免疫檢查點抑制劑治療轉移性輸尿管惡性腫瘤時產生移植腎排斥反應之病例報告

江品葭 江博暉

高雄長庚紀念醫院泌尿科

Immune checkpoint inhibitor therapy-associated kidney graft intolerance in a patient with metastatic urothelial carcinoma

Ping-Chia Chiang, Po-Hui Chiang

Department of Urology, Kaohsiung Chang Kung Memorial Hospital

Case report:

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies against inhibitory receptors on T cells or tumor cells. It has emerged as a novel treatment for several malignancy, and especially showed good therapeutic effects in urothelial cancer. However, ICIs work contradictory with immunosuppression to produce anti-cancer effect. Therefore, in patients with history of kidney transplant, there are controversial issues to be discussed. To best of our knowledge, allograft rejection after ICIs occurred up to 41%, but there are limited data of ICIs treatment effects in patients with nonfunctioning kidney grafts. In this case report, we will share our experience of ICI therapy-associated kidney graft intolerance in a patient with metastatic urothelial carcinoma.

This is an 80-year-old male with history of hypertension, type 2 Diabetes mellitus, HBV carrier, ischemic heart disease, and congestive heart failure. He had renal transplantation in China in 2001 but started H/D since 2015 due to non-functioning graft. He was brought to OPD in 2019/05 due to left flank pain. Abdominal CT revealed left retroperitoneal tumor (11*7cm) with hydronephrosis. Retroperitoneal tumor showed metastatic carcinoma of urothelial origin. Three courses of Pembrolizumab 100 mg treatment were prescribed. However, progressive abdominal fullness with hematuria were complained.

In 2019/08, kidney sonography showed graft kidney enlargement with increased resistive index, which indicated graft intolerance. Regression in size (from 11cm to 4cm) of retroperitoneal tumor but marked ascites were found on follow-up abdominal CT. Due to symptomatic progressive ascites and graft intolerance, Graft nephrectomy was done in 2019/10. Pathology report then showed chronic active antibody-mediated rejection and chronic active T cell-mediated rejection.

During follow-up, complete remission of ascites appeared in 2020/6. No tumor progression was noted after 16 months of 3rd ICI therapy. In our experience, graft nephrectomy is a feasible treatment for ICI therapy-associated kidney graft intolerance in failed kidney transplant recipient.