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Kidney Week

Abstract: TH-PO124

A Case of Steroid-Dependent Interstitial Nephritis Related to Pembrolizumab Use

Session Information

Category: Trainee Case Report

  • 101 AKI: Epidemiology, Risk Factors, and Prevention

Authors

  • Punchayil narayanankutty, Naveen, Jackson Memorial Hospital, Miami Beach, Florida, United States
  • Olickal, Jiny, Jackson Memorial Hospital, Miami Beach, Florida, United States
  • Devi, Gayathri, Providence hospital, Miami, Florida, United States
  • Munoz Mendoza, Jair, University of Miami, Miami, Florida, United States
  • Sosa, Marie A., University of Miami, Miami, Florida, United States
Introduction

Pembrolizumab is a humanized monoclonal antibody belong to class of Immune check point inhibitor (ICI)used in cancer immunotherapy which targets the programmed cell death protein 1 receptor of lymphocytes. Ever since the FDA approval of ipilimumab in 2011 for Metastatic melanoma , there has been a rapid advancement in the use of ICI in various forms of cancer. Every year the use of ICI is rising so do adverse events related to the use of Immune check point inhibitors

Case Description

77 y/o female with h/o metastatic lung cancer, on chemotherapy, transferred to ER from clinic after labs showed Creatinine of 8.95 and potassium: 7.4 compared to a baseline creatinine of 1.1 six weeks prior . Her Urinalysis showed 62 wbcs with rest of the labs unremarkable except for metabolic acidosis with a bicarbonate level of 16. She was managed supportively and subsequently a renal biopsy was done which showed diffuse severe acute tubulointerstitial nephritis with eosinophils consistent with a hypersensitivity reaction ,marked interstitial fibrosis, marked arteriosclerosis and mild arteriolosclerosis .Her history is significant for biopsy proven adenocarcinoma of the lung diagnosed in June 2017 Started on chemotherapy with Carboplatin, pemetrexed initially .She had Left upper lobectomy and wedge resection in Oct 2017, followed by maintenance immunotherapy with Pembrolizumab only since Decmeber 2017. Considering the pathology finding patient was started on high dose prednisone for AIN .Eventhough creatinine improved to 1.71 on follow up visit she remained steroid dependent and her AKI progressed to CKD IV with recent EGFR of 27

Discussion

The presence of Acute interstitial nephritis (AIN) secondary to Immune check point inhibitors has been described before but usually with the cessation of drug and with high dose prednisone therapy for few weeks renal function improves. We present a case of Acute interstitial nephritis related to pembrolizumab use which presented a year after initiation of therapy and despite early initiation of steroids , she remained steroid dependent with progression of Acute Kidney injury (AKI) to Chronic Kidney disease (CKD). Our case emphasis on keeping AIN on top of differential diagnosis in patients treated with ICI even if ICI use is not recent and patient can develop steroid dependency with progression of AKI to CKD