% CI [1.46-2.04]) with acute kidney injury, and for afatinib (ROR = 2.41; 95% CI [1.78-3.27]), cetuximab (ROR = 1.42; 95% CI [1.14-1.78]) and erlotinib (ROR = 2.23; 95% CI [1.80-2.77]) with renal failure. The preferred term "diarrhoea" was frequently reported in the included cases. An SDR was found for erlotinib with haemolytic and uremic syndrome (ROR = 4.01; 95% CI [1.80-8.94]) and thrombotic microangiopathy (ROR = 4.94; 95% CI [2.80-8.72]). No SDR was seen for glomerular or tubule-interstitial diseases. This study showed that the anti-EGFR drug renal toxicity is mainly related to renal failure in the context of digestive toxicity.

Targeting the actin nucleation promoting factor WASp provides a therapeutic approach for hematopoietic malignancies

Cancer cells depend on actin cytoskeleton rearrangement to carry out hallmark malignant functions including activation, proliferation, migration and invasiveness. Wiskott–Aldrich Syndrome protein (WASp) is an actin nucleation-promoting factor and is a key regulator of actin polymerization in hematopoietic cells. The involvement of WASp in malignancies is incompletely understood. Since WASp is exclusively expressed in hematopoietic cells, we performed in silico screening to identify small molecule compounds (SMCs) that bind WASp and promote its degradation. We describe here one such identified molecule; this WASp-targeting SMC inhibits key WASp-dependent actin processes in several types of hematopoietic malignancies in vitro and in vivo without affecting naïve healthy cells. This small molecule demonstrates limited toxicity and immunogenic effects, and thus, might serve as an effective strategy to treat specific hematopoietic malignancies in a safe and precisely targeted manner.

Cancer cells proliferate and invade via cytoskeletal proteins such as WASp, exclusively expressed in hematopoietic cells. Here the authors show a specific small molecule compound inhibiting cancer cell activity by WASp degradation and demonstrating its therapeutic potential in vitro and in vivo.

Nephrotoxicity From Molecularly Targeted Chemotherapeutic Agents

The introduction of novel molecularly targeted therapies in the last 2 decades has significantly improved the patient survival compared to standard conventional chemotherapies. However, this improvement has been accompanied by a whole new spectrum of kidney adverse events. Although known as "targeted," many of these agents lack specificity and selectivity, and they have a tendency to inhibit multiple targets including those in the kidneys. Early detection and correct management of kidney toxicities is crucial to preserve kidney functions. The knowledge of these toxicities helps guide optimal and continued utilization of these potent therapies. The incidence, severity, and pattern of nephrotoxicity may vary depending on the respective target of the drug. Here, we review the mechanism of action, clinical findings of kidney adverse events, and their proposed management strategies.

Disorders of Divalent Ions (Magnesium, Calcium, and Phosphorous) in Patients With Cancer

Disorders of the divalent ions (magnesium, calcium, and phosphorous) are frequently encountered in patients with cancer. Of these, hypomagnesemia, hypocalcemia, hypercalcemia, and hypophosphatemia are seen most commonly. These electrolyte disturbances may be related to the underlying malignancy or due to side effects of anticancer therapy. When caused by a paraneoplastic process, these abnormalities may portend a poor prognosis. Importantly, the development of severe electrolyte derangements may be associated with symptoms that negatively impact quality of life, preclude the administration of critical chemotherapeutic agents, or lead to life-threatening complications that require hospitalization and emergent treatment. In accordance, prompt recognition and treatment of these disorders is key to improving outcomes in patients living with cancer. This review will discuss selected derangements of the divalent ions seen in this population, with a focus on paraneoplastic and therapy-associated etiologies.

Protective effect of hydrogen sulfide on the kidney (Review)

Hydrogen sulfide (H₂S) is a physiologically important gas transmitter that serves various biological functions in the body, in a manner similar to that of carbon monoxide and nitric oxide. Cystathionine-β-synthase, cystathionine-γ-lyase and cysteine transaminase/3-mercaptopyruvate sulphotransferase are important enzymes involved H₂S production in vivo, and the mitochondria are the primary sites of metabolism. It has been reported that H₂S serves an important physiological role in the kidney. Under disease conditions, such as ischemia-reperfusion injury, drug nephrotoxicity and diabetic nephropathy, H₂S serves an important role in both the occurrence and development of the disease. The present review aimed to summarize the production, metabolism and physiological functions of H₂S, and the progress in research with regards to its role in renal injury and renal fibrosis in recent years.

Upregulation of Chemoresistance by Mg2+ Deficiency through Elevation of ATP Binding Cassette Subfamily B Member 1 Expression in Human Lung Adenocarcinoma A549 Cells

Several anticancer drugs including cisplatin (CDDP) induce hypomagnesemia. However, it remains fully uncertain whether Mg²⁺ deficiency affects chemosensitivity of cancer cells. Here, we investigated the effect of low Mg²⁺ concentration (LM) on proliferation and chemosensitivity using human lung adenocarcinoma A549 cells. Cell proliferation was reduced by continuous culture with LM accompanied with the elevation of G1 phase proportion. The amounts of reactive oxygen species (ROS) and stress makers such as phosphorylated-ataxia telangiectasia mutated and phosphorylated-p53 were increased by LM. Cell injury was dose-dependently increased by anticancer drugs such as CDDP and doxorubicin (DXR), which were suppressed by LM. Similar results were obtained by roscovitine, a cell cycle inhibitor. These results suggest that LM induces chemoresistance mediated by ROS production and G1 arrest. The mRNA and protein levels of ATP binding cassette subfamily B member 1 (ABCB1) were increased by LM and roscovitine. The LM-induced elevation of ABCB1 and nuclear p38 expression was suppressed by SB203580, a p38 MAPK inhibitor. PSC833, an ABCB1 inhibitor, and SB203580 rescued the sensitivity to anticancer drugs. In addition, cancer stemness properties were suppressed by SB203580. We suggest that Mg²⁺ deficiency reduces the chemotherapy sensitivity of A549 cells, although it suppresses cell proliferation.

Genetic and drug-induced hypomagnesemia: different cause, same mechanism

Magnesium (Mg2+) plays an essential role in many biological processes. Mg2+ deficiency is therefore associated with a wide range of clinical effects including muscle cramps, fatigue, seizures and arrhythmias. To maintain sufficient Mg2+ levels, (re)absorption of Mg2+ in the intestine and kidney is tightly regulated. Genetic defects that disturb Mg2+ uptake pathways, as well as drugs interfering with Mg2+ (re)absorption cause hypomagnesemia. The aim of this review is to provide an overview of the molecular mechanisms underlying genetic and drug-induced Mg2+ deficiencies. This leads to the identification of four main mechanisms that are affected by hypomagnesemia-causing mutations or drugs: luminal transient receptor potential melastatin type 6/7-mediated Mg2+ uptake, paracellular Mg2+ reabsorption in the thick ascending limb of Henle's loop, structural integrity of the distal convoluted tubule and Na+-dependent Mg2+ extrusion driven by the Na+/K+-ATPase. Our analysis demonstrates that genetic and drug-induced causes of hypomagnesemia share common molecular mechanisms. Targeting these shared pathways can lead to novel treatment options for patients with hypomagnesemia.

Sarcoid-like reaction in cases treated by checkpoint inhibitors

Sarcoidosis is a multisystem granulomatous disorder characterized by helper T cell inflammation. Sarcoid-like reaction (SLR) is a well-defined entity and may be related with several malignant disorders and/or their therapies. SLR has been reported more than 20 years ago and in recent years in cases treated by checkpoint inhibitors (CPIs). Better outcome has been reported in cases developing granulomatous reaction and/or SLRs during CPI treatments. However, these lesions clinically may be thought as disease progression and may cause to stop treatment or alterations. These therapeutic manipulations may be harmful for the patients. Clinicians should be aware of SLRs in cases treated by CPIs and tissues must be sampled and reviewed by an experienced pathologist to avoid misdiagnosis and also unnecessary CPI treatment cessations.Significance StatementClinicians should be aware of sarcoid-like reactions in cases treated by checkpoint inhibitors and tissues must be sampled and reviewed by an experienced pathologist to avoid misdiagnosis and CPI treatment stops.

