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Gomez-Preciado F, Martinez-Valenzuela L, Anton-Pampols P, Fulladosa X, Tena MG, Gomà M, Jove M, Nadal E, Merino-Ribas A, Martin-Alemany N, Cruzado JM, Torras J, Draibe J. Urinary soluble PD-1 as a biomarker of checkpoint inhibitor-induced acute tubulointerstitial nephritis. Clin Kidney J 2024; 17:sfae200. [PMID: 39131079 PMCID: PMC11316395 DOI: 10.1093/ckj/sfae200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Indexed: 08/13/2024] Open
Abstract
Background Acute interstitial nephritis (AIN) related to immune checkpoint inhibitors (ICI-AIN) has a not completely understood pathophysiology. Our objectives were to analyze possible biomarkers for the differentiation between acute tubular necrosis (ATN) and AIN, especially in cancer patients, and to study the participation of the immune checkpoint pathway in ICI-AIN. Methods We performed an observational study. We recruited patients with incident diagnosis of ICI-AIN (n = 19). We measured soluble PD-1 (sPD-1), sPD-L1, and sPD-L2 in serum and urine at diagnosis and compared to it patients with non-ICI-related AIN (non-ICI-AIN) (n = 18) and ATN (n = 21). The findings were validated in an independent cohort from another institution (n = 30). Also, we performed PD-L1 and PD-L2 immunostaining of kidney biopsies from patients with ICI-AIN and compared to patients with non-ICI-AIN. Results Urinary sPD-1 (usPD-1) was higher in patients with AIN compared to ATN (P = .03). Patients with AIN also showed higher serum sPD-1 (ssPD-1) than patients with ATN (P = .021). In cancer patients, usPD-1 <129.3 pg/ml had a 71.43% sensitivity and 94.44% specificity to differentiate ATN from ICI-AIN, with a likelihood ratio of 12.86. In the external validation cohort, the same cutoff showed a sensitivity of 80%. In kidney biopsies, patients with ICI-AIN showed higher density of PD-L1 positive tubules than patients with non-ICI-AIN (P = .02). The proportion of patients having >2.64/mm2 PD-L2 positive tubules was higher among patients with ICI-AIN compared to non-ICI-AIN (P = .034). There was a positive correlation (P = .009, r = 0.72) between usPD-1 and the number of PD-L1 positive tubules. Conclusions UsPD-1 and ssPD-1 are higher in AIN than ATN. Moreover, there was a strong correlation between usPD-1 and renal tubular PD-L1 expression. Our findings suggest a role of usPD-1 as non-invasive biomarker to differentiate ICI-AIN from ATN, especially in cancer patients, which has been confirmed in an external validation cohort.
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Affiliation(s)
- Francisco Gomez-Preciado
- Department of Nephrology, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Martinez-Valenzuela
- Department of Nephrology, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Paula Anton-Pampols
- Department of Nephrology, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Fulladosa
- Department of Nephrology, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Marina Gomez Tena
- Department of Pathology, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain
| | - Montserrat Gomà
- Department of Pathology, Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain
| | - María Jove
- Department of Medical Oncology, Catalan Institute of Oncology, and Clinical Research in Solid Tumors Group, Oncobell, l’Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet, Barcelona, Spain
| | - Ernest Nadal
- Department of Medical Oncology, Catalan Institute of Oncology, and Clinical Research in Solid Tumors Group, Oncobell, l’Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet, Barcelona, Spain
| | - Ana Merino-Ribas
- Department of Nephrology, Dr Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Nadia Martin-Alemany
- Department of Nephrology, Dr Josep Trueta University Hospital, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Josep María Cruzado
- Department of Nephrology, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Torras
- Department of Nephrology, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Juliana Draibe
- Department of Nephrology, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
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Gork I, Xiong F, Kitchlu A. Cancer drugs and acute kidney injury: new therapies and new challenges. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00164. [PMID: 38712677 DOI: 10.1097/mnh.0000000000001001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
PURPOSE OF REVIEW Cancer therapies continue to evolve at a rapid pace and although novel treatments, including immunotherapies and targeted therapies have allowed for substantial improvements in cancer survival, they carry associated risks of acute kidney injury (AKI). We aim to summarize the existing literature on AKI associated with the spectrum of systemic cancer treatments, including conventional chemotherapies, newer immunotherapies, and the growing number of targeted cancer therapies, which may be associated with both AKI and 'pseudo-AKI'. RECENT FINDINGS Conventional cytotoxic chemotherapies (e.g. cisplatin and other platinum-based agents, methotrexate, pemetrexed, ifosfamide, etc.) with well recognized nephrotoxicities (predominantly tubulointerstitial injury) remain in widespread use. Immunotherapies (e.g., immune checkpoint inhibitors and CAR-T therapies) may be associated with kidney immune-related adverse events, most often acute interstitial nephritis, and rarely, glomerular disease. Recently, multiple targeted cancer therapies have been associated with reduced renal tubular secretion of creatinine, causing elevations in serum creatinine and apparent 'pseudo-AKI'. To complicate matters further, these agents have had biopsy-proven, 'true' kidney injury attributed to them in numerous case reports. SUMMARY Clinicians in nephrology and oncology must be aware of the various potential kidney risks with these agents and recognize those with clinically meaningful impact on both cancer and kidney outcomes.
