Zanidatamab
Ziihera · HER2 bispecific antibody
2024 biliary-tract HER2 bispecific; renal data emerging.
PRELYTE
Mild#1 · 100% phenotype match
Zenocutuzumab
Bizengri · ZEN
HER2×HER3 bispecific antibody · approved 2024 · 2 citations
Up to date· through 2025
Thinly sourced3/9 · 3 signals
- Not met: 2 citations
- Not met: 12+ references
- Not met: Accrued over 10+ years (span: 3y)
- Not met: Beyond single case reports
- Met: High-impact journal
- Met: Landmark reference
- Met: Current through 2025
- Not met: Real-world FAERS signal
Describes how this page is sourced, not how dangerous the drug is. Thinly sourced means fewer of the sourcing signals are met — not that the agent is kidney-safe. A rule-based summary, not a formal certainty appraisal.
A HER2xHER3 bispecific antibody for NRG1-fusion cancers whose adverse events are mostly grade 1-2 — its only route to the kidney is indirect, through diarrhea-driven volume loss.
MildHER2xHER3 bispecific antibody
Advanced NRG1-fusion-positive non-small-cell lung cancerAdvanced NRG1-fusion-positive pancreatic adenocarcinomaA tumor-agnostic footprint across NRG1-fusion-positive solid tumors
§01
Signature kidney injury
Signature lesion
Zenocutuzumab carries no meaningful direct renal signal and no discrete published incidence of drug-related acute kidney injury. In the registrational phase 2 eNRGy study (Schram, N Engl J Med 2025; n=204) adverse events were primarily grade 1 or 2, the most common treatment-related events were diarrhea (18%), fatigue (12%), and nausea (11%), infusion-related reactions occurred in 14%, and only one patient discontinued for a treatment-related event. The only renal-relevant route is indirect: diarrhea and, less often, infusion reactions can produce volume depletion and prerenal physiology if significant. Unlike T-cell-engaging bispecifics, this HER2xHER3 antibody does not carry a cytokine-release or tumor-lysis mechanism, so it lacks that class's renal hazards.Source: No direct renal signal; mostly grade 1-2 AEs with diarrhea 18% (eNRGy, Schram 2025); at most diarrhea-related prerenal risk, no CRS/TLS mechanism
Onset & rechallenge
Time to injuryAcute (~1–7 days)
No direct renal onset; infusion-related effects are hyperacute (during/around the infusion), and diarrhea-related prerenal physiology, if it occurs, follows the diarrheal episodes across treatment.
Distilled from: “No drug-specific direct renal onset. Infusion-related effects are hyperacute (during/around the infusion); diarrhea-related prerenal physiology, if it occurs, follows the diarrheal episodes across treatment.” · PMID 39908431 (opens PubMed in a new tab)
§02
Renal toxicities, ranked
This agent's kidney lesions ordered by prominence — the #1 signature lesion first, then secondary and rare patterns. Cited incidence is shown where a citable figure exists; otherwise the tier stands qualitatively.
Renal hypoperfusion from capillary leak and cytokine storm — IL-2 and CAR-T cytokine release syndrome.
Renal electrolyte derangement — magnesium/potassium/calcium wasting (cisplatin, anti-EGFR antibodies) or retention (FGFR-inhibitor hyperphosphatemia, tumor-lysis hyperkalemia/hyperphosphatemia).
§03
Kidney injury
Mechanism of kidney injury
Zenocutuzumab has no established direct renal toxicity. As a HER2xHER3 antibody that blocks NRG1-driven signaling, it acts on tumor receptor dimerization and is cleared by reticuloendothelial catabolism rather than the kidney; the nephron is neither a target of injury nor the clearance route. Importantly, unlike CD3-engaging bispecifics, it does not redirect T cells and so does not cause the cytokine-release or tumor-lysis syndromes that drive bispecific-associated AKI (Joseph, Cells 2022, describes those T-cell-engager mechanisms — which do not apply here). The realistic route to kidney trouble is therefore indirect: diarrhea (18%) or, less commonly, an infusion reaction with hypotension causing prerenal, volume-depletion physiology, potentially with mild electrolyte loss. There is no described tubular, interstitial, or glomerular lesion attributable to the drug.
Clinical presentation
No characteristic direct renal presentation. When a renal issue arises it is prerenal: a patient with significant diarrhea (or an infusion reaction with transient hypotension) who becomes volume-depleted, with a rising creatinine and a low fractional excretion of sodium that corrects with rehydration, sometimes with mild hypokalemia. A bland sediment is expected; an active sediment or heavy proteinuria points elsewhere.
