Two Severe Kidney Injuries After Lung Cancer Immunotherapy

What happened, in summary

A 74-year-old Japanese man had squamous cell cancer in the lower part of his right lung. He underwent lung surgery, but the cancer later returned. Cisplatin and vinorelbine were started and then stopped because of nausea. In April 2022, he received his first combined immunotherapy dose: ipilimumab 60 mg and nivolumab 360 mg.

About 2 weeks later, he developed a rash. Fever and loss of appetite began on day 18, and by day 26 his creatinine had risen from a usual 0.9–1.1 mg/dL to 2.33 mg/dL. Hydration and antibiotics did not reverse the kidney injury. His creatinine reached 4.34 mg/dL, and he needed 4 hemodialysis sessions. A biopsy showed acute tubulointerstitial nephritis, an immune-related inflammation of the kidney. Prednisolone 30 mg daily was started, and the blood and protein in his urine disappeared within 2 days. He left the hospital on day 41 and stopped steroids on day 93, although kidney function did not fully return to baseline.

On day 211, more than 6 months after the single immunotherapy dose, fever and appetite loss returned. This time, testing found anti-GBM antibodies, and a second biopsy confirmed a different and more aggressive kidney disease. He received high-dose intravenous steroids, further hemodialysis and 14 plasma-exchange sessions. His fever and appetite improved, but his kidneys did not recover enough to stop dialysis.

Immunotherapy and other curative cancer treatment remained on hold. His lung cancer remained stable without progression, while he continued hemodialysis and a gradual steroid taper.