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Tong R, Luo Z, Zhong X, Fan L, Lai H, Shen M, Huang Y. Atypical anti-glomerular basement membrane disease with membranous hyperplasia: diagnostic challenges and treatment variability. BMC Nephrol 2024; 25:132. [PMID: 38622525 PMCID: PMC11017607 DOI: 10.1186/s12882-024-03571-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 04/04/2024] [Indexed: 04/17/2024] Open
Abstract
This case report presents a detailed analysis of a 31-year-old male patient who presented with a complex array of clinical symptoms, including proteinuria, hematuria, edema, and kidney insufficiency. Despite undergoing multiple tests, the results for anti-glomerular basement membrane antibodies yielded negative findings. Subsequently, kidney biopsy pathology revealed a distinct diagnosis of atypical anti-glomerular basement membrane (anti-GBM) disease with membrane hyperplasia. Treatment was initiated with a comprehensive approach involving high doses of corticosteroids therapy and cyclophosphamide (CTX). However, contrary to expectations, the patient's kidney function exhibited rapid deterioration following this therapeutic regimen. The culmination of these complications necessitated a pivotal transition to maintenance hemodialysis. This case underscores the intricate challenges associated with diagnosing and managing rare and atypical presentations of kidney disorders. The negative anti-GBM antibody results and subsequent identification of atypical anti-GBM nephropathy highlight the need for tailored diagnostic strategies to discern subtle nuances within complex clinical scenarios. Additionally, the unexpected response to the treatment regimen emphasizes the potential variability in individual patient responses, underlining the necessity for vigilant monitoring and adaptable treatment strategies. This case report contributes to the evolving understanding of atypical kidney pathologies and the complexities involved in their management.
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Affiliation(s)
- Ruoyu Tong
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Zhengmao Luo
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Xianyang Zhong
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Liming Fan
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Huangwen Lai
- Pathology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Meng Shen
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Yuanhang Huang
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China.
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Ishiga K, Kobayashi R, Kanaoka T, Harada J, Kato I, Fujii S, Wakui H, Toya Y, Tamura K. Two acute kidney injury episodes after ICI therapy: a case report. CEN Case Rep 2024:10.1007/s13730-024-00855-5. [PMID: 38453804 DOI: 10.1007/s13730-024-00855-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/22/2024] [Indexed: 03/09/2024] Open
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.
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Affiliation(s)
- Kohei Ishiga
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Ryu Kobayashi
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan.
| | - Tomohiko Kanaoka
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Jotaro Harada
- Department of Molecular Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ikuma Kato
- Department of Molecular Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Satoshi Fujii
- Department of Molecular Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiromichi Wakui
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Yoshiyuki Toya
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
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Rivedal M, Haaskjold YL, Berge H, Knoop T. Antiglomerular Basement Membrane Disease Possibly Triggered by Undiagnosed Renal Cell Carcinoma: A Case Report. Kidney Med 2023; 5:100709. [PMID: 37693652 PMCID: PMC10485625 DOI: 10.1016/j.xkme.2023.100709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
Antiglomerular basement membrane (anti-GBM) disease is a rare, small-vessel vasculitis that affects the capillary beds of the kidneys and lungs. Although exceedingly rare, several case reports have described anti-GBM disease with a concurrent cancer diagnosis, suggesting a possible correlation between these 2 conditions. Herein, we describe the first known case to our knowledge of a woman in her early 60s with simultaneous anti-GBM disease and clear cell renal cell carcinoma, in which the tumor was thought to have been the substrate for anti-GBM disease. We believe that renal cell carcinoma may have contributed to the production of anti-GBM autoantibodies and, thus, anti-GBM disease. The concurrence of these 2 conditions complicated the treatment of the patient, who was hemodialysis-dependent at the time of hospital discharge. This report highlights the importance of considering anti-GBM disease as a potential diagnosis in patients with acute kidney failure, and how important it is to identify both clear cell renal cell carcinoma and anti-GBM disease at an early stage to improve outcomes.
