Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.
Institute of Nephrology, Peking University, No.8 Xishuku Street, Beijing, Xicheng District, 100034, People's Republic of China.
BMC Geriatr. 2023 Aug 9;23(1):478. doi: 10.1186/s12877-023-04181-w.
Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment. However, their use has been restricted in patients with preexisting autoimmune diseases due to concerns about increased risk of immune-related adverse events (irAEs).
We present a case of a patient with stage IV lung adenocarcinoma and a history of complement-mediated autoimmune hemolytic anemia in remission. After receiving a single dose of pembrolizumab, the patient experienced life-threatening recurrent hemolytic anemia, de novo thrombocytopenia, diarrhea, myocarditis, and acute kidney injury. Laboratory tests confirmed the diagnosis of Evan's syndrome, with positive PAIgG and direct antiglobulin test. Treatment with intravenous methylprednisolone at a dose of 2 mg/kg resulted in a favorable response, with resolution of symptoms and rapid recovery of kidney function. The probable cause of pre-renal hypoperfusion (evidenced by a BUN-to-creatinine ratio of 48.1) leading to acute tubular injury was attributed to pembrolizumab-induced diarrhea.
This case illustrates a life-threatening recurrence of complement-mediated autoimmune hemolytic anemia induced by ICIs. Clinicians should carefully consider the expected efficacy and potential toxicity before initiating ICIs therapy in patients with preexisting autoimmune diseases. Additionally, the occurrence of acute kidney injury during ICIs therapy adds complexity and requires careful differential diagnosis.
免疫检查点抑制剂 (ICIs) 彻底改变了癌症治疗方法。然而，由于担心免疫相关不良事件 (irAE) 的风险增加，它们在患有自身免疫性疾病的患者中的使用受到限制。
我们报告了一例患有 IV 期肺腺癌且既往有补体介导的自身免疫性溶血性贫血缓解病史的患者。在接受单次帕博利珠单抗治疗后，该患者出现危及生命的复发性溶血性贫血、新发血小板减少症、腹泻、心肌炎和急性肾损伤。实验室检查证实了 Evans 综合征的诊断，存在阳性 PAIgG 和直接抗球蛋白试验。给予 2mg/kg 的静脉甲基强的松龙治疗后，病情得到了良好的反应，症状得到缓解，肾功能迅速恢复。导致急性肾小管损伤的可能原因是肾前灌注不足（BUN-to-creatinine 比值为 48.1），这归因于帕博利珠单抗诱导的腹泻。
本例说明了 ICI 引起的补体介导的自身免疫性溶血性贫血的危及生命的复发。在开始 ICI 治疗之前，临床医生应仔细考虑患有自身免疫性疾病的患者的预期疗效和潜在毒性。此外，在 ICI 治疗期间发生急性肾损伤增加了复杂性，需要仔细进行鉴别诊断。
