Steroid-induced tumor lysis syndrome in the setting of pembrolizumab use

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Conference Proceeding

Publication Date


Publication Title

American Journal of Kidney Diseases


Immune checkpoint inhibitors (CPI), such as pembrolizumab, utilize monoclonal antibodies to prevent evasion of cancer cell death by Tcells. We present a case of tumor lysis syndrome in an elderly male with metastatic prostate cancer following steroid initiation for treatment of pembrolizumab-induced liver injury and acute kidney injury. A 71-year-old man with a history of metastatic castrate-resistant prostate cancer presented with a creatinine at 2.44 mg/dL with a baseline at 0.99 mg/dL eight weeks prior to admission. He had hematuria for the last three weeks. Physical exam revealed a holosystolic murmur and 3+ lower extremity edema. He started immunotherapy one month earlier. His AST and ALT were elevated at 580 U/L (normal 10-37 U/L) and 337 U/L (normal 9-47 U/L), respectively. Urine dipstick had 300+ protein. Renal ultrasonography was unremarkable and other causes of acute kidney injury were investigated. The patient was initially treated with solumedrol for CPIinduced acute liver injury. Our patient was diagnosed with acute interstital nephritis (AIN) from CPI therapy and steroids were continued. Three days later, the patient developed tumor lysis syndrome (TLS) as evident by a uric acid at 26 mg/dL (normal 1.5-6.0 mg/dL) and phosphorus at 7.2 mg/dL (normal 2.3-4.3 mg/dL). Rasburicase and hemodialysis were initiated. He eventually went into hospice care. CPI's are a novel class of medications associated with AIN. Steroids are recommended for treatment although an established guideline does not exist. Caution must be taken when initiating steroid treatment in patients with solid tumors as TLS may not be a rareity in patients exposed to CPI therapy





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National Kidney Foundation Spring Clinical Meeting, Boston, MA, May 8-12, 2019.

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