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Affiliation(s)
- Mariell Rivedal
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Yngvar Lunde Haaskjold
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Hedda Berge
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Thomas Knoop
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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El Yamani N, Cote G, Riopel J, Marcoux N, Mac-Way F, Philibert D, Agharazii M. Pembrolizumab-Induced Anti-GBM Glomerulonephritis: A Case Report. Kidney Med 2023; 5:100682. [PMID: 37415622 PMCID: PMC10320380 DOI: 10.1016/j.xkme.2023.100682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Immune checkpoint inhibitors are known to have a wide range of autoimmune toxicities, such as acute interstitial nephritis. Immunotherapy induced glomerulonephritis has been described, but anti-glomerular basement membrane disease (anti-GBM) is rarely reported. We present a case report of a 60-year-old woman with squamous cell carcinoma of the cervix who was treated with pembrolizumab, an anti-programmed cell death protein 1, and who developed severe acute kidney injury 4 months after therapy initiation. The immune workup showed a positive serum anti-GBM antibody (24 U/mL). The kidney biopsy showed crescentic glomerulonephritis with linear immunoglobulin G2 glomerular basement membrane staining, compatible with anti-GBM glomerulonephritis. The patient was treated with plasmapheresis, IV steroids, and cyclophosphamide, but she developed kidney failure, necessitating dialysis. Few case reports, such as the present case, provide a possible link between anti-GBM glomerulonephritis and immune checkpoint inhibitors, warranting early clinical suspicion and investigation in patients who are treated with these agents and subsequently develop acute kidney injury.
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Affiliation(s)
- Nidal El Yamani
- CHU de Québec Research Center- L’Hôtel-Dieu de Québec Hospital, Québec City, Québec, Canada
| | - Gabrielle Cote
- Division of Nephrology, Department of Medicine, Université Laval, Québec City, Québec, Canada
| | - Julie Riopel
- Division of Pathology, Department of Molecular Biology, Medical Biology and Pathology, Université Laval, Québec City, Québec, Canada
| | - Nicolas Marcoux
- Division of Hematology and Oncology, Department of Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center- L’Hôtel-Dieu de Québec Hospital, Québec City, Québec, Canada
| | - David Philibert
- Division of Nephrology, Department of Medicine, Université Laval, Québec City, Québec, Canada
| | - Mohsen Agharazii
- CHU de Québec Research Center- L’Hôtel-Dieu de Québec Hospital, Québec City, Québec, Canada
- Division of Nephrology, Department of Medicine, Université Laval, Québec City, Québec, Canada
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Bharati J, Yang Y, Sharma P, Jhaveri KD. Atypical Anti-Glomerular Basement Membrane Disease. Kidney Int Rep 2023; 8:1151-1161. [PMID: 37284681 PMCID: PMC10239794 DOI: 10.1016/j.ekir.2023.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/09/2023] [Accepted: 03/15/2023] [Indexed: 06/08/2023] Open
Abstract
Atypical anti-glomerular basement membrane (anti-GBM) disease is characterized by linear immunoglobulin G (IgG) deposition along the GBM without circulating IgG anti-GBM antibodies. Compared to classic anti-GBM disease, atypical anti-GBM disease tends to be milder with a more indolent course in certain cases. Moreover, pathologic disease pattern is much more heterogenous in atypical anti-GBM disease than in the classic type, which is uniformly characterized by diffuse crescentic and necrotizing glomerulonephritis. Although there is no single well-established target antigen in atypical anti-GBM disease, the target antigen (within the GBM) and the autoantibody type are hypothesized to be different from the classic type. Some patients have the same antigen as the Goodpasture antigen that are detected only by a highly sensitive technique (biosensor analysis). Some cases of atypical anti-GBM disease have autoantibodies of a different subclass restriction like IgG4, or of monoclonal nature. Antibodies targeting antigen/epitope structure other than the Goodpasture antigen can be detected using modified assays in some cases. Patients with IgA- and IgM-mediated anti-GBM disease are known to have negative circulating antibodies because conventional assays do not detect these classes of antibodies. A significant proportion of cases with atypical anti-GBM disease do not have any identifiable antibodies despite extensive evaluation. Nevertheless, extensive evaluation of atypical autoantibodies using modified assays and sensitive techniques should be attempted, if feasible. This review summarizes the recent literature on atypical anti-GBM disease.
