DUAL THIN GLOMERULAR MEMBRANE DISEASE AND FOCOL SEGMENTAL GLOMERULARSCLEROSIS IN A PATIENT ON LORLATINIB AND AVELUMAB TRIAL FOR ALK POSITIVE METASTATIC PULMONARY ADENOCARCINOMA: A CASE REPORT
Liam Qi1, PRIANKA PURI1,2, KIRSTEN HEPBURN1,2 1Kidney Health Service, Metro North Hospital and Health Service, Herston, Queensland, Australia2Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
Abstract
Background
Dual therapy with Anaplastic Lymphoma Kinase (ALK) Tyrosine Kinase Inhibitors (TKIs), lorlatinib, and anti-Programmed Cell Death Ligand-1 (anti-PD-L1), avelumab, is used as part of trials with promising antitumour activity in patients with ALK+ non-small cell lung cancer (NSCLC). There is emerging data that these new cancer therapies may cause a variety of renal pathologies including nephrotic syndrome. There are no case reports to date describing glomerular disease with lorlatinib or avelumab administration.
Case Report
A 63-year-old female was referred to renal outpatient clinic with nephrotic syndrome in the context of 7-years of dual lorlatinib (ALK TKI) and avelumab (anti-PD-L1) use for metastatic ALK+ pulmonary adenocarcinoma. She had a bland urine sediment with 4300mg/24hr proteinuria, a serum albumin of 25g/L, serum creatinine 68μmol/L and an estimated glomerular filtration rate of 83mL/min/1.73m2. Glomerulonephritis screen was negative including negative anti-glomerular basement membrane antibodies. She had no history of hypertension, diabetes, or obesity.
Renal biopsy revealed thin glomerular basement membrane lesion and approximately 50% podocyte foot effacement . A diagnosis of likely secondary FSGS from anti-PD-L1 use on a background of thin basement membrane disease (TBMD) was made.
Avelumab was ceased and proteinuria was treated with an angiotensin receptor blocker but was unable to be increased due to postural hypotension. A sodium-glucose cotransporter-2 inhibitor was added after 8 months as proteinuria did not improve with a urine PCR of 420g/mol. Renal function continued to remain stable.
Conclusions
This novel case describes dual pathology with TBMD and secondary FSGS associated with lorlatinib and avelumab administration for ALK+ NSCLC. With the growing number of new cancer therapies, it is important to understand and identify renal complications of therapy.
Biography
Dr Liam Qi is a general medicine advanced trainee who plans on dual training in nephrology. He is an early career researcher who has a special interest in glomerular disease. Outside of work, he enjoys playing the piano for his dog, Sumo.