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Kidney Week

Abstract: SA-PO215

Interleukins and Hyponatremia in Patients with Cancer

Session Information

Category: Onconephrology

  • 1700 Onconephrology

Authors

  • Pantanowitz, Joshua, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
  • Keyser, Michelle Nguyen, UPMC, Pittsburgh, Pennsylvania, United States
  • Amarapurkar, Pooja D., UPMC, Pittsburgh, Pennsylvania, United States
Introduction

There is renewed interest in the use of targeted delivery systems and engineered forms of Interleukin-12 (eIL-12) for the treatment of several advanced cancers. We present a unique case of hyponatremia in a patient with eIL-12 therapy for pancreatic cancer that was unresponsive to 3% saline and tolvaptan and treated with tocilizumab.

Case Description

A 77 year old male with invasive poorly differentiated metastatic ampullary adenocarcinoma of the pancreas who failed multiple lines of therapy was seen in the hospital for altered mental status. Initial laboratory data showed a serum sodium of 121 mMol/L. 3% saline was administered after admission to the ICU and he remained hemodynamically stable. The serum sodium remained unchanged for 8 hours after 100 ml bolus and 25 ml/hr of 3% saline for several hours and tolvaptan 7.5 mg. Given the lack of response to 3% saline and tolvaptan, hyponatremia was thought to be related to eIL-12 infusions. After discussion with his oncologist, he received tocilizumab. Within hours of the tocilizumab administration his serum sodium increased to 127 mMol/L in 10 hours. Tocilizumab was repeated the following day with serum sodium stabilizing at 131mMol/L. 3 weeks prior to the current admission he started cycle 1 of eIL-12 and was found to have a hyponatremia with serum sodium of 127 mMol/l (baseline sodium 132-134 mMol/L).This was attributed to cancer-related syndrome of inappropriate anti-diuretic hormone and he was started on sodium chloride tablets 1 gram three times a day as an outpatient, but the hyponatremia persisted. 4 days prior to the current admission he received cycle 2 of eIL-12. Unfortunately, he developed severe cytokine release syndrome with subsequent infusions with disease progression and impending home hospice.

Discussion

With the increased use of immuno-modulatory therapies like eIL-12 and chimeric antigen receptor (CAR) T-cells, it is important to understand their kidney side effects. eIL-12 and CART-cells increase other pro-inflammatory cytokines such as interleukin-6 (IL-6). Evidence supports IL-6 causing a non-osmotic, non-volume-mediated increase in anti-diuretic hormone leading to hyponatremia. Tocilizumab (IL-6 receptor blocker) has been used to treat IL-6 side effects and in our case, hyponatremia. Our case highlights the unique immune mediated pathophysiology of hyponatremia and role of tocilizumab to treat the specific cause.