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Affiliation(s)
- Joyita Bharati
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Yihe Yang
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Purva Sharma
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
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Hoshina A, Endo S. Anti-glomerular basement membrane glomerulonephritis concurrent with membranous nephropathy and acute tubular interstitial nephritis in a lung cancer patient treated with pembrolizumab. CEN Case Rep 2022; 12:230-236. [PMID: 36401746 PMCID: PMC10151296 DOI: 10.1007/s13730-022-00750-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/06/2022] [Indexed: 11/21/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have become the standard treatment for many types of cancer and have improved patient prognosis. However, ICIs upregulate the immune system against tumors, leading to immune-related adverse events (irAEs). Kidney irAEs are less common, and most of them are acute tubulointerstitial nephritis (ATIN). However, there has been a recent increase in recognition of glomerular disease related to ICI therapies. We report the case of a 65-year-old man with lung adenocarcinoma who was treated with pembrolizumab (a monoclonal antibody targeting programmed cell death protein-1 [PD-1]). Pembrolizumab was discontinued after seven cycles due to the development of destructive thyroiditis. Within three months of discontinuing the pembrolizumab treatment, the patient developed rapid progressive glomerulonephritis (RPGN), liver dysfunction, and dysgeusia. The patient underwent renal biopsy and was diagnosed with crescentic glomerulonephritis due to anti-glomerular basement membrane (GBM) antibodies complicated with membranous nephropathy (MN) and ATIN. Treatment with systemic corticosteroids resulted in a favorable clinical response. Various ICI-associated glomerular diseases have been described; however, this is the first reported case of anti-GBM glomerulonephritis associated with MN and ATIN following ICI treatment.
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Affiliation(s)
- Azusa Hoshina
- Department of Nephrology, Shiga General Hospital, 5-4-30 Moriyama, Moriyama-City, Shiga, 524-8524, Japan.
| | - Shuichiro Endo
- Department of Nephrology, Shiga General Hospital, 5-4-30 Moriyama, Moriyama-City, Shiga, 524-8524, Japan
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Miao J, Sise ME, Herrmann SM. Immune checkpoint inhibitor related nephrotoxicity: Advances in clinicopathologic features, noninvasive approaches, and therapeutic strategy and rechallenge. FRONTIERS IN NEPHROLOGY 2022; 2:1017921. [PMID: 37674988 PMCID: PMC10479679 DOI: 10.3389/fneph.2022.1017921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/28/2022] [Indexed: 09/08/2023]
Abstract
Immune checkpoint inhibitors (ICIs) are used increasingly to treat more than 17 cancers and have shown promising therapeutic results. However, ICI use can result in a variety of immune-related adverse events (IRAEs) which can occur in any organ, including the kidneys. Acute kidney injury (AKI) is the most common nephrotoxicity, classically related to acute interstitial nephritis. Much more diverse patterns and presentations of ICI-related kidney injury can occur, and have implications for diagnostic and therapeutic management approaches. In this review, we summarize the recently approved ICIs for cancer, the incidence and risk factors for nephrotoxicity, our current understanding of the pathophysiological mechanisms and the key clinicopathological features of ICI-related AKI, and therapeutic strategies. We also explore important knowledge that require further investigation, such as the risks/benefits of ICI rechallenge in patients who recover from an episode of ICI-related AKI, and the application of liquid biopsy and microbiome to identify noninvasive biomarkers to diagnose and predict kidney injury and guide ICI therapy.
