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irAE Nephritis — SCE Medical Oncology MCQ

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ModerateImmunotherapy & Targeted TherapyirAE NephritisSCE Medical Oncology

A 68-year-old man with advanced NSCLC on pembrolizumab + chemotherapy develops immune-related nephritis (creatinine 280 µmol/L, baseline 85 µmol/L, bland urine sediment with proteinuria). Renal biopsy shows acute tubulointerstitial nephritis (ATIN). What is the management?

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Correct answer: E — Hold pembrolizumab, start prednisolone 1 mg/kg/day, nephrology review

Immune-related nephritis (most commonly ATIN) occurs in approximately 1-2% of ICI-treated patients. For grade 2-3 (creatinine 2-3× baseline), ICI should be held and corticosteroids started (prednisolone 0.5-1 mg/kg/day). Nephrology referral and renal biopsy confirm the diagnosis. Most cases respond to steroids with taper over 4-8 weeks. ICI rechallenge can be considered after resolution if grade 2, but grade 3 generally warrants permanent discontinuation.

Reference: ESMO 2024 irAE Management Guidelines; Cortazar et al CJASN 2020