Epidermal Growth Factor Receptor: A Potential Therapeutic Target for Diabetic Kidney Disease

Diabetic kidney disease (DKD) is a leading cause of end-stage renal disease worldwide and the major cause of renal failure among patients on hemodialysis. Numerous studies have demonstrated that transient activation of epidermal growth factor receptor (EGFR) pathway is required for promoting kidney recovery from acute injury whereas its persistent activation is involved in the progression of various chronic kidney diseases including DKD. EGFR-mediated pathogenesis of DKD is involved in hemodynamic alteration, metabolic disturbance, inflammatory response and parenchymal cellular dysfunction. Therapeutic intervention of this receptor has been available in the oncology setting. Targeting EGFR might also hold a therapeutic potential for DKD. Here we review the functional role of EGFR in the development of DKD, mechanisms involved and the perspective about use of EGFR inhibitors as a treatment for DKD.

Interstitial nephritis with pembrolizumab: A case report and review

Introduction

Pembrolizumab is a monoclonal antibody approved for adult patients with advanced non–small-cell lung cancer (NSCLC). Although immune related adverse events are considered to be well tolerated, complications may occur and discontinuation of the treatment could be required.

Case report

A 62-year old patient diagnosed with advanced non-small cell lung cancer experienced a decline in the renal function after seven cycles with pembrolizumab. Management & outcome: After ruling out other common causes of interstitial nephritis, pembrolizumab was attributed as a cause of interstitial nephritis. At first, toxicity was managed with corticosteroids and closely monitoring the patient, but finally pembrolizumab had to be discontinued due to the kidney function did not recover.

Discussion

Renal and urinary disorders were reported in <3% of patients treated with pembrolizumab, being interstitial nephritis the most reported toxicity. The kidney damage can be a complication to consider in patients receiving pembrolizumab. Early identification of an increase in serum creatinine levels may help with prevention by establishing an effective treatment, although it may not mean a total recovery of kidney function.

Epidermal growth factor signaling through transient receptor potential melastatin 7 cation channel regulates vascular smooth muscle cell function

OBJECTIVE

Transient receptor potential (TRP) melastatin 7 (TRPM7) cation channel, a dual-function ion channel/protein kinase, regulates vascular smooth muscle cell (VSMC) Mg2+ homeostasis and mitogenic signaling. Mechanisms regulating vascular growth effects of TRPM7 are unclear, but epidermal growth factor (EGF) may be important because it is a magnesiotropic hormone involved in cellular Mg2+ regulation and VSMC proliferation. Here we sought to determine whether TRPM7 is a downstream target of EGF in VSMCs and if EGF receptor (EGFR) through TRPM7 influences VSMC function. Approach and results: Studies were performed in primary culture VSMCs from rats and humans and vascular tissue from mice deficient in TRPM7 (TRPM7+/Δkinase and TRPM7R/R). EGF increased expression and phosphorylation of TRPM7 and stimulated Mg2+ influx in VSMCs, responses that were attenuated by gefitinib (EGFR inhibitor) and NS8593 (TRPM7 inhibitor). Co-immunoprecipitation (IP) studies, proximity ligation assay (PLA) and live-cell imaging demonstrated interaction of EGFR and TRPM7, which was enhanced by EGF. PP2 (c-Src inhibitor) decreased EGF-induced TRPM7 activation and prevented EGFR-TRPM7 association. EGF-stimulated migration and proliferation of VSMCs were inhibited by gefitinib, PP2, NS8593 and PD98059 (ERK1/2 inhibitor). Phosphorylation of EGFR and ERK1/2 was reduced in VSMCs from TRPM7+/Δkinase mice, which exhibited reduced aortic wall thickness and decreased expression of PCNA and Notch 3, findings recapitulated in TRPM7R/R mice.

