Abstract: FR-PO284
IgA Glomerulonephritis in the Setting of Immune Checkpoint Inhibitor Use Successfully Treated with Rituximab
Session Information
- Onconephrology: From AKI to CKD and Everything in Between
November 03, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Onconephrology
- 1700 Onconephrology
Authors
- Calder, Madison B., University of California Davis School of Medicine, Sacramento, California, United States
- Wiegley, Nasim, University of California Davis School of Medicine, Sacramento, California, United States
- Jen, Kuang-Yu, University of California Davis School of Medicine, Sacramento, California, United States
- Ananthakrishnan, Shubha, University of California Davis School of Medicine, Sacramento, California, United States
- Goetz, Lindsey Rae, University of California Davis School of Medicine, Sacramento, California, United States
Introduction
IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide, and occurs as either a primary autoimmune response or secondary to other pathology. Immune checkpoint inhibitor (ICI) therapy has improved the prognosis for many patients with advanced cancers, but despite the benefits, immune-related adverse effects remain common. We report a case of ICI-associated IgAN successfully treated with rituximab.
Case Description
A 73-year-old White man with hepatocellular carcinoma on nivolumab was initially referred for acute kidney injury (AKI). History and physical, serology, urine, and imaging was unrevealing. Steroids were deferred, serum creatinine (sCr) partially recovered, and nivolumab was resumed. Four months later, he developed recurrent, now dialysis-dependent AKI along with gross hematuria and nephrotic range proteinuria. Kidney biopsy demonstrated a proliferative, crescentic glomerulonephritis with both IgA and C3 deposition (Figure 1). Nivolumab was discontinued, glucocorticoids were administered without improvement, and rituximab was initiated. Five months later, he discontinued dialysis with recovery of sCr and proteinuria to baseline levels.
Discussion
Rituximab has been shown to be effective for IgA vasculitis affecting the kidney, but has yet to demonstrate consistent benefit in primary IgAN. Case reports of IgAN affecting kidney transplant recipients report positive outcomes, possibly due to a B-cell depleting effect within the enhanced post-transplant immunologic milieu. Our case illustrates a potential role for rituximab in salvage therapy for ICI-related IgAN, where it may act similarly to provide a "check” to the amplified immune response caused by immune checkpoint disruption. Nephrologists and oncologists must remain aware of ICI-associated glomerular disease and maintain a low threshold to obtain a kidney biopsy when the presentation is atypical for AIN.
Figure 1. Native kidney biopsy demonstrating crescentic glomerulonephritis in the setting of active ICI use (left, light microscopy) with strong IgA staining (right, immunofluorescence).