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Abstract: PO1828

Case of FSGS in a Patient on Pembrolizumab

Session Information

Category: Trainee Case Report

  • 1202 Glomerular Diseases: Immunology and Inflammation

Authors

  • Mansoor, Shoaib, Lehigh Valley Health Network, Allentown, Pennsylvania, United States
  • Maynard, Sharon E., Lehigh Valley Health Network, Allentown, Pennsylvania, United States
  • Markowitz, Glen S., Columbia University, New York, New York, United States
  • Schairer, Henry L., Lehigh Valley Health Network, Allentown, Pennsylvania, United States
Introduction

Pembrolizumab, a humanized antibody directed against human cell surface receptor PD-1 with immune check point inhibitory and antineoplastic activities, has been reported to cause minimal change disease (MCD). Here we report a case of focal segmental glomerulosclerosis (FSGS) glomerular tip lesion (GTL) in a patient on pembrolizumab.

Case Description

A 55 year old man with a history of HTN, ex-smoker, and bladder cancer in 2014, presented with leg edema and raised creatinine. His bladder cancer was treated with cystoprostatectomy. Chemotherapy included methotrexate, vinblastine, doxorubicin, and cisplatin (2015), pembrolizumab and epacadostat (7/2016-5/2018) and guadecitabine and atezolizumab (6/2018-12/2018). Pembrolizumab was given again Dec 2018-July 2019.
On physical examination he had 3+ edema up to his knees. Labs showed creatinine 1.4 mg/dl (baseline 1.0 mg/dl). Urinalysis showed proteinuria without hematuria. Urine protein excretion was 19.5 g/day. Kidney biopsy showed 8 out of 24 glomeruli were globally sclerotic. Of the remaining 16 glomeruli, 4 displayed cellular lesions of FSGS and one glomerular tip lesion (GTL). There was GBM duplication and focal endothelial swelling, suggestive of mild endothelial injury (i.e. thrombotic microangiopathy).

Discussion

Glomerular tip lesion (GTL) is a prognostically favorable variant of FSGS with presenting features intermediate between FSGS and MCD. There are reports of MCD with pembrolizumab but no reports of GTL. Given the clinical presentation and similarities between MCD and GTL, it is likely that pembrolizumab contributed to the development of GTL in this case. His FSGS was treated with steroids and pembrolizumab was withheld. His proteinuria started to improve and renal function stabilized.

Glomerular Tip Lesion of FSGS