CONCLUSIONS

We show that EGFR directly interacts with TRPM7 through c-Src-dependent processes. Functionally these phenomena regulate [Mg2+]i homeostasis, ERK1/2 signaling and VSMC function. Our findings define a novel signaling cascade linking EGF/EGFR and TRPM7, important in vascular homeostasis.

Electrolyte Disorders Induced by Antineoplastic Drugs

The use of antineoplastic drugs has a central role in treatment of patients affected by cancer but is often associated with numerous electrolyte derangements which, in many cases, could represent life-threatening conditions. In fact, while several anti-cancer agents can interfere with kidney function leading to acute kidney injury, proteinuria, and hypertension, in many cases alterations of electrolyte tubular handling and water balance occur. This review summarizes the mechanisms underlying the disturbances of sodium, potassium, magnesium, calcium, and phosphate metabolism during anti-cancer treatment. Platinum compounds are associated with sodium, potassium, and magnesium derangements while alkylating agents and Vinca alkaloids with hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH). Novel anti-neoplastic agents, such as targeted therapies (monoclonal antibodies, tyrosine kinase inhibitors, immunomodulators, mammalian target of rapamycin), can induce SIADH-related hyponatremia and, less frequently, urinary sodium loss. The blockade of epidermal growth factor receptor (EGFR) by anti-EGFR antibodies can result in clinically significant magnesium and potassium losses. Finally, the tumor lysis syndrome is associated with hyperphosphatemia, hypocalcemia and hyperkalemia, all of which represent serious complications of chemotherapy. Thus, clinicians should be aware of these side effects of antineoplastic drugs, in order to set out preventive measures and start appropriate treatments.

Pembrolizumab-associated nephrotic syndrome recovered from transient hemodialysis in a patient with lung cancer

A 70-year-old man diagnosed with lung adenocarcinoma was referred to our department for an evaluation of acute onset of nephrotic syndrome with acute kidney injury (AKI) after the 7th course of pembrolizumab treatment. Renal biopsy could not be performed, because he needed anticoagulation therapy for venous thrombosis. Pembrolizumab was discontinued, and prednisolone was started. Hemodialysis was also started, because oliguria was not resolved, and dyspnea due to pulmonary congestion appeared even with the high dose of diuretics. Hemodialysis was successfully withdrawn within 5-week duration because of renal function recovery and increase of urine volume. Complete remission was achieved 4 months after initiating prednisolone. He has never experienced hemodialysis again and remains remission of nephrotic syndrome even the dose of prednisolone was tapered for 8 months. Renal pathology in the current case was uncertain. However, minimal change disease seemed to be a plausible cause of nephrotic syndrome with AKI because of a good response to steroid therapy and acute onset of nephrotic syndrome. In addition, renal pathology in all of the reported cases of pembrolizumab-associated nephrotic syndrome with AKI was minimal change disease. Our case shows for the first time that renal function could be reversible with prednisolone in pembrolizumab-associated nephrotic syndrome with severe AKI even after progression of renal failure which needs dialysis.

HUWE1 promotes EGFR ubiquitination and degradation to protect against renal tubulointerstitial fibrosis

Injury of renal tubular epithelial cells is a key feature of the pathogenicity associated with tubulointerstitial fibrosis and other kidney diseases. HUWE1, an E3 ubiquitin ligase, acts by participating in ubiquitination and degradation of its target proteins. However, the detailed mechanisms by which HUWE1 might regulate fibrosis in renal tubular epithelial cells have not been established. Here, the possible regulation of renal tubulointerstitial fibrosis by HUWE1 was investigated by examining the expression of HUWE1 and EGFR in unilateral ureteral obstruction (UUO) mice. Markedly consistent reciprocal changes in HUWE1 and EGFR expression were observed at the protein and mRNA levels in the kidney after UUO injury. Expression of HUWE1 inhibited TGF-β-induced injury to HK-2 cells, while HUWE1 overexpression decreased the expression of EGFR. Further analysis indicated that HUWE1 physically interacted with EGFR and promoted its ubiquitination and degradation. HUWE1 expression also showed clinical relevance in renal disease, as it notably decreased in multiple types of clinical nephropathy, while EGFR expression significantly increased when compared to the normal kidney. Therefore, this study demonstrated that HUWE1, which serves as an E3 ubiquitin ligase specific for EGFR, promotes EGFR ubiquitination and degradation, thereby regulating EGFR expression and providing protection against kidney injury.

