Abstract: PUB194
A Patient with Cholangiocarcinoma with Secondary Membranous Nephropathy Who Developed Immune Checkpoint Inhibitor-Related AKI
Session Information
Category: Onconephrology
- 1600 Onconephrology
Author
- Lee, Monica, Taipei Medical University Shuang Ho Hospital Ministry of Health and Welfare Department of Internal Medicine, New Taipei City, Taiwan
Introduction
Membranous nephropathy occurs as primary form or secondary to multiple nonrenal diseases, including malignancies. Immune checkpoint inhibitors are associated with T-cell invasion of solid organs including the kidneys, leading to a form of acute tubulointerstitial nephritis. Here we present a case of cholangiocarcinoma with secondary membranous nephropathy who developed immune checkpoint inhibitor-related acute kidney injury.
Case Description
This is a 75-year-old man who had lower limbs edema for 1 year. Physical exam showed extremities: pitting edema 3+. Laboratory data showed cre 0.89, BUN 16, albumin 2.6, cholesterol 399. Urinalysis showed protein 4+. UPCR was 11932.36. C3, C4, IgG, IgA, IgM were within normal limits, and ANA, ANCA, anti-GBM, cryoglobulin, ASLO, and anti-PLA2R IgG were all negative. Kidney biopsy (day 0) showed membranous glomerulonephritis, stage I-II. PLA2R and THSD7a staining were negative. Initial abdominal sonography (day -17) showed negative findings. About 2 months after his kidney biopsy, a liver triphasic CT showed liver tumors (day 61). A CT-guided biopsy showed adenocarcinoma. He was diagnosed with cholangiocarcinoma, cT2N0M0, stage II, inoperable. He received durvalumab/gemcitabine/carboplatin C1D1 and C1D8 (day 99 and day 106, respectively).
However, he developed acute kidney injury. His creatinine level increased from 1.26 (day 121) to 2.87 (day 124). He also had skin rash grade II and diarrhea. His laboratory data showed WBC 19.6, eosinophil 16%, Hb 7.1, PLT 181, Na 144, K 3.6, Ca 7.6, P 4.2, uric acid 8.8, ALT 36, T bil 1.5, LDH 539, haptoglobin 249. Urinalysis showed protein 3+, granular cast 0-2. Kidney echo showed no hydronephrosis. Kidney biopsy showed (1) diffuse acute tubular injury; (2) tubulointerstitial nephritis; (3) membranous glomerulonephritis, stage II (day 141). He was diagnosed with immune checkpoint inhibitor-related acute kidney injury.
He was treated with methylprednisolone 60 mg/day (1 mg/kg/day). However, his kidney function continued to worsen. Hemodialysis was initiated. Because of cholangiocarcinoma progression with liver failure, the patient expired.
Discussion
It is important to perform cancer screening not only at the time to MN diagnosis but also screen during follow up. It is important to evaluate the cause of AKI in cancer patients and treat accordingly.