Management
Management is supportive and aimed at the indirect driver. For diarrhea-related prerenal AKI, control the diarrhea and restore volume (oral or IV fluids), correcting any potassium loss. For an infusion reaction with hypotension, stop/slow the infusion, support hemodynamics, and treat per protocol; the associated prerenal insult resolves with perfusion. Provide standard supportive AKI care and avoid additional nephrotoxins. Because the antibody does not injure the tubule directly and is not renally cleared, there is no drug-specific renal rescue and no dialysis role for the drug itself.Lesion-level management framework
Risk factors
- Significant or poorly controlled diarrhea (the main prerenal driver)
- Infusion-related reactions with hypotension
- Baseline CKD or volume depletion
- Concurrent nephrotoxins or diuretics
- Poor oral intake during GI toxicity
Prevention
- Manage diarrhea early (antidiarrheals, hydration) to prevent volume depletion
- Use infusion-reaction precautions/premedication per protocol and monitor during infusions
- Encourage hydration; give IV fluids when intake is inadequate
- Review and minimize concurrent nephrotoxins
Anticancer mechanism· how it treats cancer
Humanized IgG1 bispecific antibody that binds both HER2 and HER3 (a 'Dock & Block' mechanism): one arm docks onto HER2 while the other blocks the neuregulin-1 (NRG1) binding site on HER3, preventing HER2-HER3 heterodimerization and shutting down downstream PI3K-AKT growth signaling. This is specifically effective in NRG1-fusion-positive solid tumors (notably non-small-cell lung and pancreatic cancer), where the fusion protein drives aberrant HER3 activation. Given intravenously every two weeks.
§04
Clinical depth
Renal dose adjustment
No pharmacokinetic renal dose adjustment is defined: zenocutuzumab is an IgG1 antibody cleared by reticuloendothelial catabolism rather than glomerular filtration, so creatinine clearance is not expected to change exposure, and dedicated data in severe renal impairment or dialysis are limited. Dose interruption is driven by infusion reactions and other toxicity rather than by GFR; pre-existing CKD mainly raises the stakes of diarrheal or infusion-related volume depletion and warrants closer supportive monitoring.
Dialyzability & ESKD dosing
Not dialyzable — a full-size IgG1 bispecific antibody vastly exceeds any dialysis-membrane cutoff and stays in the vascular/interstitial compartment, so hemodialysis does not remove the drug. Renal replacement therapy would only support an unrelated severe AKI, not clear the antibody.
Differential diagnosis
Attribute any AKI to the indirect driver and exclude alternatives. Diarrhea- or infusion-related prerenal AKI is favored by a clear precipitant, volume depletion, low fractional excretion of sodium, and a bland sediment that corrects with rehydration. Distinguish it from concurrent nephrotoxins, contrast, sepsis, and pre-existing CKD, and from a primary renal lesion (active sediment, proteinuria). Critically, do not attribute a cytokine-release- or tumor-lysis-pattern AKI to this drug — those belong to T-cell-engaging bispecifics, not to a HER2xHER3 antibody.
Monitoring
- Diarrhea frequency/severity and volume status (the primary indirect renal-risk driver)
- Vital signs during infusions for infusion-related reactions/hypotension
- Serum creatinine/eGFR and electrolytes during treatment
- Potassium if diarrhea is significant
Key trials & series
- eNRGy (Schram, N Engl J Med 2025) — registrational phase 2 study of zenocutuzumab in NRG1-fusion-positive cancers (n=204; 12 tumor types); responses in 30% overall (including NSCLC and pancreatic cancer) with adverse events primarily grade 1-2 — diarrhea 18%, fatigue 12%, nausea 11%, infusion-related reactions 14% — and only one treatment-related discontinuation, defining a tolerability profile with, at most, indirect (prerenal) renal risk.
- Acute kidney injury with cancer immunotherapy (Joseph, Cells 2022) — reviews the AKI mechanisms of T-cell-engaging bispecifics (cytokine release, tumor lysis); a useful contrast showing why a HER2xHER3 antibody like zenocutuzumab, which does not engage T cells, lacks those renal hazards.
Clinical pearls
- Not that kind of bispecific: zenocutuzumab blocks HER2-HER3 dimerization and does not engage T cells, so it lacks the cytokine-release/tumor-lysis AKI of CD3 engagers.
- Its only real route to the kidney is diarrhea (18%) — manage the diarrhea and you manage the prerenal risk.
- Watch infusions: a reaction with hypotension is a transient prerenal insult that resolves with perfusion support.
- A large IgG1 antibody is not dialyzable and not renally cleared — GFR doesn't change its dosing.
- A creatinine rise here is volume, not tubular poisoning — rehydrate and reassess.
