Penpulimab

Acute Interstitial Nephritis — representative incidence ~3% (2–5% range across studies).

Penpulimab-specific renal data are limited. In the pivotal first-line phase 3 trial (penpulimab plus chemotherapy), grade >=3 immune-related adverse events occurred in only 4.1% of patients, and renal events were not separately prominent; the most common toxicities were hematologic. By class, immune checkpoint inhibitor-associated AKI (predominantly acute tubulointerstitial nephritis) occurs in roughly 2-5% of patients on PD-1 monotherapy, with higher rates when combined with nephrotoxic chemotherapy. Platinum (cisplatin) and gemcitabine in the registrational backbone independently contribute ATN and (rarely) thrombotic microangiopathy risk, so observed kidney injury in this regimen is often multifactorial.

Source: Class incidence of ICI-associated AKI/AIN ~2-5% (Zhou P et al., Front Immunol 2024, PMID 38464524; Miao J et al., Front Nephrol 2022, PMID 37674988). Penpulimab grade >=3 irAEs 4.1% in the first-line phase 3 trial (Huang S et al., Signal Transduct Target Ther 2026, PMID 41946687).

Reported injury signatures: Acute Interstitial Nephritis, Acute Tubular Necrosis, Electrolyte Disturbance, Glomerular Injury / Proteinuria.

1. Acute Interstitial NephritisPrimaryAcute tubulointerstitial nephritis is the signature ICI renal lesion — dominant in 93% of the 60 biopsied patients in a 138-patient multicenter ICI-AKI cohort (a biopsy-lesion proportion, not a treated-population incidence).
2. Electrolyte DisturbanceSecondary
3. Acute Tubular NecrosisRareMinority histologic pattern — tubulointerstitial nephritis dominates 93% of ICI-AKI biopsies, with ATN and other lesions making up the remainder.
4. Glomerular Injury / ProteinuriaRareCase-level; glomerular lesions (2 membranous nephropathy, 2 minimal change disease) among 12 biopsy/nephrologist-attributed ICI nephrotoxicity cases.

Delayed (>6 weeks / cumulative) — ICI-AIN commonly weeks to several months (median ~3–4 months); combination-chemo ATN occurs earlier, peri-infusion.

Rechallenge: Case-by-case — In the multicenter ICI-AKI cohort ~22% were rechallenged and ~23% of those developed recurrent AKI — feasible but an individualized, co-managed decision.

• Concurrent use of other AIN-associated drugs (proton-pump inhibitors, NSAIDs, antibiotics)
• Combination with nephrotoxic chemotherapy (cisplatin/carboplatin plus gemcitabine) in the registrational regimen
• Prior or concurrent extrarenal immune-related adverse events
• Lower baseline eGFR / pre-existing chronic kidney disease
• Combination immunotherapy (e.g., dual checkpoint or PD-1 plus TIM-3 blockade under study)
• Volume depletion and intercurrent illness

• Review and minimize concomitant nephritis-associated drugs (PPIs, NSAIDs)
• Maintain euvolemia and adequate hydration, especially around platinum/gemcitabine cycles

• Urinalysis with microscopy (sterile pyuria, white-cell casts, proteinuria)
• Spot urine protein-to-creatinine ratio if proteinuria develops
• Serum electrolytes including sodium, potassium, magnesium (combination chemotherapy)
• Surveillance for extrarenal immune-related adverse events (thyroid, liver, GI, skin)
• Blood pressure and CBC/peripheral smear if TMA is suspected with the platinum/gemcitabine backbone

• AK105-304 / NCT04974398: randomized double-blind phase 3 of penpulimab plus cisplatin-or-carboplatin/gemcitabine vs placebo plus chemotherapy, first-line R/M NPC (n=291); median PFS 9.63 vs 7.00 months, HR 0.45; grade >=3 irAEs 4.1% (PMID 41946687)
• Single-arm phase 2 of penpulimab monotherapy in heavily pretreated metastatic NPC (n=130); ORR 28.0%, grade >=3 irAEs 7.6% (PMID 38890298)
• Phase 2 exploratory study of penpulimab/gemcitabine with or without anlotinib in metastatic NPC (PMID 42093316)

• Kidney injury from penpulimab is class-typical immune AIN, not a direct tubular toxin — treat suspected cases with drug hold plus corticosteroids, not just hydration.
• An unexplained creatinine rise in a patient on a checkpoint inhibitor is AIN until proven otherwise; do not anchor on pre-renal causes.
• In the registrational regimen the kidney sees three potential hits at once — penpulimab (AIN), cisplatin (ATN), and gemcitabine (rare TMA) — so always parse the timing and urine sediment.
• Penpulimab's Fc-silent IgG1 design is intended to lower immune-related toxicity (grade >=3 irAEs were only ~4% in the phase 3 trial), but interstitial nephritis can still occur.
• Penpulimab is not renally cleared and is not dialyzable — no eGFR-based dose change is needed; toxicity management is steroid- and grade-driven.
• Co-prescribed PPIs and NSAIDs are common AIN co-triggers under PD-1 blockade — deprescribe them when feasible.

