PF Hepatitis – Grade 4
May 11, 2025Muscle pathology
May 11, 2025Nephritis
Symptom Grade 1
- Creatinine 1.5x baseline
- or > ULN-1.5x ULN
Management escalation pathway
- Continue ICPI
- Repeat creatinine weekly
- When worsening treat as grade II
Assessment and Investigations
- Review hydration status, 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
Symptom Grade 2
- Creatinine 1.5x baseline
- or > ULN-1.5x ULN
Management escalation pathway
- Continue ICPI
- Repeat creatinine weekly
- When worsening treat as grade II
Assessment and Investigations
- Review hydration status, 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
Symptom Grade 3
- Creatinine > 1.5 – 3x baseline
- or > 1.5 – 3x ULN
Management escalation pathway
- Withhold ICPI
- Hydration and review creatinine in 48-72h; if not improving, discuss with nephrologist the need for biopsy and if attributed to irAE, initiate steroids (oral prednisolone 1mg/kg)
- When returning to Grade 1, or baseline: restart ICPI might be discussed upon corticoid stop
Assessment and Investigations
- Renal ultrasound +/- doppler to exclude obstructions or a clot
- If proteinuria: 24h collection or UPCR
- Advise patient to notify if oliguric
Symptom Grade 4
- Creatinine > 3x baseline
- or > 3 – 6x ULN
Management escalation pathway
- Withhold ICPI
- Admit patient for monitoring and fluid balance
- Repeat creatinine every 24h
- Early discussion with nephrologist and need for biopsy and initiation of i.v. (methyl)prednnisolone 2 mg/kg
- Restart ICPI only when steroids are completely stopped and after multidisciplinary discussion
Assessment and Investigations
- Consider renal biopsy
- Perform UPCR