Ipilimumab/nivolumab

Abstract

Graft intolerance syndrome: case report A 66-year-old man developed graft intolerance syndrome during treatment with ipilimumab and nivolumab for metastatic papillary renal and urothelial cell cancer. The man had a history of diabetes, renal cell carcinoma and a left native nephrectomy in 1996. He developed end-stage kidney disease and eventually received a deceased donor kidney transplant in 2012. His allograft failed after 6 years due to biopsy-proven recurrent diabetic nephrosclerosis with interstitial fibrosis and tubular atrophy (IFTA) and started haemodialysis in 2018. One year after initiating dialysis, surveillance MRI showed new lesions on his right native kidney suggestive of cancer. A right native nephrectomy and histopathology showed papillary renal and urothelial cell cancer. Lung nodules and diffuse lymphadenopathy were noted on CT scan consistent with metastatic disease. Thus, he was started on combination immunotherapy with nivolumab and ipilimumab with a notable decrease in the size of his palpable lymph nodes. However, 28 days following his first cycle of immunotherapy, he was hospitalized due to gross haematuria, pain over his allograft, malaise and anemia consistent with graft intolerance syndrome. A contrast-enhanced abdominal CT scan revealed an enlarged right lower quadrant allograft with patchy enhancement and perinephric stranding. Following a multidisciplinary discussion, a decision was made to perform a transplant nephrectomy. Histopathology revealed grade II chronic active T cell mediated rejection. His postoperative course was uneventful, and he was discharged 3 days later. Four months postnephrectomy, he remained clinically stable and was scheduled for resumption of immunotherapy.