Expert Clinical Management of Severe Immune-Related Adverse Events: Results from a Multicenter Survey on Hot Topics for Management

Abstract

Acute kidney injury; Immune checkpoint inhibitors; Immune-related hepatitis

Lesión renal aguda; Inhibidores del punto de control inmunitario; Hepatitis relacionada con el sistema inmunitario

Lesió renal aguda; Inhibidors del punt de control immunitari; Hepatitis associada a la immunitat

There are differences in recommendations for the management of immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICIs). To assess the real-world management of irAEs, three surveys regarding ICI-induced hepatitis (IIH), renal irAEs, and myositis were developed and sent to experts in each area. Fifty-six surveys were completed (17 IIH, 20 renal irAEs, and 19 myositis). All experts agreed on performing imaging in every suspected case of severe IIH. Sixty-five percent agreed on performing a liver biopsy in patients not responding to corticosteroids. The most common indication for corticosteroid use (59%) was for severe IIH not improving after discontinuation of ICIs. Additionally, 60% of the experts agreed on performing a biopsy for stage 2/3 acute kidney injury (AKI), and 70% recommended imaging for any stage of AKI. Thirty-five percent favored corticosteroids in AKI patients with creatinine levels 2–3-fold above baseline. For myositis, 58% would recommend a muscle biopsy in a patient with weakness and creatine kinase levels of 5000 U/L; 47% would also opt for an endomyocardial biopsy when the troponin levels are increased. Fifty-eight percent recommended oral corticosteroids for myositis, and 37% recommended additional therapy, mainly immunoglobulins. These results show substantial differences in expert practice patterns for the management of severe liver, kidney, and muscular irAEs.

This research was funded by ISCIIII-FEDER and ISCIII-RETICS REDinREN (grant numbers PI17/00257, PI21/01292, RD16/0009/0030, and RICORS RD21/0005/0016) and Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR) enfermedades glomerulares complejas. Supported in part by the University of Texas MD Anderson’s Cancer Center Support Grant from the National Cancer Institute (NCI P30 CA016672).