Adverse Renal Effects of Anticancer Immunotherapy: A Review

Knowledge mapping and visualized analysis of research progress in onconephrology: a bibliometric analysis

OBJECTIVES

Onconephrology is an expanding subspecialty focused on the management of cancer patients with renal injury. This study used a comprehensive bibliometric analysis to emphasize the need for cooperation between oncologists and nephrologists, exploring current trends and future research areas in onconephrology.

METHODS

Relevant literature on onconephrology published between 1 January 2000 and 27 April 2024 was retrieved from the Science Citation Index Expanded of the Web of Science Core Collection, followed by manual screening. Bibliometric analyses were performed using CiteSpace, VOSviewer, and Bibliometrix software.

RESULTS

A total of 1,853 publications, including 1,647 articles and 206 reviews, by 11,606 authors from 2,757 institutions in 73 countries, were analyzed. Annual publications generally follow a steadily increasing trend, ranging from 25 to 161 documents. The United States (n = 464), The University of Texas MD Anderson Cancer Center (n = 39), Meletios A. Dimopoulos (n = 21), and Nephrology Dialysis Transplantation (n = 35) were the most productive country, institution, author, and journal, respectively. Immune checkpoint inhibitors, glomerular filtration rate, and cisplatin were clusters of highly cited references after 2015. Oxaliplatin, calcium, open-label, and thrombotic microangiopathy were trending topics after 2020. Outcome, acute kidney injury, immunotherapy, and chronic kidney disease were keyword bursts that persisted through 2024.

CONCLUSION

Current research of onconephrology is focusing on chemotherapeutic nephrotoxicity, kidney function assessment, dosing of chemotherapeutic agents in chronic kidney disease, glomerular disease in cancer, immunotherapy, and electrolyte disturbances. Future directions in this field include clinical trials and thrombotic microangiopathy.

Epigenetic regulators combined with tumour immunotherapy: current status and perspectives

Immunotherapy, particularly immune checkpoint inhibitor therapy, has demonstrated clinical benefits in solid tumours. Despite its satisfactory clinical efficacy, it still faces several issues, such as limited eligibility, low response rates and cytotoxicity. Cancer epigenetics implies that tumour cells exhibit unique phenotypes because of their unique characteristics, thus reprogramming of the epigenome holds promise for cancer therapy. Epigenetic regulation plays an important role in regulating gene expression during tumour development and maintenance. Epigenetic regulators induce cancer cell cycle arrest, apoptosis and differentiation of cancer cells, thereby exerting anti-tumour effects. Recent studies have revealed a significant correlation between epigenetic regulatory factors and immune checkpoint therapy. Epigenetics can modulate various aspects of the tumour immune microenvironment and immune response to enhance the sensitivity of immunotherapy, such as lowering the concentration required and mitigating cytotoxicity. This review primarily discusses DNA methyltransferase inhibitors, histone deacetylase inhibitors, enhancer of zeste homolog 2 inhibitors and lysine-specific demethylase 1 inhibitors, which are associated with transcriptional repression. This repression alters the expression of genes involved in the immune checkpoint, thereby enhancing the effectiveness of immunotherapy. We also discuss the potential and challenges of tumour immunotherapy and highlight its advantages, application challenges and clinical research on integrating epigenetic regulatory factors with tumour immunotherapy.

Antitumoral effectiveness and safety of intravenous versus subcutaneous administration of immunomodulatory peptide GK-1 in a murine breast cancer model

INTRODUCTION

GK-1 is a safe and effective molecule with high antimetastatic activity against murine breast and skin cancer. GK-1 treatment enhances cytotoxic response of CD8+ lymphocytes against the tumor and modifies the oxidative stress in the tumor. This study was designed to compare the antitumor efficacy of GK-1 by subcutaneous (SC) versus intravenous (IV) route of administration in the 4T1 mouse mammary carcinoma model and to extend its innocuity in heart and kidney, key tissues for observing damage induced by anticancer drugs and immunotherapy.

