Severe Acute Kidney Injury Due to Nivolumab/Ipilimumab-induced Granulomatosis and Fibrinoid Vascular Necrosis

Immune-checkpoint inhibitors have revolutionized the treatment of cancers in recent years. Four drugs have obtained FDA approval in a variety of cancer types. Immune-related adverse events are common and occur in up to 60% of treated patients. Common manifestations of immune-related adverse events include rash, colitis, hepatitis, and hypophysitis. Most cases are mild to moderate in grade; however, severe manifestations with lethal outcomes have been described. Acute kidney injury is reported as a rare complication. In this case report, we present a patient with metastatic melanoma undergoing combined immune-checkpoint inhibitor therapy and displaying multiple immune-related adverse events. Despite receiving systemic steroid therapy for extrarenal immune-related adverse events, the patient developed acute progressive kidney injury requiring renal replacement therapy. Findings on renal biopsy included granulomatous interstitial nephritis, vasculitis, and thrombotic microangiopathy–like lesions. This case indicates that, although severe acute kidney injury is a rare complication of immune-checkpoint inhibitors, fulminant cases do occur and can be resistant to therapeutic intervention.