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Kidney Week

Abstract: PO1869

Primary Adrenal Insufficiency Secondary to Immune Checkpoint Inhibitors

Session Information

Category: Onco-Nephrology

  • 1500 Onco-Nephrology

Authors

  • Bai, Joti, AtlantiCare Regional Medical Center, Atlantic City, New Jersey, United States
  • Kohli, Jatinder, AtlantiCare Regional Medical Center, Atlantic City, New Jersey, United States
Introduction

ICI's are humanized or human immunoglobulin antibodies. Administration of a monoclonal antibody that interrupts the interaction between PD-L1 and PD-L2 and the T-cell PD-1receptor allows tumor-infiltrating lymphocytes (activated T cells) to aggressively identify and destroy cancer cells. However, Use of ICIs can result in toxicity called immune-related adverse events (IrAEs). We present a case of a 55 year old male with history of metastatic malignant melanoma who presented with ICI induced adrenal insufficiency.

Case Description

55-year-old male PMH of HTN, COPD, Hypothyroidism, metastatic malignant melanoma was recently started Nivolumab presented to the ED with altered mental status and confusion. Laboratory values were notable for hypoglycemic (46mg/dl), hyponatremia (124mmol/l) and borderline High K (5mmol/l), serum osmolality 256 mosm/kg and urine osmolality 538 Mosm/kg. He was initially treated with IV dextrose. Serum cortisol and ACTH were checked to rule out adrenal insufficiency as etiology for above laboratory abnormalities and history of treatments with ICI (nivolumab) . while awaiting these lab results, patient was started on fluid restriction and salt tablets for management of hyponatremia based on available labs at that point which pointed to hypotonic hyponatremia with high urine osmolality pointing to ADH release and goal for correction for sodium level maintained 6-8 Meq for 24hours. Both serum early morning cortisol and ACTH levels were reported to be low with values of 1.4ug/dl and 3.5pg/ml respectively. Patient was subsequently started on IV fluids and IV Hydrocortisone 100 Q8H. Serum sodium level improved at an appropriate rate during the course of hospitalization and serum sodium at the time of discharge was in safe range (136mmol/l) . Other peripheral hormones including prolactin , GH, TSH ,LH and FSH which were normal. MRI Brain was done to rule out Hypophysitis which revealed normal sella.

Discussion

Long-term follow-up of endocrine irAEs suggests that on occasions thyroid function may recover, but that dysfunction of the corticosteroid and gonadal axis is likely to be permanent. Patients should be informed of the potential adverse events prior to initiation of immune checkpoint inhibitors. Laboratory findings similar to our patient should raise concern for adrenal insufficiency to allow timely diagnosis and management and thus prevent morbidity and mortality.