MATERIAL AND METHODS

BALB/c female mice were injected orthotopically with 1000 4T1 cells. When palpable primary tumors of about 1 mm3 were detected, GK-1 (5 mg/kg) was administered IV or SC weekly for 21 days. Tumor growth and mouse weight were monitored weekly. The primary tumor weight and volume, the number of lung metastases, and programmed cell death protein 1 (PD-1) expression were recorded after 28 days of starting treatment. Kidney, heart, spleen, serum, and blood samples from naïve mice were obtained to evaluate the safety of GK-1 administration by measuring the degree of damage to these tissues with specific cytotoxic markers.

RESULTS

Subcutaneous or intravenous administration of GK-1 significantly increased the lifespan of mice and significantly reduced the primary tumor weight and volume and the number of lungs macrometastases. GK-1 reduced the expression of PD-1 in tumor-infiltrating lymphocytes in mice regardless of the route of immunization used, which is especially encouraging. No evidence of damage to kidney or heart tissues was detected in the tumor-free mice.

CONCLUSIONS

This study supports that subcutaneous GK-1 administered, has an efficacy non-inferior to intravenous administration, well-tolerated with a similar safety profile and therefore offers a less invasive valid treatment alternative.

Pharmacotherapy considerations in patients who develop acute kidney injury during anti-cancer therapy

INTRODUCTION

Acute kidney injury (AKI) frequently develops in patients receiving cancer therapy and requires a wide differential diagnosis due to possible role of unique cancer and drug-related factors, in addition to common pre- and post-renal causes. Rapid development of new molecular targeted anti-cancer drugs and immunotherapies has opened unprecedented possibilities of treatment at the price of an increased spectrum of renal side effects.

AREAS COVERED

The present review aims at providing a state-of-the-art picture of AKI in cancer patient (PubMed and Embase libraries were searched from inception to January 2024), with a focus on differential diagnosis and management of diverse clinical settings. Reports of parenchymal AKI due to glomerular, microvascular, tubular and interstitial damage have been constantly increasing. Complex electrolyte and acid-base disorders can coexist. The role of renal biopsy and possible therapeutic approaches are also discussed.

EXPERT OPINION

Onconephrology has become an important subspecialty of clinical nephrology, requiring constantly updated skills and a high degree of interdisciplinary integration to tackle diagnostic challenges and even therapeutic and ethical dilemmas. Integrated onconephrological guidelines and availability of biomarkers may provide new tools for management of this unique type of patients in the near future.

Onconephrology: mitigation of renal injury in chemotherapy administration

PURPOSE OF REVIEW

Onconephrology was first coined as a name for the intersection of cancer medicine and nephrology in the early 2010s. It was recognized then that beyond and understanding of kidney physiology, a new generation of nephrologists skilled in both molecular biology and precision medicine were needed to deal with the challenges of emerging cancer therapies. Stem cell transplants, biologic agents, adjuvants blocking basic cellular signaling pathways, immunotherapy were found to promote novel anticancer outcomes, but also to pose new risks to the kidneys. The field rapidly overlapped with emerging expertise in vascular glomerular disease, glomerular disease, and the same biologic agents now applied to auto immune systemic and kidney diseases.

RECENT FINDINGS

Many categories of chemotherapeutic agents have been discovered to have adverse renal side effects. In this review, we address classic chemotherapeutic nephrotoxicity and oncologic clinical situations leading to acute kidney injury. We also review the frontiers of nephrotoxicity reported with cell cycle inhibitors, diverse classes of tyrosine kinase inhibitors, immune checkpoint inhibitors, chimeric antigen receptor T-cell therapy, anticancer vaccines, and thrombotic microangiopathies triggered by malignancy and chemotherapy. The aim will be to focus on published strategies to mitigate nephrotoxicity.

SUMMARY

As onconephrology expands into its own field, it gives birth to new subdisciplines. An understanding that patient populations want the benefits of chemotherapy without the renal (and other) systemic toxicities is emerging. A need to develop a new class of molecular and genetic experts in onconephrology to mitigate nephrotoxicity from chemotherapy is apparent and urgent.

