Abstract: PUB438
The Final Hit: A Case of IgA Nephropathy with Pembrolizumab
Session Information
Category: Onconephrology
- 1700 Onconephrology
Authors
- Shringi, Sandipan, Rhode Island Hospital, Providence, Rhode Island, United States
- Gohh, Reginald Y., Rhode Island Hospital, Providence, Rhode Island, United States
Introduction
Immune checkpoint inhibitors (ICI) have been implicated in the development of IgA Nephropathy (IgAN) and may not always respond to steroids leading to poor outcomes. We present a case of IgAN in a patient with lung cancer treated with pembrolizumab.
Case Description
A 73-year-old male presented with dark urine and dyspnea for a feew days and developed progressive AKI. He had a history of CAD, hypertension, DVT, tonsillectomy, soft palate invasive squamous cell carcinoma in 2012 treated with radiation, chronic dysphagia, and recently diagnosed bilateral lung squamous cell carcinoma in 2022 for which he was on carboplatin, paclitaxel and pembrolizumab for 3 months with latest dose 1 month ago.
Physical exam was remarkable for tachypnea, bibasilar crackles without edema. Presentation labs were BUN 45 mg/dl, creatinine 2.77 mg/dl, Urinalysis with 3+ blood, >180 RBC, 51 WBC, 300 protein, urine culture had Enterococcus faecalis. UA 12 years ago had 6 RBC and one month ago had 3 RBCs. A chest radiograph showed multifocal interstitial and airspace opacities.
Urine sediment had muddy brown casts, many isomorphic RBCs. C3 150 mg/dl, C4 28 mg/dl, ANCA, MPO, PR3, anti GBM were all negative, kappa chains 519 mg/L, lambda chains 216 mg/L, K/L ratio 2.4, serum IFE with 2 equivocal IgG kappa bands, urine IFE with equivocal IgG band. Renal biopsy had mesangial hypercellularity, focal endocapillary neutrophilic hypercellularity without crescents, several RBC casts, mild IFTA with predominant IgA staining on IF without C1q, fibrinogen or albumin and mesangial immune type electron dense deposits with partial foot process effacement on EM.
He was treated with ceftriaxone but sCr did not improve and peaked at 9.4 mg/dl. He did not respond to pulse steroids which were then tapered. Due to poor overall health, he was not a candidate for chemotherapy or immunosuppression and transitioned to hospice. He died shortly after.
Discussion
IgAN occurs after four hits and our case was likely dormant for >10 years. It possibly got activated upon exposure to ICI but did not respond to steroids.
Light microscopy and Immunoflourescence