Acute toxic kidney injury

Substances toxic to the kidney are legion in the modern world. The sheer number and variety, their mutual interactions and, metabolism within the body are a challenge to research. Moreover, the kidney is especially prone to injury owing to its physiology. Acute kidney injury (AKI) induced by poisonous or primarily nephrotoxic substances, may be community acquired with ingestion or inhalation or nosocomial. Many nephrotoxic plants, animal poisons, medications, chemicals and illicit drugs can induce AKI by varying pathophysiological pathways. Moreover, the epidemiology of toxic AKI varies depending on country, regions within countries, socioeconomic status and health care facilities. In this review, we have selected nephrotoxic insults due to medication, plants, animal including snake venom toxicity, environmental, (agri)chemicals and also illicit drugs. We conclude with a section on diagnosis, clinical presentation and management of poisoning accompanied by various organ dysfunction and AKI.

[Renal toxicities of targeted therapies in oncology]

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.

Acute tubulointerstitial nephritis and IgM deposits on glomerular capillary walls after immunotherapy with nivolumab for metastatic renal cell carcinoma

Nivolumab is an anti-programmed cell death-1 antibody that is utilized as an immune checkpoint inhibitor for several malignancies. However, this agent is associated with immune-related adverse events (irAEs), mainly in the spectrum of autoimmune disease including interstitial pneumonia, colitis, type 1 diabetes, and renal impairment. We herein present the case of a 59-year-old man with renal cell carcinoma who developed worsening renal function approximately 4 months after initiation of nivolumab. Urinalysis showed proteinuria and microscopic hematuria along with increase levels of N-acetyl-β-D-glucosaminidase. Renal biopsy revealed acute tubulointerstitial nephritis and thickening of the glomerular basement membranes. Immunofluorescence showed granular IgM deposits in capillary loops. We initiated high-dose prednisolone therapy with nivolumab, which improved renal function and achieved complete remission of proteinuria. Although renal irAEs are considered to be rare and glomerulonephropathy is not typical presentation, physicians need the close monitoring of renal function and urinalysis in patients under immunotherapy with this agents. In addition, our case provides a possible link between nivolumab and immune-mediated glomerulonephropathy.

CTLA-4 Expression Inversely Correlates with Kidney Function and Serum Immunoglobulin Concentration in Patients with Primary Glomerulonephritides

Major causes of chronic kidney disease are primary proliferative and nonproliferative glomerulonephritides (PGN and NPGN). However, the pathogenesis of PGN and NPGN is still not fully understood. Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) is a T-cell membrane receptor that plays a key role in T-cell inhibition. Despite its role in autoimmunological diseases, little is known about the involvement of CTLA-4 in the pathogenesis of PGN and NPGN. The objective of this study was to determine the role of CTLA-4 in the pathogenesis of PGN and NPGN by evaluating the frequencies of T and B lymphocytes expressing CTLA-4 and the serum concentration of the sCTLA-4 isoform in patients with PGN and NPGN in relation to clinical parameters. The study included peripheral blood (PB) samples from 40 PGN and NPGN patients and 20 healthy age- and sex-matched volunteers (control group). The viable PB lymphocytes were labeled with fluorochrome-conjugated monoclonal anti-CTLA-4 antibodies and analyzed using flow cytometry. The serum concentration of sCTLA-4 was measured using ELISA. The frequencies and absolute counts of CD4+/CTLA-4+ T lymphocytes, CD8+/CTLA-4+ T lymphocytes and CD19+/CTLA-4+ B lymphocytes and the serum sCTLA-4 concentration were lower in PGN and NPGN patients that in the control group. Reduced sCTLA-4 expression was associated with a lower concentration of serum immunoglobulins. Our results indicate that deregulation of CTLA-4 expression may result in continuous activation of T cells and contribute to the pathogenesis of PGN and NPGN.

