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Checkpoint Inhibitor AIN — ESENeph MCQ

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ModerateAcute Kidney InjuryCheckpoint Inhibitor AINESENeph

A 48-year-old woman with previously normal kidney function develops AKI (creatinine 280 umol/L) after starting Pembrolizumab (anti-PD1 checkpoint inhibitor) for melanoma. She has no other cause identified. Kidney biopsy shows acute interstitial nephritis with abundant T-lymphocyte infiltration. What is the first-line treatment?

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Correct answer: D — Stop Pembrolizumab and start high-dose Glucocorticoids

Immune checkpoint inhibitor (ICI)-associated nephritis is an increasingly recognised cause of AKI, most commonly presenting as AIN with T-cell infiltration. Management involves stopping the ICI and starting high-dose glucocorticoids (Prednisolone 1 mg/kg or IV Methylprednisolone for severe cases). Most cases respond to steroids. The decision to rechallenge with the ICI after resolution is complex and requires oncology-nephrology discussion. KDIGO and ASCO guidelines address this emerging nephrotoxicity.

Reference: Cortazar et al 2020 – ICI Nephrotoxicity; ASCO 2021 – ICI Toxicity Guidelines