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Kidney Week

Abstract: SA-PO521

Immune Interstitial Nephritis Complicating Treatment of Lung Cancer

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Baradhi, Krishna M., University of Oklahoma, Tulsa, Oklahoma, United States
  • Guruswamy sangameswaran, Kothai divya, OU -Tulsa School of Community Medicine, Tulsa, Oklahoma, United States
Introduction

Immune check point inhibitors (ICPIs) have revolutionized the treatment of cancer therapy in the modern era. Amongst these, Nivolumab targeting programmed-death-1 (PD-1) and its ligand (PD-L1) is increasingly being used for treatment of metastatic melanoma, non-small cell lung cancer, and renal carcinomas. The advent of these novel biologics, also brought with them the unique spectrum of immune mediated adverse effects. We describe a case of nivolumab induced immune nephritis and stress the importance of renal surveillance, as early recognition and treatment can prevent irreversible renal damage.

Case Description

An 82-yr-old female with metastatic squamous cell carcinoma of lung was admitted to the hospital due to Acute kidney injury (AKI) (creatinine 3.3 mg/dl), found on routine labs. Her chemotherapy was recently changed from paclitaxel to nivolumab due to non-response to paclitaxel as well as positive PD-1 mutation. Urinalysis showed persistent pyuria with 1% eosinophils and renal ultrasound was unremarkable. Renal biopsy done to further evaluate, revealed diffuse mononuclear infiltrate, predominantly plasma cells in the tubulointerstitial compartment with severe tubulitis. Patient was diagnosed with nivolumab induced immune tubulointerstitial nephritis. Her kidney function gradually improved to creatinine of 1 mg/dl, with withdrawal of nivolumab and short course of steroids. Our case spotlights the immune mediated injury and warrants renal monitoring while on ICPIs.

Discussion

Nivolumab is an IgG4 fully humanized monoclonal antibody, precisely a PD-1 inhibitor. Nivolumab is highly effective in treating melanoma, lung and renal cancers. As the use of these ICPIs is widening, prevalence of immune adverse effects is also spiraling. The incidence of AKI associated with these ICPIs was found to be 2.2 % per Cortazar et al, however recent studies showed higher incidence of 9.9 – 29 %. Clinical awareness regarding these unfamiliar immune side effects of ICPIs should be raised, as timely diagnosis and early intervention plays a crucial role in the management of these complications. Renal surveillance every two weeks is recommended while on ICPIs and withdrawal of offending agent is based on the severity of AKI and cancer prognostic risk. Multidisciplinary approach and close alliance between oncologists and nephrologists is advocated for optimal clinical outcomes.