Each recommendation below is this atlas's faithful summary of the source, not a quotation from it — follow the PubMed link for the wording the society published. Summaries may be superseded; consult the current full text and individualize to the patient.

• ASON (2025) — Diagnosis and management of immune checkpoint inhibitor-associated nephrotoxicity: a position statement from the American Society of Onco-nephrologyICI-AKI most commonly presents as acute interstitial nephritis; nephrology consultation and kidney biopsy should be considered for stage 2 or higher AKI or suspected glomerular disease, but where biopsy is not feasible, prompt empiric corticosteroids (prednisone ~1 mg/kg/day) should be started for clinically suspected ICI-AKI since early steroids improve renal recovery, with cautious individualized consideration of ICI rechallenge after recovery.Kidney Int · PMID 39455026
• ASCO (2021) — Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline UpdateFor grade 2 or higher ICI-related nephritis/AKI, hold the ICI, exclude alternative causes, and initiate corticosteroids (prednisone 0.5-1 mg/kg/day for grade 2, 1-2 mg/kg/day for grade 3-4) tapered over 4-6 weeks once creatinine improves; permanently discontinue for grade 4 toxicity.J Clin Oncol · PMID 34724392
• ESMO (2022) — Management of toxicities from immunotherapy: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-upFor ICI-related AKI, exclude alternative etiologies and stop concomitant nephrotoxins (PPIs, NSAIDs); ESMO permits continuing the ICI for stage 1 AKI with monitoring, but recommends withholding the ICI and starting corticosteroids for stage 2 or higher nephritis, escalating immunosuppression for steroid-refractory disease.Ann Oncol · PMID 36270461
• SITC (2021) — Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse eventsGrade ICI-related AKI by CTCAE; for persistent grade 2 or higher renal toxicity, discontinue the ICI, exclude other causes, and treat with corticosteroids with a taper begun once creatinine improves toward grade 1, considering kidney biopsy and additional immunosuppression for refractory cases.J Immunother Cancer · PMID 34172516
• IC-OS (2026) — Immune Checkpoint Inhibitor-Associated Cardiovascular Toxic Effects: International Cardio-Oncology Society Position StatementConcerns for myocarditis continue to dominate the spectrum of CV toxic effects in patients receiving ICI therapy. Recommendations for management vary according to severity. Multidisciplinary collaborations remain key for managing acute toxic effects and future cancer treatment decisions, including ICI rechallenge.JAMA Oncol · PMID 41231466
• EULAR (2021) — EULAR points to consider for the diagnosis and management of rheumatic immune-related adverse events due to cancer immunotherapy with checkpoint inhibitorsOncologists should be encouraged to consult rheumatologists promptly for assessment when rheumatic musculoskeletal and systemic signs or symptoms are suspected due to immunotherapy, and rheumatologists should provide facilitated access for such patients.Ann Rheum Dis · PMID 32327425
• ASCO (2018) — Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: American Society of Clinical Oncology Clinical Practice GuidelineWithhold the checkpoint inhibitor and start corticosteroids for grade 2 or higher immune-related renal toxicity after excluding other causes of AKI, with steroid taper as renal function recovers and permanent discontinuation for severe (grade 4) events.J Clin Oncol · PMID 29442540
• PUMCH Expert Panel (2020) — Clinical recommendations on diagnosis and treatment of immune checkpoint inhibitor-induced renal immune-related adverse eventsScreen and monitor with serum creatinine, urinalysis/sediment, and 24-hour urine protein; strongly recommend kidney biopsy to confirm ICI-related ATIN and exclude other AKI causes, withdraw nephrotoxins (PPIs, NSAIDs), and initiate corticosteroids when a grade 2 or higher renal irAE is highly suspected, with multidisciplinary decisions on ICI withdrawal and rechallenge.Thorac Cancer · PMID 32232975
• ADQI (2026) — Immune Checkpoint Inhibitor-Associated Acute Kidney Injury: A Report from the 34th Acute Disease Quality Initiative (ADQI) Consensus ConferenceAKI occurs in up to 20% of ICI-treated patients with ICI-AKI accounting for roughly 2-5% of cases, and acute tubulointerstitial nephritis dominates (80-90% of biopsies); no clinical feature reliably separates ICI-AKI from other causes, so kidney biopsy remains the diagnostic gold standard and emerging biomarkers are not yet ready for routine use. Early glucocorticoid initiation (within 3 days of diagnosis) is associated with higher rates of kidney recovery, and recurrent ICI-AKI occurs in fewer than 20% of rechallenged patients, supporting cautious rechallenge in selected patients with individualized multidisciplinary decisions for transplant recipients and other high-risk groups.J Am Soc Nephrol · PMID 42536415
• ADQI (2026) — The nephrotoxic effects of anti-cancer therapies: consensus report of the 34th Acute Disease Quality Initiative workgroupProvides expert-based statements (modified Delphi) on preventing and managing cisplatin/platinum-associated AKI, including isotonic IV hydration, attention to volume status and concomitant nephrotoxins, and incorporates evidence that IV magnesium supplementation may reduce cisplatin-associated AKI; emphasizes risk stratification and standardized AKI definitions.Nat Rev Nephrol · PMID 41361704
