Nephritis
Symptom Grade
Grade 1Creatinine 1.5 x baseline or > ULN-1.5x ULN |
Grade 2Creatinine > 1.5 – 3x baseline or > 1.5 – 3x ULN |
Grade 3Creatinine > 3x baseline or > 3 – 6x ULN |
Grade 4Creatinine > 6x |
Management escalation pathway
| Continue ICPI Repeat creatinine weekly When worsening, manage as per criteria below | Withhold ICPI; hydration and review creatinine in 48h72h; if not improving, discuss with nephrologist and need for biopsy and if attributed to irAE, initiate steroid
Oral prednisolone 1mg/kg When returning to Grade 1 or baseline: restart ICPi If on steroids, only once < 10mg prednisolone If not attributes to irAE: continue ICPi |
Withhold ICPI; admit patient for monitoring and fluid balance; repeat creatinine every 24h; early discussion with nephrologist and need for biopsy; when worsening. initiate i.v. (methyl)prednnisolone 2 mg/kg | As per Grade 3; patient should be managed in hospital where renal replacement therapy is available |
Assessment and Investigations
| Review hydration status, As for Grade 2 medications, urine test, culture if urinary tract infection symptoms
Dipstick urine and send for protein assessment UPCR If obstruction suspected: renal US +/- doppler to exclude obstructions or a clot |
As above Renal ultrasound +/- doppler to exclude obstructions or a clot
If proteinuria: 24h collection or UPCR Advise patient to notify if oliguric |
As for Grade 2
Consider renal biopsy |
As for Grade 2 |
Abbreviations
Abbrevations
US: Ultra Sound
ULN: Upper Limit of Normal
ICPi: Immune Checkpoint Blockade Inhibition
UPCR: Urine Protein to Creatinine Ratio
ANCA: Anti Neutrophil Cytoplasmic Antibody
CRP: C Reactive Protein
RF: Rheuma Factor
ACPA: Anti Citrullinated Protein Antibody
ESR: Erythrocyte Sedimentatio Rate