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When is A Kidney Biopsy Indicated During the Treatment of Brain Cancer?
Catarina Oliveira-Silva1, Johanna Viana1, Claudia Coelho1
1Nephrology Department, Unidade Local de Saúde de Braga, Braga, Portugal.
Introduction:
Bevacizumab is a monoclonal antibody that targets vascular endothelial growth factor (VEGF) and is widely used in oncology for its anti-angiogenic properties. However, VEGF inhibition may result in significant nephrotoxicity, including thrombotic microangiopathy (TMA). While systemic TMA is well-described, isolated renal-limited TMA remains under recognised.
Case Description:
We present a 46-year-old woman with WHO grade IV IDH-wildtype EGFR-amplified gliosarcoma. She received second-line treatment with bevacizumab and, after 12 months of therapy, developed progressive hypertension and nephrotic-range proteinuria up to 6.2 g/day, with normal renal function and without anaemia or thrombocytopenia. A kidney biopsy revealed glomerular microangiopathy, and a diagnosis of bevacizumab-associated renal-limited TMA was established. Given the stability of the intracranial disease, the drug was discontinued with complete resolution of proteinuria after seven months.
Conclusion:
Anti-VEGF therapy causes renal TMA and may present with nephrotic-range proteinuria associated with a pattern of glomerular microangiopathy. Recognising anti-VEGF-associated nephrotoxicity is essential in the differential diagnosis of proteinuria in cancer patients, and kidney biopsy is fundamental for guiding clinical decisions. Drug cessation led to the complete resolution of proteinuria.
Learning Points:
Bevacizumab can cause renal-limited thrombotic microangiopathy and may present with nephrotic-range proteinuria, without renal dysfunction.Kidney biopsy is essential to distinguish drug-induced thrombotic microangiopathy from malignancy-associated nephropathies in cancer patients.Early recognition and drug discontinuation can lead to complete proteinuria resolution.
Insights
Bevacizumab, an anti-angiogenic cancer drug, can cause kidney problems like thrombotic microangiopathy (TMA). Early detection and stopping the drug can fully resolve proteinuria, a key symptom of this kidney issue.
Area of Science:
- Oncology
- Nephrology
- Pharmacology
Background:
- Bevacizumab, a vascular endothelial growth factor (VEGF) inhibitor, is used in cancer therapy for its anti-angiogenic effects.
- VEGF inhibition can lead to nephrotoxicity, specifically thrombotic microangiopathy (TMA), which can be localized to the kidneys.
- Renal-limited TMA is an under-recognized complication of anti-VEGF therapy.
Purpose of the Study:
- To highlight the occurrence and clinical presentation of bevacizumab-associated renal-limited TMA.
- To emphasize the importance of recognizing this specific nephrotoxicity in cancer patients undergoing anti-VEGF treatment.
- To underscore the diagnostic role of kidney biopsy and the therapeutic impact of drug discontinuation.
Main Methods:
- A case report of a 46-year-old woman with gliosarcoma treated with bevacizumab.
- Clinical data including development of hypertension and nephrotic-range proteinuria were recorded.
- Renal biopsy was performed, and the patient was monitored after bevacizumab discontinuation.
Main Results:
- The patient developed nephrotic-range proteinuria (6.2 g/day) and hypertension after 12 months of bevacizumab.
- Kidney biopsy confirmed glomerular microangiopathy consistent with TMA.
- Discontinuation of bevacizumab led to complete resolution of proteinuria within seven months, with stable intracranial disease.
Conclusions:
- Bevacizumab can induce renal-limited TMA presenting as nephrotic-range proteinuria without significant renal dysfunction.
- Kidney biopsy is crucial for differentiating drug-induced TMA from other nephropathies in cancer patients.
- Prompt recognition and cessation of bevacizumab can result in complete recovery from proteinuria.
