IMMUNE CHECKPOINT BLOCKADE INDUCED ACUTE INTERSTITIAL NEPHRITIS: A CASE REPORT
Joy Samuel1, Holly Hutton2, Leo Francis3 1Hervey Bay Hospital, Urraween, Queensland, Australia2Alfred Health, Melbourne, Victoria, Australia3Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
Abstract
Background: Immune checkpoint blockade (ICB) with Nivolumab and Ipilimumab is used in patients with advanced melanoma. These medications improve survival by blocking inhibitory receptors, PD1 and CTLA4 respectively, enhancing T-cell-mediated antitumor responses. Immune-related adverse events occur in up to 60% of patients, with acute kidney injury (AKI), typically due to acute interstitial nephritis (AIN), less common than colitis and rash. Observational data suggest that treatment with glucocorticoids is beneficial in ICB related AIN.
Case report: CB, a 62-year-old-woman, was diagnosed with metastatic lung melanoma in May 2022, and began monthly Nivolumab/Ipilimumab. Baseline eGFR was >90ml/min. During the third cycle she felt lethargic and was found to have AKI with serum creatinine (SCr) peak at 159umol/l, eGFR 30ml/l in October. Investigations showed normal renal ultrasound, no proteinuria or active sediment. PET/CT showed hypophysitis, thyroiditis and reactive nodes, thought to be immune reactions related to ICB. Blood tests revealed a TSH of 33.5mu/l; thyroxine was started. SCr improved to 108umol/L, eGFR 48ml/min on prednisolone at initial dose 75mg daily. After this, Nivolumab was continued by the oncology team. In January 2023, after the next cycle, with prednisolone at 25mg/day, CB represented with SCr 190umol/l, eGFR 24ml/min. A renal biopsy confirmed AIN. Further steroids were given, and currently her renal function is SCr 140umol/l, eGFR 35ml/min.
Conclusion: Monitoring of renal function and prompt diagnosis is important to allow early use of steroids in cases of AIN due to ICB. In this case, rechallenge with Nivolumab whilst on weaning steroids resulted in renal function decline, but the balance between kidney function and improved survival needs to be considered as there are limited alternative treatments.
Biography
My name is Joy Samuel and I am a first year Basic Physician Trainee with an interest in nephrology.