Renal Immune-related Adverse Event of Pembrolizumab Masked by Pemetrexed

• Published in: Internal Medicine Vol. 63; no. 2; pp. 265 - 270
• Main Authors: Nagase, Koya, Murai, Yukari, Yokoyama-Kokuryo, Waka, Nagasaka, Toru, Sato, Yuki, Watanabe, Tsuyoshi, Ito, Yuki, Nagase, Fumika, Fujita, Yoshiro
• Format: Journal Article
• Language: English
• Published: Japan The Japanese Society of Internal Medicine 15.01.2024; Japan Science and Technology Agency
• Subjects: acute tubulointerstitial nephritis; Adenocarcinoma; Antibodies, Monoclonal, Humanized; Biopsy; Carboplatin; Carcinoma, Non-Small-Cell Lung - drug therapy; Case Report; Chemotherapy; Female; Humans; Immune checkpoint; immune checkpoint inhibitors; immune-related adverse event; Inflammation; Inflammation - chemically induced; Kidney - pathology; Kidneys; Lung Neoplasms - pathology; Nephritis; Nephropathy; Pembrolizumab; pemetrexed; Pemetrexed - adverse effects; tertiary lymphoid tissues; pembrolizumab; pemetrexed; tertiary lymphoid tissues; immune checkpoint inhibitors; acute tubulointerstitial nephritis; immune-related adverse event
• ISSN: 0918-2918; 1349-7235
• DOI: 10.2169/internalmedicine.1640-23

A Japanese woman in her 60s developed a kidney injury 9 weeks after treatment with pemetrexed, carboplatin, and pembrolizumab for stage IV lung adenocarcinoma. A renal biopsy showed chronic tubulointerstitial damage with minimal focal interstitial inflammation, consistent with pemetrexed-induced nephropathy; thus, pemetrexed was withdrawn. However, the kidney injury continued to worsen. A repeated biopsy showed severe acute tubulointerstitial nephritis, suggestive of a pembrolizumab-induced immune-related adverse event (irAE). The worsening after pemetrexed discontinuation suggested that the irAE had already begun, as the first biopsy showed focal inflammation. This case suggests thatcombining immune checkpoints and chemotherapy requires considering concurrent drug-induced nephrotoxicity.