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Affiliation(s)
- Ittamar Gork
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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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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Miao J, Herrmann SM. Immune checkpoint inhibitors and their interaction with proton pump inhibitors-related interstitial nephritis. Clin Kidney J 2023; 16:1834-1844. [PMID: 37915905 PMCID: PMC10616479 DOI: 10.1093/ckj/sfad109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Indexed: 11/03/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy and outcomes, leading to an expanding use in millions of patients worldwide. However, they can cause a spectrum of immune-related adverse events (irAEs). Essentially, any organs can be affected by irAEs, which have emerged as therapy-limiting side effects. In the kidneys, ICI-associated acute interstitial nephritis (ICI-AIN) leads to acute kidney injury (AKI) in 2%-5% of patients on ICI therapy. AKI associated with ICI therapy pathologically presents with AIN in nearly 90% of the cases, but the pathophysiology of ICI-AIN remains to be defined. The generation of autoreactive T cells in patients receiving AIN-inducible drugs, such as proton pump inhibitors (PPIs), is one of the leading theories, supported by a higher incidence of ICI-AIN in patients on these AIN-inducible drugs. In this review, we will discuss our understanding of the incidence, potential pathophysiological mechanisms, clinical presentations, risk factors, diagnosis, and management of PPI-related AIN and its interaction with ICI therapy.
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Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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Seethapathy H, Mistry K, Sise ME. Immunological mechanisms underlying clinical phenotypes and noninvasive diagnosis of immune checkpoint inhibitor-induced kidney disease. Immunol Rev 2023; 318:61-69. [PMID: 37482912 PMCID: PMC10865966 DOI: 10.1111/imr.13243] [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] [Received: 03/23/2023] [Accepted: 06/28/2023] [Indexed: 07/25/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have become a mainstay of cancer therapy, with over 80 FDA-approved indications. Used in a variety of settings and in combination with each other and with traditional chemotherapies, the hyperactive immune response induced by ICIs can often lead to immune-related adverse events in bystander normal tissues such as the kidneys, lungs, and the heart. In the kidneys, this immune-related adverse event manifests as acute interstitial nephritis (ICI-AIN). In the era of widespread ICI use, it becomes vital to understand the clinical manifestations of ICI-AIN and the importance of prompt diagnosis and management of these complications. In this review, we delve into the clinical phenotypes of ICI-AIN and how they differ from traditional drug-induced AIN. We also detail what is known about the mechanistic underpinnings of ICI-AIN and the important diagnostic and therapeutic implications behind harnessing those mechanisms to further our understanding of these events and to formulate effective treatment plans to manage ICI-AIN.
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Affiliation(s)
- Harish Seethapathy
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kavita Mistry
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Meghan E. Sise
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Orozco Scott P, Deshpande P, Abramson M. Genitourinary Cancer: Updates on Treatments and Their Impact on the Kidney. Semin Nephrol 2023; 42:151344. [PMID: 37172546 DOI: 10.1016/j.semnephrol.2023.151344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Genitourinary cancers are diverse in their presentation, prevalence, and mortality risk. Although there have been significant advancements in medical (eg, immune checkpoint inhibitors and tyrosine kinase inhibitors) and surgical treatments of genitourinary cancers, patients are still at risk for chronic kidney disease, hypertension, and electrolyte derangements in the short and long term. In addition, pre-existing kidney disease may increase the risk of developing some genitourinary cancers. This review focuses on the kidney-related effects of treatments for renal cell carcinoma and bladder and prostate cancers.
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Affiliation(s)
- Paloma Orozco Scott
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Medical School, New York, NY.
| | - Priya Deshpande
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthew Abramson
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Seethapathy H, Herrmann SM, Rashidi A. Immune Checkpoint Inhibitor-Associated AKI: Debates in Diagnosis, Management, and Rechallenge. Semin Nephrol 2023; 42:151346. [PMID: 37137187 DOI: 10.1016/j.semnephrol.2023.151346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are now established treatments for advanced cancer and their use is now ubiquitous. The high upside of ICIs is tempered by their toxicity profile affecting almost every organ, including the kidneys. Although acute interstitial nephritis is the major kidney-related adverse effect of checkpoint inhibitors, other manifestations such as electrolyte abnormalities and renal tubular acidosis have been described. With increasing awareness and recognition of these events, the focus has shifted to non-invasive identification of ICI-acute interstitial nephritis, with sophisticated approaches involving biomarkers and immunologic signatures being studied. Although the management of immune-related adverse events with corticosteroids is straightforward, there now are more data to help guide immunosuppressive regimens, ICI rechallenge, and delineate risk and efficacy in special populations such as individuals on dialysis or those who have received a transplant.
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Affiliation(s)
- Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | | | - Arash Rashidi
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
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PCSK9 Inhibitors in Cancer Patients Treated with Immune-Checkpoint Inhibitors to Reduce Cardiovascular Events: New Frontiers in Cardioncology. Cancers (Basel) 2023; 15:cancers15051397. [PMID: 36900189 PMCID: PMC10000232 DOI: 10.3390/cancers15051397] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Cancer patients treated with immune checkpoint inhibitors (ICIs) are exposed to a high risk of atherosclerosis and cardiometabolic diseases due to systemic inflammatory conditions and immune-related atheroma destabilization. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key protein involved in metabolism of low-density lipoprotein (LDL) cholesterol. PCSK9 blocking agents are clinically available and involve monoclonal antibodies, and SiRNA reduces LDL levels in high-risk patients and atherosclerotic cardiovascular disease events in multiple patient cohorts. Moreover, PCSK9 induces peripheral immune tolerance (inhibition of cancer cell- immune recognition), reduces cardiac mitochondrial metabolism, and enhances cancer cell survival. The present review summarizes the potential benefits of PCSK9 inhibition through selective blocking antibodies and siRNA in patients with cancer, especially in those treated with ICIs therapies, in order to reduce atherosclerotic cardiovascular events and potentially improve ICIs-related anticancer functions.
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