MDCalc

Immune-Related Adverse Events for Renal Toxicities - Nephritis

Grades severity of nephritis secondary to immune checkpoint inhibitor therapy.

Use in adult patients with elevations in creatinine levels or symptoms suggesting nephritis while on treatment with immune checkpoint inhibitors.

Criteria

Result:

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Advice

Monitor patients for elevated serum creatinine prior to every dose. 

For suspected ICPi nephritis, consider holding therapy while other potential causes are evaluated (i.e. recent IV radiographic contrast administration, dehydration, other medicines, urinary tract infections) and monitor creatinine weekly.

Routine urinalysis is not necessary other than to rule out urinary tract infections, etc.

Presume ICPi nephritis for patients without other obvious causes or for those who do not respond to alternative treatment measures.

If no potential alternative cause of acute kidney injury (AKI) is identified, then consider biopsy and proceed directly with immunosuppressive therapy.

Management

For all patients where an IRAE diagnosis is being considered, it is always recommended to involve the specialist or team prescribing the immune checkpoint therapy. 

All patients:

Monitor creatinine weekly.

Kidney biopsy should be discouraged until corticosteroid treatment has been attempted.

Grade 1: 

  • Consider temporarily holding ICPi, pending consideration of potential alternative etiologies (recent IV contrast, medications, fluid status) and baseline renal function.

  • A change that is still <1.5 ULN could be meaningful.

Grade 2:

  • Hold treatment temporarily.

  • Consider nephrology consultation.

  • Evaluate for other causes (recent IV contrast, medications, fluid status, etc). If other etiologies are ruled out, administer 0.5-1 mg/kg/d prednisone equivalents.

  • If worsening or no improvement, consider 1-2 mg/kg/d prednisone or equivalent and permanently discontinue ICPi.

  • If improved to ≤ Grade 1, taper corticosteroids over 4-6 weeks.

  • If no recurrence of chronic renal insufficiency, discuss resumption of ICPi with patient after thorough discussion of risks and benefits.

Grade 3-4:

  • Permanently discontinue ICPi.

  • Consider Consult nephrology consultation.

  • Evaluate for other causes (recent IV contrast, medications, fluid status, etc).

  • Consider corticosteroids (initial dose of 1-2 mg/kg/d prednisone or equivalent).

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