Nephrological Detrimental Impacts Resulting From Novel Immunotherapy Drugs Used in the Treatment of Cancer: A Systematic Review

The most recent advancements in cancer therapy center on efficiently and conveniently enhancing a patient's natural immune system. Immune checkpoint inhibitors (ICIs) are antibodies that target cytotoxic thymus (T) lymphocyte antigen-4 (CTLA-4) and its receptor. They function by stimulating T-cell activity against malignancies. Immune-related adverse events (irAEs) are a distinct class of inflammatory side effects that are specific to a given organ. Antineoplastic medications can impact any part of the kidney, leading to the development of proteinuria, hypertension, electrolyte abnormalities, glomerulonephritis, and both acute and chronic interstitial nephritis. We reviewed the scientific literature regarding kidney problems that can arise from chemotherapy and immunotherapy for neoplasms, such as various cancers, melanoma, non-small cell lung cancer, and colorectal cancer. We discussed the pathophysiology, associated risk factors, management, and safety measures for patients experiencing acute renal injury after a new immunotherapy medication treatment. Antineoplastic drugs have the potential to damage the renal tubules, glomeruli, parenchyma, and blood vessels, among other kidney tissues. This can result in a broad spectrum of complications, spanning from a rise in serum creatinine levels without symptoms to the development of acute kidney injury (AKI). The research examined a range of risk factors associated with acute kidney injury (AKI). These factors encompassed age, gender, preexisting medical conditions (such as diabetes, hypertension, and chronic kidney disease), and the medications that patients were taking at the beginning of the study, which included non-steroidal anti-inflammatory drugs, renin-angiotensin system inhibitors, allopurinol, diuretics, corticosteroids, and proton pump inhibitors. The data suggests that patients who were receiving baseline treatment with proton pump inhibitors (PPIs) or corticosteroids had a higher risk of mortality. This study serves as an illustration of the effective management of acute kidney injury and proteinuria linked to novel immunotherapy drugs like pembrolizumab. The approach involved the use of corticosteroids tailored to the patient's condition. Furthermore, it references the recommendations outlined in the Common Terminology Criteria for Adverse Events (CTCAE). Prompt recognition and effective management of these side effects are essential to optimizing outcomes for patients undergoing immunotherapy. Our results were refined and focused by utilizing Medical Subject Headings (MeSH) keywords in our search strategy. The MeSH keywords used were "renal side effects" OR "immunotherapy" OR "cancer treatment." The studies reviewed encompassed a total of 48,529 participants among the 21 studies examined.

Biopsy-proven acute tubulointerstitial nephritis in patients treated with immune checkpoint inhibitors: a pooled analysis of case reports

Introduction

Acute kidney injury (AKI) in cancer patients receiving immune checkpoint inhibitors (ICIs) may recognize multiple causes. Here, we reviewed cases of biopsy-proven acute tubulointerstitial nephritis (ATIN) to describe the clinical characteristics and outcomes of this condition.

Method

We conducted a pooled analysis of clinical cases of ICI-related biopsy-proven ATIN up to 1 May 2022. We collected data on clinical characteristics, AKI, biopsy findings, laboratory examinations, and renal outcomes.

Results

Eighty-five patients (61.4 ± 19 years, 56 male) were evaluated. Melanoma was the most prevalent diagnosis (51%), followed by non-small cell lung cancer (30%). ICI treatment consisted of PD-1, PDL-1 (nivolumab, pembrolizumab, atezolizumab), and CTLA-4 inhibitors (i) (ipilimumab) or combination PD-1i+CTLA4i. Renal toxicity developed after a median of four cycles of therapy. Fifty-one patients (65.5%) developed the most severe form of AKI- stage 3, including five patients requiring dialysis. All the 19 patients treated with dual ICI blockade developed AKI-stage 3, compared with 29 patients out of the 60 receiving a single agent (p<0.001). Most events were managed with corticosteroids associated with ICI withdrawal. In 15 patients ICI was restarted, but in six (40%) AKI recurred. Overall, 32 patients (40%) presented a complete renal recovery, which chance was inversely associated with dual ICI blockade (OR 0.15, 95CI 0.03-0.7, p=0.01).

Conclusion

ICI-related ATIN may develop late after the therapy initiation, presenting as severe AKI, particularly in patients with dual ICI blockade. Although this complication may be partially reversible, concerns remain about the renal function sequelae and the possibility of restarting ICI treatment.