[(Immuno‑)Pathology of drug side effects in the kidney]

Nephrotoxicity or renal side effects of drugs are frequent and may vary in their clinical presentation. Various types of acute and chronic kidney disease are known to develop as a consequence or side effect of a long list of drugs with nephrotoxicity most commonly being associated with injury in the tubulointerstitial compartment. In addition, drug-induced glomerular and vascular disease have also been reported, either as the result of direct cellular injury or immune-mediated injury to glomerular or endothelial cells. From a clinical point of view it is important to recognize such drug-induced nephropathies early in order to prevent or adequately treat them to favour kidney recovery and to avoid long-lasting negative consequences for kidney function.This article will focus on the typical morphology and pathogenesis of some frequent drug-induced renal diseases.

TRPM7, Magnesium, and Signaling

The transient receptor potential melastatin-subfamily member 7 (TRPM7) is a ubiquitously expressed chanzyme that possesses an ion channel permeable to the divalent cations Mg2+, Ca2+, and Zn2+, and an α-kinase that phosphorylates downstream substrates. TRPM7 and its homologue TRPM6 have been implicated in a variety of cellular functions and is critically associated with intracellular signaling, including receptor tyrosine kinase (RTK)-mediated pathways. Emerging evidence indicates that growth factors, such as EGF and VEGF, signal through their RTKs, which regulate activity of TRPM6 and TRPM7. TRPM6 is primarily an epithelial-associated channel, while TRPM7 is more ubiquitous. In this review we focus on TRPM7 and its association with growth factors, RTKs, and downstream kinase signaling. We also highlight how interplay between TRPM7, Mg2+ and signaling kinases influences cell function in physiological and pathological conditions, such as cancer and preeclampsia.

The adverse kidney effects of cancer immunotherapies

Cancer therapies are a common cause of acute and chronic kidney disease, which are increasingly being seen by nephrologists in clinical practice. Conventional chemotherapeutic drugs and novel targeted agents are effective cancer therapies but their use is complicated by nephrotoxicity. Cancer immunotherapies exploit various properties of immune cells to enhance immune-mediated tumor killing. Interferon and high-dose interleukin-2 are older immunotherapies first employed clinically in the 1980s and 1990s to treat a number of different cancers. While effective, these two therapies have well-known systemic toxicities, which include acute kidney disease. The emergence of the new cancer immunotherapies over the past decade brings more effective treatment options. The immune checkpoint inhibitors and chimeric antigen receptor T cells are exciting additions to the cancer treatment armamentarium. These agents effectively treat a several and a growing list of cancers that have otherwise failed other therapies. However, as with the conventional and targeted cancer agents, drug-induced acute and chronic kidney disease is an untoward effect of this group of drugs. We will undertake a case-based review: the newer immunotherapies followed by the older therapies, interferon and interleukin-2.

