Checkpoint Inhibitor AIN Grade 3 Management — ESENeph MCQ

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HardAcute Kidney InjuryCheckpoint Inhibitor AIN Grade 3 ManagementESENeph

A patient receiving pembrolizumab develops a creatinine rise from 88 to 270 micromol/L. Urine microscopy shows sterile pyuria and biopsy confirms acute tubulointerstitial nephritis. He is euvolaemic and has no dialysis indication. What is the best initial immune-toxicity strategy?

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Correct answer: C — Withhold pembrolizumab and start glucocorticoid treatment

Checkpoint-inhibitor acute interstitial nephritis requires the immune checkpoint inhibitor to be withheld and competing causes of AKI excluded. Biopsy-confirmed, clinically important nephritis is treated with glucocorticoids followed by a taper guided by renal response. A mandatory 500 mg methylprednisolone pulse is not required for every grade-3 creatinine rise; escalation is reserved for severe or steroid-refractory disease and should be coordinated with oncology. The competing options do not fit the renal phenotype, temporal relationship, treatment threshold or safety constraint described. Management still requires confirmation of current medicines, renal trajectory and relevant contraindications, followed by timely biochemical and clinical reassessment. Escalate urgently if life-threatening electrolyte disturbance, respiratory compromise, shock, neurological deterioration or a dialysis indication develops.

Reference: NICE NG148: Acute kidney injury. https://www.nice.org.uk/guidance/ng148/chapter/recommendations; KDIGO 2024 Clinical Practice Guideline for CKD. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf