Severe immune-related kidney and lung toxicity during treatment for lung adenocarcinoma

What happened, in summary

A 66-year-old Japanese man with advanced lung adenocarcinoma began pembrolizumab, cisplatin, and pemetrexed. He was also taking esomeprazole and celecoxib. Twenty-seven days after treatment began, his creatinine increased from 1.09 to 1.99 mg/dL, and the cancer regimen was changed to pembrolizumab alone.

On day 41, he was brought to hospital unconscious. Creatinine had risen to 5.08 mg/dL. Electrolyte disturbances, meningitis, and direct malignant involvement were excluded, and immune-related encephalitis was considered. Intravenous hydration and stopping the non-steroidal anti-inflammatory drug improved creatinine to 2.46 mg/dL.

Kidney biopsy then showed active acute interstitial nephritis with severe tubulitis, supporting a serious immune-related kidney complication. Prednisone was started at 30 mg daily. At the same time, an immune-related lung problem worsened substantially, so methylprednisolone pulse therapy and additional intravenous corticosteroid treatment were added. Kidney function eventually returned to its previous baseline, with creatinine approximately 0.8–1.0 mg/dL.

Despite the renal recovery, the combined burden of lung toxicity, neurological illness, and cancer treatment was significant. He and his family chose palliative care, and aggressive treatment was tapered. His course demonstrates that immune-related complications can affect several organs at once and may alter the overall goals of cancer care even when one organ recovers.