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Granulomatous ICI Nephritis — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyGranulomatous ICI NephritisSCE Medical Oncology

A patient on nivolumab for NSCLC develops immune-related nephritis. Renal biopsy shows granulomatous interstitial nephritis (GIN) rather than the more common acute tubulointerstitial nephritis (ATIN). What is the clinical significance of the granulomatous pattern?

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Correct answer: B — Granulomatous ICI nephritis may respond less well to corticosteroids alone and may require additional immunosuppression (mycophenolate or infliximab) — it is also associated with concurrent sarcoidosis-like systemic granulomatous disease

ICI-related nephritis has several histological patterns: ATIN (most common, ~60-70%), granulomatous interstitial nephritis (~10-15%), minimal change disease, and membranous nephropathy. Granulomatous nephritis may be more steroid-resistant and is sometimes part of a systemic sarcoidosis-like irAE. Renal biopsy guides both diagnosis and immunosuppressive strategy. Infection (particularly tuberculosis and fungal causes) must be excluded in granulomatous disease before immunosuppression escalation.

Reference: ESMO 2024 irAE Management; Cortazar et al JASN 2020; Seethapathy et al JASN 2019