Where it strikes· nephron segments & injury signatures
Nephron segments
Vasculature / Endothelium
Glomerular & peritubular capillaries
Injury signatures
Beyond the kidney — non-renal toxicities· 3 organ systems
Class-level context for the major non-renal toxicities of her2×her3 bispecific antibodys.
Immune / Infusion
CRS, infusion reactions, irAEs, anaphylaxis
- Cytokine release syndrome
Neurologic
Neuropathy, encephalopathy, ICANS, PRES
- ICANS / neurotoxicity
Hematologic
Cytopenias, thrombosis, TMA
- Cytopenias, hypogammaglobulinemia
§05
References
2 primary references — trials, cohorts, mechanism, and reviews. Single-patient case reports are listed separately below, graded by strength. Citation metadata via PubMed / NLM.
Evidence accrual
2 references · 2022–2025 · 1 since 2023Primary (non–case-report) references per year — a proxy for how actively the agent's renal literature is accruing. Recent years are highlighted. Reflects curation depth, not a systematic bibliometric count.
- 1.LandmarkEfficacy of Zenocutuzumab in NRG1 Fusion-Positive Cancer.Schram AM, Goto K, Kim DW, et al. · N Engl J Med · 2025 · PMID 39908431Registrational phase 2 eNRGy trial: adverse events were primarily grade 1-2 (diarrhea 18%, fatigue 12%, nausea 11%, infusion-related reactions 14%) with a single treatment-related discontinuation — establishing a tolerability profile with, at most, indirect diarrhea-driven prerenal renal risk and no direct nephrotoxicity.
- 2.Acute Kidney Injury in Cancer Immunotherapy Recipients.Joseph A, Lafarge A, Azoulay E, Zafrani L. · Cells · 2022 · PMID 36552755Reviews the renal injury mechanisms of T-cell-engaging bispecifics (cytokine release, tumor lysis) — the useful contrast that explains why zenocutuzumab, a HER2xHER3 antibody that does not engage T cells, does not carry those hazards.
FDA label — boxed warning & renal dosing· boxed warning
Quoted verbatim from this agent's current FDA label (May 2026) — not paraphrased or interpreted. Full label on DailyMed .
Boxed warning
WARNING: EMBRYO-FETAL TOXICITY Embryo-Fetal Toxicity: Exposure to BIZENGRI during pregnancy can cause embryo-fetal harm. Advise patients of this risk and the need for effective contraception [see Warnings and Precautions (5.4) , Use in Specific Populations (8.1 , 8.3) ]. WARNING: EMBRYO-FETAL TOXICITY See full prescribing information for complete boxed warning. Embryo-Fetal Toxicity: Exposure to BIZENGRI during pregnancy can cause embryo-fetal harm. Advise patients of this risk and the need for effective contraception [see Warnings and Precautions (5.4) , Use in Specific Populations (8.1 , 8.3) ].
What gets reported — FAERS
Everything below is FAERS — adverse events someone chose to report, about 8 of them for this agent. Nobody counts the patients who were fine, so none of these numbers is an incidence, a risk, or a rate: they describe what gets reported, shaped by a drug's fame, its indication, and who was watching. How these numbers work.
- Outcomes — a share of this agent's own reports, not of patients: how many were filed as involving a death or a hospitalization. Not a case-fatality rate.
FAERS outcomes & reporting trend· 1 of 8 reports w/ death · 1 w/ hospitalization
8 reports is below the 50 this atlas requires before quoting a percentage, so the counts are shown instead of shares.
1 of 8
Reported with a death outcome
too few reports to express as a share
1 of 8
Reported with hospitalization
too few reports to express as a share
Reports per year
- 2015: 0 reports
- 2016: 0 reports
- 2017: 0 reports
- 2018: 0 reports
- 2019: 0 reports
- 2020: 0 reports
- 2021: 0 reports
- 2022: 0 reports
- 2023: 0 reports
- 2024: 0 reports
- 2025: 6 reports
- 2026: 2 reports
Yearly FAERS report volume · most recent year is partial.
FAERS adverse-event signal — all organ systems· 5 systems · 8 reports
Bars rank systems by summed reaction-term mentions (a report counts once per term it names) — an ordinal “more vs less reported” cue, not a tally of distinct reports. Renal & urinary first. As of 2026-08-08.
Respiratory
Dysphonia2
Immune / infection
Infusion Related Reaction1Sepsis1
Gastrointestinal
Diarrhoea1
Skin
Rash Maculo-Papular1
Blood & lymphatic
Thrombocytopenia1
Guidelines & consensus· 12
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.
