Two acute kidney injury episodes after ICI therapy: a case report

Abstract

A 74-year-old Japanese male with lung squamous cell carcinoma received his first dose of immune checkpoint inhibitors (ICIs): ipilimumab and nivolumab. He developed acute kidney injury (AKI) and was admitted to our department. We diagnosed kidney immune-related adverse effects (irAE), and a kidney biopsy revealed acute tubulointerstitial nephritis. We started oral prednisolone (PSL) and his AKI immediately improved. The patient maintained stable findings after PSL was tapered off. However, seven months after the ICI administration, he developed rapid progressive glomerular nephritis and was admitted to our department again. The second kidney biopsy showed findings consistent with anti-glomerular basement membrane glomerulonephritis. Although the patient was treated with pulse methylprednisolone followed by oral PSL and plasma exchange, he became dependent on maintenance hemodialysis. To our knowledge, no case report has described two different types of biopsy-proven nephritis. In cases of suspected relapsing kidney irAEs, both a relapse of previous nephritis and the development of another type of nephritis should be considered.

Keywords: Acute tubulointerstitial nephritis; Anti-glomerular basement membrane disease; Immune-related adverse events.

Fig. 1

Pathological findings of the first kidney biopsy. a Hematoxylin–eosin (HE) staining shows lymphocyte infiltration and granuloma (×200). b PAS staining shows lymphocyte infiltration in interstitium (×200). c, d PAS staining shows a glomerulus without significant lesions (×200, ×400, respectively). e–h CD-3 positive (e) and CD-4 positive (f) lymphocytes are dominant. CD-8 positive (g) and CD-20 positive (h) lymphocytes are also present (×200)

Fig. 2

Pathological findings of the second kidney biopsy. a PAS staining shows mesangial and endocapillary hypercellularity in a glomerulus (×400). b PAM staining shows a ruptured Bowman’s capsule (×400). c Hematoxylin–eosin staining shows leucocyte infiltration, mainly neutrophils, around a glomerulus (×200). d Immunofluorescence(IF) staining shows linear IgG deposit (×40). e–h IgG subclass IF staining. IgG1 (e), IgG2 (f) and IgG4 (h) are dominant (×40)

Fig. 3

The patient’s clinical course