Abstract: FR-PO1288
Checkpoint Inhibitor Storm: Severe Hepatic, Renal, and Gastrointestinal Immune-Related Adverse Events After Pembrolizumab
Session Information
- Onconephrology: Diagnostic Dilemmas, Therapy-Related Toxicities, and Clinical Cases
October 23, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Onconephrology
- 1600 Onconephrology
Authors
- Gonzalez Hernandez, Dina R., Johns Hopkins University, Baltimore, Maryland, United States
- Cervantes, C. Elena, Johns Hopkins University, Baltimore, Maryland, United States
- Hanouneh, Mohamad, Johns Hopkins University, Baltimore, Maryland, United States
Introduction
Pembrolizumab, a programmed death 1 (PD1) inhibitor, is associated with immune related adverse events (irAEs) including hepatitis, colitis and acute interstitial nephritis (AIN). However, concurrent occurrence of all three progressing to acute liver failure and dialysis requiring acute kidney injury (AKI) is uncommon.
Case Description
A 62 year old woman with metastatic non small cell lung cancer receiving carboplatin, pemetrexed, and pembrolizumab presented with altered mental status and diarrhea. She was hemodynamically stable. Laboratories (Fig. 1) revealed acute liver injury and AKI; urinalysis showed proteinuria and pyuria. Acetaminophen level was normal. Brain imaging showed a metastatic lesion with edema. Given recent exposure to pembrolizumab with no alternative causes, patient was diagnosed with pembrolizumab induced colitis, acute liver failure and presumed immune mediated nephritis. Kidney biopsy was deferred due to thrombocytopenia. Continuous renal replacement therapy (CRRT) was initiated for hyperkalemia and metabolic acidosis. High dose corticosteroids resolved diarrhea, normalized liver enzymes within one week, and restored kidney function, allowing dialysis discontinuation (creatinine stabilized at 1.6 mg/dL). She ultimately transitioned to hospice due to progressive malignancy.
Discussion
Immune mediated colitis is the most common gastrointestinal toxicity of checkpoint inhibitors and may signal systemic immune activation. Pembrolizumab associated hepatitis (2-10% incidence) and AIN (2–5% incidence) are recognized irAEs; however, simultaneous multi organ failure is rare (<1%). Mechanisms include loss of self tolerance, T cell activation, and autoantibody formation. Concomitant exposure to medications associated with AIN may increase susceptibility to immune mediated nephritis. This case highlights early recognition of multi system irAEs and prompt initiation of corticosteroids, for rapid organ recovery.