General onco-nephrology references
ADQIThe nephrotoxic effects of anti-cancer therapies: consensus report of the 34th Acute Disease Quality Initiative workgroupNat Rev Nephrol 2026 · PMID 41361704Provides 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.SIRMSIRM-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)Radiol Med 2022 · PMID 35303246Recommends 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.KDIGOKDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancerKidney Int 2020 · PMID 33126977Identifies 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.KDIGOKDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantationKidney Int 2020 · PMID 33276867Addresses 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.ADDIKDIntegrating International Consensus Guidelines for Anticancer Drug Dosing in Kidney Dysfunction (ADDIKD) into everyday practiceEClinicalMedicine 2025 · PMID 40290844Provides 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.ADDIKDAligning kidney function assessment in patients with cancer to global practices in internal medicineEClinicalMedicine 2025 · PMID 40290845Three 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.ADDIKDA methodology for determining dosing recommendations for anticancer drugs in patients with reduced kidney functionEClinicalMedicine 2025 · PMID 40290846Establishes 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.KDIGODiagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)Crit Care 2013 · PMID 23394211Defines/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.KDIGOExecutive summary of the KDIGO 2021 Guideline for the Management of Glomerular DiseasesKidney Int 2021 · PMID 34556300Provides 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.KDIGOExecutive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of ANCA-Associated VasculitisKidney Int 2024 · PMID 38388147Updates 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.KDIGOExecutive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of Lupus NephritisKidney Int 2024 · PMID 38182299Updates 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.KDIGOExecutive summary of the KDIGO 2025 Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV)Kidney Int 2025 · PMID 40975525Encourages 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.
Where Zenocutuzumab sits in nephrotoxicity space — each dot is an anti-cancer agent, positioned so neighbors share a kidney-injury phenotype. Its 6 closest are filled and lead to a numbered marker, matching the numbered cards below.
Phenotype-similar agents· the numbered markers on the map above
Profile
Daratumumab
Darzalex · Anti-CD38 antibody
Tumor lysis; usable in renal impairment.
PRELYTE
Mild#2 · 97% phenotype match
Isatuximab
Sarclisa · Anti-CD38 antibody
Tumor lysis in myeloma.
PRELYTE
Mild#3 · 97% phenotype match
Imetelstat
Rytelo · Telomerase inhibitor
2024 MDS agent; tumor lysis risk.
PRELYTE
Mild#4 · 89% phenotype match
Mirdametinib
Gomekli · MEK inhibitor
2025 NF1 MEK inhibitor; creatinine rise and edema.
PRELYTE
Mild#5 · 89% phenotype match
Quizartinib
Vanflyta · FLT3 inhibitor
2023 AML FLT3 inhibitor; tumor lysis and QT.
PRELYTE
Mild#6 · 89% phenotype match
Nearest agents by kidney-injury phenotype (shared injuries, nephron target, severity, class) — a similarity approximation, not a claim of shared drug identity or mechanism.
Kidney risk across Monoclonal antibodies (other)
Same-class agents ordered by their documented kidney-injury profile — atlas severity, an acute-kidney-injury FAERS signal, and how many injury types each is documented to cause. Agents nearer the top carry the lighter documented renal profile.
- 1MogamulizumabPRE — Prerenal / Hemodynamic AKIMild
- 2Zenocutuzumab· this agentPRE — Prerenal / Hemodynamic AKIMild
- 3ElotuzumabPRE — Prerenal / Hemodynamic AKIFAERS AKIMild
- 4CetuximabLYTE — Electrolyte DisturbanceFAERS AKIMild
- 5DaratumumabPRE — Prerenal / Hemodynamic AKIFAERS AKIMild
- 6IsatuximabPRE — Prerenal / Hemodynamic AKIFAERS AKIMild
- 7PanitumumabLYTE — Electrolyte DisturbanceFAERS AKIMild
- 8TafasitamabPRE — Prerenal / Hemodynamic AKIFAERS AKIMild
- 9ZanidatamabPRE — Prerenal / Hemodynamic AKIFAERS AKIMild
- 10NecitumumabLYTE — Electrolyte DisturbanceModerate
- 11ZolbetuximabPRE — Prerenal / Hemodynamic AKIModerate
- 12AmivantamabLYTE — Electrolyte DisturbanceModerate
- 13NaxitamabPRE — Prerenal / Hemodynamic AKIModerate
- 14DinutuximabPRE — Prerenal / Hemodynamic AKIFAERS AKIModerate
- 15ObinutuzumabXTAL — Crystal / Obstructive NephropathyFAERS AKIModerate
- 16RituximabXTAL — Crystal / Obstructive NephropathyFAERS AKIModerate
A comparison of documented kidney-injury data within one drug class — not a substitution recommendation. Efficacy, indication, and non-renal toxicity differ between these agents and are out of scope here. Educational only, not medical advice.