Ibrutinib-induced acute kidney injury via interstitial nephritis

Abstract

The introduction of Bruton's tyrosine kinase inhibitor ibrutinib has made a significant progress in the treatment of chronic lymphocytic leukemia and other B-cell malignancies. Due to the reduction of cytokine release, it is effective in chronic graft-versus-host disease, and its use has also been suggested in autoimmune diseases and in prevention of COVID-19-associated lung damage. Despite this effect on the immune response, we report a severe hypersensitivity reaction in a 76-year-old male patient diagnosed with prolymphocytic leukemia. Four weeks after the ibrutinib start, non-oliguric acute kidney injury with proteinuria and microscopic hematuria developed and that was accompanied by lower limb purpuras and paresthesia. Renal biopsy revealed acute interstitial nephritis. Employing 1 mg/kg methylprednisolone administration, serum creatinine decreased from 365 μmol/L to 125 μmol/L at 11 days and the proteinuria-hematuria as well as the purpura, paresthesia resolved. Three months later at stabile eGFR of 56 ml/min/1.73 m² methylprednisolone was withdrawn and a rituximab-venetoclax treatment was initiated without side effects. We conclude that despite the beneficial effect on cytokines response in Th1 direction, ibrutinib can cause acute interstitial nephritis. Early detection, discontinuation of ibrutinib, glucocorticoid administration may help to better preserve renal function, thereby lowering the risk of potential subsequent kidney injury.

Keywords: Acute kidney injury; acute interstitial nephritis; chronic lymphocytic leukemia; cytokines; glucocorticoids; ibrutinib.

Figure 1.

Kidney biopsy specimen, monoclonal interstitial infiltration cannot be confirmed. (A) CD68-positive macrophages (100×), (B) CD20-positive B cells (100×), (C) CD3-positive T cells (100×), (D) CD117-positive mastocytes in the interstitium (3 cells on the right side of the FOV), (E) HE (40×) focal, mixed inflammatory cell infiltration in the interstitium