Rapidly Progressive Pauci-Immune Glomerulonephritis with Aberrant Fibrinoid Necrosis Associated with Atezolizumab, an Immune Check Point Inhibitor: A Case Report and Review of Literature

Abstract

Stimulation of the antitumor activity of the immune system using immune checkpoint inhibitors (ICIs) has proven efficacy in the treatment of multiple types of cancer, inducing the speedily expanding approval of therapeutic indications for ICIs. The literature regarding the immune-related toxicities and nephrotoxicity of ICIs is limited. Herein, we present a patient with lung cancer treated with atezolizumab, an IgG1 monoclonal antibody aimed at the programmed death ligand 1 (PD-L1), who presented with vasculitic skin rash and rapidly deteriorating renal function, new onset of significant glomerular hematuria and proteinuria. The renal biopsy revealed acute necrotizing pauci-immune vasculitis, with fibrinoid necrosis. The patient received a course of high-dose glucocorticoids with recovery of renal function and skin lesions. Further immunosuppressive therapy was withheld, due to active malignancy in the lung, while oncology consultation recommended the continuation of treatment with atezolizumab, as the patient had shown substantial response.

Keywords: acute kidney injury (AKI); checkpoint inhibitors; immune related adverse effect; immunotherapy; onconephrology; vasculitis.

Figure 1

Fibrinoid necrosis in a parenchymal structure, most likely corresponding to a vessel wall. Although many sections were obtained, the exact vessel type cannot be clearly identified and determined (i.e., artery, vein, or lymph vessel), since it is entirely damaged ((a) H&E ×400, (b) H&E ×200).

Figure 2

Fibrinoid necrosis is highlighted with a bright red (fuchsinophilic) color in Masson trichrome stain (Masson ×400).