Lung cancer treated with nivolumab: rare kidney inflammation as a side effect

What happened, in summary

A 72-year-old man underwent removal of the lower lobe of his left lung and nearby lymph nodes for lung squamous cell carcinoma. Cancer cells were found in pleural washings and at the surgical margin, so he received 4 cycles of carboplatin plus S-1. Three months after chemotherapy ended, CT showed recurrence in the left lung, pleura, and lymph nodes.

He began nivolumab 240 mg for the recurrent metastatic disease. Before treatment, his kidney function was normal. He had longstanding microscopic blood in the urine related to kidney stones but no proteinuria. One week after nivolumab, protein appeared in the urine and his creatinine began rising. By week 3, creatinine had reached 5.15 mg/dL and 24-hour urine protein was 4.75 g.

A kidney biopsy showed ANCA-negative pauci-immune crescentic glomerulonephritis, a severe form of kidney inflammation. The timing and biopsy findings supported an immune-related adverse effect from nivolumab.

Oral prednisolone was started, followed by methylprednisolone 1,000 mg daily for 3 days. Because his urine output became very low and fluid overload affected his heart, hemodialysis was also required. Despite the intensive treatment, kidney function did not recover. He remained dependent on maintenance dialysis. His lung cancer also continued to advance, and he died 10 months after the kidney injury.

The biopsy found crescents in 25 of 60 kidney filters, together with scarring and inflammation. This extensive damage made dialysis dependence more likely even though immune-suppressing treatment began promptly.