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ICI-Induced MCD — RACP Adult Medicine MCQ

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HardMedical OncologyICI-Induced MCDRACP Adult Medicine

A 60-year-old woman with breast cancer develops new-onset bilateral leg oedema and proteinuria (6 g/day) while on pembrolizumab. Her creatinine rises from 80 to 150 µmol/L. Renal biopsy shows podocyte effacement consistent with minimal change disease. What is the diagnosis?

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Correct answer: E — IgA nephropathy

Immune checkpoint inhibitors can cause a spectrum of renal irAEs. The most common is acute interstitial nephritis (~70% of ICI nephritis), but glomerular diseases including minimal change disease, FSGS, membranous nephropathy, and IgA nephropathy have been reported. ICI-induced MCD presents with acute-onset nephrotic syndrome with podocyte effacement on biopsy. Treatment includes holding the ICI and commencing corticosteroids (prednisolone 1 mg/kg). Most cases respond well to steroids but may relapse if the ICI is restarted. This is distinct from paraneoplastic membranous nephropathy (which is associated with PLA2R-negative anti-THSD7A-positive MN in some malignancies).

Reference: ASCO – 2021 – irAE Management; KDIGO – 2024 – Immune Nephritis