Abstract: TH-PO0719
PLUVICTO-Induced Radiation Nephritis Presenting as Thrombotic Microangiopathy
Session Information
- AKI: Prevention, Diagnostics, and Management
October 22, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 101 AKI: Epidemiology, Risk Factors, and Prevention
Authors
- Abalos, Cherylene S., Southern Arizona VA Health Care System, Tucson, Arizona, United States
- Rabenou, Rahmin A., Southern Arizona VA Health Care System, Tucson, Arizona, United States
- Brucks, Eric, Southern Arizona VA Health Care System, Tucson, Arizona, United States
Introduction
Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) is a radioligand therapy approved for PSMA-positive metastatic castration-resistant prostate cancer after androgen receptor pathway inhibition and taxane-based chemotherapy. Treatment consists of six infusions administered every six weeks. We report a case of radiation nephritis presenting as thrombotic microangiopathy (TMA) following Pluvicto therapy.
Case Description
A 79-year-old man with hypertension and metastatic castration-resistant prostate cancer presented with acute anemia. During transfusion, he developed malignant hypertension. Laboratory evaluation revealed AKI with creatinine rising from a baseline of 1.1 mg/dL to 2.6 mg/dL and nephrotic-range proteinuria (5,073 mg/24 h). Given severe hypertension, anemia, and kidney injury, workup for microangiopathic hemolytic anemia was pursued. LDH was elevated at 414 U/L, and peripheral smear demonstrated schistocytes. Kidney biopsy showed chronic active glomerular thrombotic microangiopathy with 50–60% interstitial fibrosis and tubular atrophy, consistent with radiation nephritis. Six months after completing therapy, creatinine had increased to 3.8 mg/dL with eGFR 15 mL/min/1.73 m.
Discussion
PSMA is expressed on proximal tubular epithelial cells, predisposing the kidneys to off-target uptake during renal excretion of Pluvicto. Resultant radiopharmaceutical retention may lead to cumulative renal radiation injury. The accepted renal radiation threshold is approximately 23 Gy. Pluvicto delivers an estimated 3.1 Gy per cycle, approaching 19 Gy cumulatively after six cycles. Actual renal exposure may vary significantly depending on radionuclide biodistribution, arguing further that a dosimetry-based approach after each cycle should be used. Baseline risk factors including CKD, HTN, and DM may increase susceptibility to nephrotoxicity.
Renal TMA is an uncommon but increasingly recognized complication of 177Lu-PSMA therapy. A recent retrospective analysis of 766 patients identified five cases of biopsy-proven chronic TMA occurring 9–20 months after treatment initiation.
This case highlights the need for vigilant renal monitoring in patients receiving 177Lu-PSMA therapy, particularly those with baseline renal risk factors. Individualized radionuclide dosing and closer surveillance beyond serum creatinine, including routine urinalysis or biomarkers such as NGAL, may allow earlier detection of kidney injury and improved outcomes.