A multi-center study on safety and efficacy of immune checkpoint inhibitors in cancer patients with kidney transplant
Among 69 kidney transplant recipients treated with immune checkpoint inhibitors, 42% developed acute rejection and 19 lost their allograft, compared with 5.4% rejection in transplant patients not receiving these drugs, while tumour response and survival in squamous cell carcinoma improved.
Background
Immune checkpoint inhibitors are widely used across malignancies, but their safety and efficacy in patients with a functioning kidney allograft had not been defined, and transplant recipients are routinely excluded from oncology trials.
Key findings
In 69 kidney transplant recipients treated between January 2010 and May 2020, 29 (42%) developed acute rejection and 19 lost their allograft, against an acute rejection rate of 5.4% in a non-treated transplant comparison cohort. Median time from initiation to rejection was 24 days. Lower rejection risk was associated with mTOR inhibitor use (odds ratio 0.26; 95% CI 0.09-0.72) and triple-agent immunosuppression (0.67, 0.48-0.92). Objective response rates were 36.4% in cutaneous squamous cell carcinoma and 40% in melanoma. In the squamous cell carcinoma subgroup, median overall survival was 19.8 months with checkpoint inhibitors versus 10.6 months without; in melanoma, survival did not differ.
Clinical implications
Checkpoint inhibitor therapy in a kidney transplant recipient should be a shared oncology-nephrology decision with explicit consent about a roughly 40% chance of rejection, most of it within the first month. Close early graft monitoring is essential, and the association of mTOR inhibitor-containing or triple-agent maintenance with lower rejection risk warrants prospective evaluation before being adopted as protocol.
Category
Transplant
Source
Kidney International
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