• SIRM (2022) — SIRM-SIN-AIOM: appropriateness criteria for evaluation and prevention of renal damage in the patient undergoing contrast medium examinations-consensus statements from Italian College of Radiology (SIRM), Italian College of Nephrology (SIN) and Italian Association of Medical Oncology (AIOM)Recommends eGFR-based renal risk assessment and pre/post-contrast isotonic saline or sodium bicarbonate hydration; advises maintaining a 5-7 day interval between iodinated contrast administration and cisplatin in cancer patients to reduce additive nephrotoxicity.Radiol Med · PMID 35303246
• KDIGO (2020) — KDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancerIdentifies platinum compounds (especially cisplatin) as leading cytotoxic causes of acute tubular injury, AKI, and electrolyte/magnesium wasting; calls for interdisciplinary onco-nephrology care, accurate GFR estimation, and individualized drug dosing in patients with reduced kidney function.Kidney Int · PMID 33126977
• KDIGO (2020) — KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantationAddresses chemotherapy-associated AKI/CKD in hematologic cancer, GFR estimation and chemotherapy dosing in patients with reduced kidney function, and management priorities and research gaps for onco-nephrology care.Kidney Int · PMID 33276867
• ADDIKD (2025) — Integrating International Consensus Guidelines for Anticancer Drug Dosing in Kidney Dysfunction (ADDIKD) into everyday practiceProvides GRADE-based, drug-specific dose-adjustment recommendations for anticancer agents in kidney dysfunction (illustrated for methotrexate, cisplatin, carboplatin and nivolumab); the recommendations build on Part 1's standardised CKD-EPI eGFR assessment rather than Cockcroft-Gault creatinine clearance.EClinicalMedicine · PMID 40290844
• ADDIKD (2025) — Aligning kidney function assessment in patients with cancer to global practices in internal medicineThree consensus recommendations: assess kidney function by GFR (measured GFR or CKD-EPI eGFR), classify it using KDIGO categories, and use this uniform approach to dose anticancer drugs — moving cancer medicine away from Cockcroft-Gault estimated creatinine clearance.EClinicalMedicine · PMID 40290845
• ADDIKD (2025) — A methodology for determining dosing recommendations for anticancer drugs in patients with reduced kidney functionEstablishes that, where RCT evidence is lacking, anticancer drug dosing recommendations in kidney dysfunction should be derived by critically appraising observational literature via GRADE combined with structured international multidisciplinary consensus voting.EClinicalMedicine · PMID 40290846
• KDIGO (2013) — Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)Defines/stages AKI by serum creatinine and urine output; emphasizes avoiding nephrotoxins, maintaining euvolemia/perfusion, dose-adjusting drugs to kidney function, and monitoring high-risk patients — the framework applied to nephrotoxic anti-cancer agents.Crit Care · PMID 23394211
• KDIGO (2024) — Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknownsEvaluate and risk-stratify CKD, manage to delay progression and its complications, and practise explicit medication management and drug stewardship — the framework the atlas's G1–G5 eGFR banding and every renal dose-adjustment recommendation sit inside. Because the guideline excludes dialysis and transplant recipients by its own statement of scope, its recommendations do not carry to those settings, where this atlas's dialyzability and post-transplant guidance rests on other sources.Kidney Int · PMID 38519239
• KDIGO (2021) — Executive summary of the KDIGO 2021 Guideline for the Management of Glomerular DiseasesProvides the staging/treatment framework for drug-associated glomerular lesions (e.g., bisphosphonate- and interferon-related collapsing FSGS, VEGF-inhibitor podocytopathy/proteinuria), including immunosuppression and supportive RAAS-blockade strategies.Kidney Int · PMID 34556300
• KDIGO (2024) — Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of ANCA-Associated VasculitisUpdates immunosuppressive induction (rituximab/cyclophosphamide), incorporates avacopan and lower-dose or glucocorticoid-sparing regimens — the management framework for drug- and checkpoint-inhibitor-associated ANCA/pauci-immune glomerulonephritis.Kidney Int · PMID 38388147
• KDIGO (2024) — Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of Lupus NephritisUpdates first-line lupus nephritis therapy to combination immunosuppression with the addition of belimumab or a calcineurin inhibitor (voclosporin) — informs management of immune-complex/lupus-like glomerulonephritis encountered with immunotherapy.Kidney Int · PMID 38182299
• KDIGO (2025) — Executive summary of the KDIGO 2025 Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV)Encourages liberal kidney biopsy and stricter proteinuria control (<0.5 g/d, ideally <0.3 g/d) with RAAS blockers, SGLT2 inhibitors, and targeted-release budesonide — the framework for IgA-dominant glomerular lesions, including those triggered by immune-modulating cancer therapy.Kidney Int · PMID 40975525