Abstract: SA-PO231
Water, Water Everywhere: Not a Drop to Diurese
Session Information
- Onconephrology: Immunological Cross-Talk
November 04, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Onconephrology
- 1700 Onconephrology
Authors
- Rodrigues, Shelden Selas, Washington University in St Louis, St Louis, Missouri, United States
- Vijayan, Anitha, Washington University in St Louis, St Louis, Missouri, United States
Introduction
Anasarca is a common yet challenging symptom to manage, with common causes being cardiac, hepatic or renal failure. It is important to consider rarer etiologies when conventional therapies fail to respond.
Case Description
A 56-year-old woman with metastatic breast cancer, on Trastuzumab-deruxtecan presented with worsening anasarca and weight gain of 40kg. Workup ruled out heart, liver and renal failure(creatinine 0.6mg/dL) and nephrotic syndrome. Attempts at diuresis using various combinations (loop, thiazide, and carbonic anhydrase inhibitors) were unsuccessful and resulted in contraction alkalosis and worsening renal function. Due to lack of alternate diagnoses, we considered a diagnosis of capillary leak syndrome (CLS) possibly induced by trastuzumab-deruxtecan and filgrastim. We started amiloride 20mg and administered one dose of tocilizumab 800mg. Over the next few days, daily urine output increased to 4L on furosemide 40mg with no contraction alkalosis or worsening renal function. She had steady improvement in volume status and decrease in weight (Figure 1). Patient was discharged on day 14 post tocilizumab with marked improvement in her functional status and edema, with weight back to baseline. She has not required re-hospitalization and her weight has remained stable on amiloride 20mg.
Discussion
Capillary leak syndrome refers to the collection of manifestations due to increased capillary permeability to proteins. Several drugs have been implicated such as gemcitabine, interleukins and monoclonal antibodies.
Management of volume status is crucial in treating CLS but there is no well-established treatment protocol due to rarity of the condition. Cytokine release syndrome is a subset of CLS occurring in the setting of malignancy treatment or administration of monoclonal antibodies resulting in cytokine surge, endothelial cell injury and capillary leakage. Therapeutic options aim to block this cytokine storm with IVIG or steroids. This case highlights the success of tocilizumab, an interleukin-6 inhibitor for CLS induced by trastuzumab and filgrastim.