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Minimizing the Impact of imAEs and Maximizing Efficacy: Renal Toxicities

  • Authors: Anushree C. Shirali, MD
  • CME / ABIM MOC / CE Released: 9/13/2019
  • Valid for credit through: 9/13/2020, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for nephrologists, hematologists/oncologists, and nurses.

The goal of this activity is to improve clinicians' ability to identify and manage renal toxicities associated with immune checkpoint inhibitor (ICI) therapy.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Clinical trial data on renal immune-mediated adverse events (imAEs) due to treatment with ICIs
    • Real-world evidence on the impact of steroids on the efficacy of ICIs in patients with cancer
  • Have greater competence related to
    • Identifying strategies to maximize clinical outcomes in patients receiving ICIs
    • Managing across the spectrum of severity of renal imAEs associated with ICIs
  • Have greater confidence related to
    • Counseling and educating patients on imAEs that could affect their kidneys


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  • Anushree C Shirali, MD

    Associate Professor
    Consulting Physician, Smilow-YNHH VHL Center of Excellence
    Medical Director, Hamden Dialysis
    New Haven, Connecticut


    Disclosure: Anushree C. Shirali, MD, has disclosed no relevant financial relationships.


  • Davecia R. Cameron, MS

    Medical Education Director, Medscape, LLC


    Disclosure: Davecia R. Cameron, MS, has disclosed no relevant financial relationships.

  • Tristin Abair, PhD

    Medical Writer, Medscape, LLC


    Disclosure: Tristin Abair, PhD, has disclosed no relevant financial relationships.

CME/CE Reviewer

  • Hazel Dennison, DNP, RN, FNP, CPHQ, CNE

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Disclosure: Hazel Dennison, DNP, RN, FNP, CPHQ, CNE, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.

Accreditation Statements


Interprofessional Continuing Education

In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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    For Nurses

  • Awarded 1.25 contact hour(s) of continuing nursing education for RNs and APNs; 0.75 contact hours are in the area of pharmacology.

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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

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Minimizing the Impact of imAEs and Maximizing Efficacy: Renal Toxicities

Authors: Anushree C. Shirali, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/13/2019

Valid for credit through: 9/13/2020, 11:59 PM EST


The following cases are modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and read evidence-based information that supports the most appropriate answer choice. The questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the activity, there will be a short post-test assessment based on the material presented.

Immunotherapy and the Impact of Renal Immune-Mediated Adverse Events

Immunotherapy with immune checkpoint inhibitors (ICIs) that target the programmed cell death protein 1 (PD-1), programmed cell death ligand 1 (PD-L1), or cytotoxic T-lymphocyte antigen 4 (CTLA-4) has significantly improved outcomes for patients with a variety of tumor types, including melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC). Currently, an estimated 600,000 patients in the United States are eligible for ICI therapy, and use of these agents is expected to increase as they are approved for more tumor types and used in patients with a wide variety of comorbid conditions, including solid organ transplant recipients. Thus, an increasing number of patients may present to a variety of clinical practices and hospitals with immune-mediated adverse effects (imAEs), including renal toxicities. Renal imAEs have been thought to be rare, with initial reports suggesting they occur in < 5% of patients, but more recent studies suggest they may affect between 9.9% and 29% of patients.[1-4] Renal imAEs are likely underestimated because they can be difficult to recognize and may be attributed to other causes. Although renal toxicities are rarely fatal, prompt diagnosis is essential to preserve patients' renal function and to ensure maximum benefit of ICI therapy.

Case 1: Patient History and Presentation

Martin is a 65-year-old man with a medical history of hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia, and basal cell carcinoma, for which he has undergone multiple resections. His medications include hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, tamsulosin 0.4 mg at night, metformin 1000 mg twice daily, pantoprazole 40 mg daily, and aspirin 81 mg daily. He presents to his dermatologist for his semi-annual skin examination, which reveals an atypical nevus on his right upper back measuring 2.0 mm and featuring irregular borders. The dermatologist performs an excisional biopsy of the nevus with sentinel lymph node biopsy. Histopathological analysis reveals melanoma with lymphatic spread. A computed tomography (CT) scan of his chest, abdomen, and pelvis show multiple bilateral lung nodules. Mutational analysis reveals the tumor is BRAF wild type. Martin consents to treating his metastatic melanoma with combination ipilimumab (1 mg/kg) and nivolumab (3 mg/kg) dosed every 3 weeks.

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