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Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Meghan E. Sise
- Department of Internal Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, United States
| | - Sandra M. Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
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Tian R, Liang J, Li R, Zhou X. Acute Kidney Injury Induced by Immune Checkpoint Inhibitors. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:190-201. [PMID: 35702709 PMCID: PMC9149491 DOI: 10.1159/000520798] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/25/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Recent advances in immune therapy have focused on several agents that target tumor suppression; specifically, use of immune checkpoint inhibitors (ICIs), such as ipilimumab, pembrolizumab, and nivolumab, has become an important strategy in cancer therapy as they improve outcomes in malignant disease. However, the incidence of renal complications arising from the widespread use of ICIs may be underestimated. SUMMARY The most frequently reported renal condition caused by ICI use is acute interstitial nephritis, and for clinicians, the crucial question is how to effectively manage patients who develop renal side effects due to cancer treatment. Currently, treatment of kidney injury associated with ICIs adheres to clinical guidelines described in Kidney Disease Improving Global Outcomes, which entails drug withdrawal and glucocorticoids or combined immunosuppressant use based on disease stage; however, there is no consensus on renal biopsy. KEY MESSAGES Despite significant progress in prevention and treatment, the incidence and mortality of ICI-induced acute kidney injury (AKI) remain very high. This article will discuss the general clinical manifestations, mechanisms of toxicity, renal complications of ICI therapy, and related biomarkers of renal damage. It is envisaged that this information would help clinicians effectively manage AKI due to ICI therapy.
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Affiliation(s)
- Ruixue Tian
- The Fifth Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Jin Liang
- The Fifth Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Rongshan Li
- Department of Nephrology, Shanxi Provincial People's Hospital, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Xiaoshuang Zhou
- Department of Nephrology, Shanxi Provincial People's Hospital, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Kidney Disease Institute, Taiyuan, China
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Jo E, Rhee H. Dabrafenib- and trametinib-associated glomerular toxicity: A case report. Medicine (Baltimore) 2022; 101:e28485. [PMID: 35029901 PMCID: PMC8735797 DOI: 10.1097/md.0000000000028485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 12/16/2021] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Combined treatment with dabrafenib, a B-RAF inhibitor, and trametinib, a mitogen-activated protein kinase inhibitor, is an effective option for patients with metastatic melanoma. A few cases of acute kidney injury associated with tubulointerstitial nephritis and 1 case of nephrotic syndrome have been reported in patients on this drug combination; however, progressive renal injury has not been reported. In this case study, we report a patient with metastatic melanoma who developed glomerular capillary endothelial toxicity and progressive glomerular sclerosis during combination therapy. PATIENT CONCERN Our patient was an 80-year-old woman with a history of type 2 diabetes and chronic kidney disease. DIAGNOSIS AND INTERVENTION She was diagnosed with metastatic melanoma and commenced combination therapy with dabrafenib and trametinib. OUTCOMES Her renal function progressively deteriorated; by month 20 after treatment commencement, her serum creatinine level had increased from 1.59 to 3.74 mg/dL. The first kidney biopsy revealed marked glomerular and endothelial cell damage. Her medication was stopped, but no improvement was evident. At 5 months after the first biopsy, her serum creatinine level had increased to 5.46 mg/dL; a second kidney biopsy revealed focal segmental glomerular sclerosis and marked tubulointerstitial fibrosis. She was started on hemodialysis. LESSONS We describe a patient with a metastatic melanoma who developed progressive kidney failure during treatment with dabrafenib and trametinib. The most prominent microscopy findings were glomerular endothelial damage in the initial kidney biopsy and accelerated glomerular sclerosis and tubulointerstitial fibrosis in the follow-up biopsy. We hypothesize that a decreased renal reserve and impairment of kidney repair capacity caused by inhibition of B-RAF, a downstream mediator of vascular endothelial growth factor, may explain the progressive kidney injury.
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Affiliation(s)
- Eunmi Jo
- Department of Nephrology, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Harin Rhee
- Department of Nephrology, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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