The PD-1/PD-L1 Inhibitory Pathway is Altered in Primary Glomerulonephritides

The pathogenesis of primary proliferative and non-proliferative glomerulonephritides (PGN and NPGN) is still not fully understood, however, current evidence suggests that most cases of PGN and NPGN are the results of immunologic response to different etiologic agents that activates various biological processes leading to glomerular inflammation and injury. Programmed cell death protein 1 (PD-1) is the major inhibitory receptor regulating T cell exhaustion. The aim of this study was to evaluate the frequencies of PD-1-positive and PD-ligand 1 (PD-L1)-positive T and B lymphocytes in patients with NPGN and PGN in relation to clinical parameters for the first time. The study included peripheral blood (PB) samples from 20 newly diagnosed PGN and NPGN patients. The control group comprised of 20 healthy age- and sex-matched subjects. The viable PB lymphocytes underwent labelling with fluorochrome-conjugated monoclonal antibodies anti-PD-1 and anti-PD-L1, and were analyzed using a flow cytometer. The frequencies of CD4+/PD1+ T lymphocytes, CD8+/PD1+ T lymphocytes, and CD19+/PD-1+ B lymphocytes in the PGN group exceeded values obtained both in the NPGN group, and the control group. Alteration of PD-1/PD-L1 pathway may be involved in poorer prognosis, as patients with PGN are characterized by higher frequencies of PD-1-positive and PD-L1-positive T and B lymphocytes than patients with NPGN. Our results suggest that deregulation of PD-1/PD-L1 axis may contribute to the PGN and NPGN pathogenesis. High percentages of lymphocytes with PD-1 and PD-L1 expression may be related to the continuous T-cell activation and development of glomerular inflammation and injury.

Immune checkpoint inhibitor (nivolumab)-associated kidney injury and the importance of recognizing concomitant medications known to cause acute tubulointerstitial nephritis: a case report

BACKGROUND

Acute tubulointerstitial nephritis (ATIN) has been increasingly recognized as an important manifestation of kidney injury associated with the use of immune checkpoint inhibitors (anti-PD-1 and anti-CTLA-4). While the exact pathophysiology remains unknown, corticosteroids are the mainstay of management.

CASE PRESENTATION

We describe a 67-year-old man with stage IV non-small-cell lung cancer who developed kidney injury during treatment with the anti-PD-1 antibody nivolumab. A kidney biopsy showed ATIN without granuloma formation. Considering their mechanism of action, immune checkpoint inhibitors can alter immunological tolerance to concomitant drugs that have been safely used for a long time. For more than 4 years before the initiation of nivolumab therapy, the patient had been receiving the proton pump inhibitor lansoprazole, known to cause drug-induced ATIN, without significant adverse events including kidney injury. He showed rapid improvement in kidney function in 3 days (creatinine decreased from 2.74 to 1.82 mg/dl) on discontinuation of lansoprazole. He then received 500 mg intravenous methylprednisolone for 3 days followed by 1 mg/kg/day oral prednisolone and his creatinine levels eventually stabilized around 1.7 mg/dl. Drug-induced lymphocyte stimulation test (DLST) for lansoprazole was positive.

CONCLUSIONS

The rapid improvement of kidney function after discontinuation and DLST positivity indicate that lansoprazole contributed to the development of ATIN during nivolumab therapy. Considering the time course, it is plausible that nivolumab altered the long-lasting immunological tolerance against lansoprazole in this patient. To the best of our knowledge, this is the first case report of DLST positivity for a drug that had been used safely before the initiation of an immune checkpoint inhibitor. Although corticosteroid therapy is recommended, the recognition and discontinuation of concomitant drugs, especially those known to induce ATIN, is necessary for the management of kidney injury associated with anti-PD-1 therapy.

Cancer and the kidney: dangereoux liasons or price paid for the progress in medicine?

A long time ago, the links between renal disease and malignancy were observed, however, quite recently, their importance was recognized and 'new' subspecialty in nephrology, namely 'onconephrology' was established. In the XXI century, patients with malignancy make up the most growing number of the subjects seen for nephrology consult and/or critical care nephrology services. A plethora of renal problems may be found in patients with malignancy. They may influence not only their short-term outcomes but also the adequate therapy of the underlying oncological problem. Thus, all these kidney-related issues pose an important challenge for both specialities: oncology and nephrology. In the review a spectrum of acute and chronic renal injury caused by the malignancy is presented as well as the associations between renal disease and cancer. Assessment of kidney function and its importance in patients with malignancy is also discussed as medical oncologists should check the appropriate dose of chemotherapeutic drugs in relation to the actual renal function before prescribing them to the patients. Moreover, effects of kidney function on outcomes in oncology is presented. In addition, nephrology services should better understand both the biology of malignancy with its treatment to become a valuable part treating team to yield the best possible outcome. It is important for nephrology services to be acknowledged and to take an active participation in care of oncology patients.