Urine Trouble: A review of Immune checkpoint inhibitor associated nephritis
See below some of the data I collected on this topic from a recent inservice! @OncoPharmPod #nephrotwitter #oncopharm
See below some of the data I collected on this topic from a recent inservice! @OncoPharmPod #nephrotwitter #oncopharm
Immune checkpoint inhibitors (ICI) ➡️revolutionized tx 💊 of various malignancies
✅Treatment that offers some pts🙋🏻♀️a chance of cure🤯
Also see a range of unique toxicities⚠️➡️autoimmune in nature
An emerging one of which is nephritis! (Insert a needed kidney emoji)
✅Treatment that offers some pts🙋🏻♀️a chance of cure🤯
Also see a range of unique toxicities⚠️➡️autoimmune in nature
An emerging one of which is nephritis! (Insert a needed kidney emoji)
Pathogenesis of ICI-nephritis is unknown
Some hypothesis exist 🧐
✅stopping the breaks on the immune system results in excessive immune activation➡️ATIN
✅Previous renal insult or concurrent medications that lead to ATIN can accelerate the emergence of renal injury ☢️
Some hypothesis exist 🧐
✅stopping the breaks on the immune system results in excessive immune activation➡️ATIN
✅Previous renal insult or concurrent medications that lead to ATIN can accelerate the emergence of renal injury ☢️
It’s important ☝🏻to evaluate other causes of renal toxicity in patients on ICI
1️⃣Pre-renal AKI secondary to colitis and dehydration💦 and bleeding🩸
2️⃣Post renal AKI related to obstruction by a mass
ICI-nephritis▶️acute tubular interstitial nephritis
1️⃣Pre-renal AKI secondary to colitis and dehydration💦 and bleeding🩸
2️⃣Post renal AKI related to obstruction by a mass
ICI-nephritis▶️acute tubular interstitial nephritis
Not all ICI are the same in terms of incidence and time ⏰ to onset of ICI-nephritis📶
🔑 Point:
Combination therapy: higher↗️incidence vs monotherapy
PD1/PDL1 ⏩ incidence is lower, onset is slower at 3-12 months
CLTA4 ⏩incidence is high and onset is faster 6-12 weeks ⌛️
🔑 Point:
Combination therapy: higher↗️incidence vs monotherapy
PD1/PDL1 ⏩ incidence is lower, onset is slower at 3-12 months
CLTA4 ⏩incidence is high and onset is faster 6-12 weeks ⌛️
Treatment recommendations per NCCN classified by grade:
Biggest conundrum is the efficacy of steroids: studies report ~87% efficacy for partial/complete renal recovery⏩ leaving many pts with no/marginal renal outcomes
Begs the❓: should other IS agents be used earlier?🤔
Biggest conundrum is the efficacy of steroids: studies report ~87% efficacy for partial/complete renal recovery⏩ leaving many pts with no/marginal renal outcomes
Begs the❓: should other IS agents be used earlier?🤔
When is it safe to rechallenge? Well, that’s a challenging question.
Recurrence of renal damage can result in dismal patient outcomes. However withholding immunotherapy can rid pts of their main chance of durable resp (esp melanoma!)
✅ out the NCCN/ASCO guidelines 👇🏻
Recurrence of renal damage can result in dismal patient outcomes. However withholding immunotherapy can rid pts of their main chance of durable resp (esp melanoma!)
✅ out the NCCN/ASCO guidelines 👇🏻
Some 🔑 points for pharmacists when managing supportive care on steroids in pts with ICI-nephritis
✅Steroids >2 wks⏩ PCP PPX w. Atovaquone or dapsone (caution w Bactrim & added renal damage)
✅Rx to prevent GI ulcers⏩ dose adjusted famotidine over PPI (PPI= RF for ATIN)
✅Steroids >2 wks⏩ PCP PPX w. Atovaquone or dapsone (caution w Bactrim & added renal damage)
✅Rx to prevent GI ulcers⏩ dose adjusted famotidine over PPI (PPI= RF for ATIN)
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