Infliximab for Immune Checkpoint Inhibitor Associated AKI

Infliximab for Immune Checkpoint Inhibitor Associated Acute Kidney Injury: A Pilot Randomized Clinical Trial

This is a multi-center, 1:1 randomized pilot study examining the efficacy and safety of infliximab 5mg/kg x 1 paired with 2 weeks of prednisone 1mg/kg per day for 2 weeks versus standard-of-care glucocorticoid therapy (prednisone 1mg/kg/day x 2 weeks followed by a 4 week taper) on the rate and speed of renal recovery from immune checkpoint inhibitor-associated AKI.

Data to guide treatment of immune-checkpoint inhibitor associated acute kidney injury (ICI-AKI) are limited, with current guidelines recommending 4-8 weeks of glucocorticoids (GCs). However, GCs have numerous side effects and can attenuate the anti-tumor response induced by ICI therapy, commonly leads to adverse events, and can delay anti-cancer therapy.

Infliximab is an FDA-approved monoclonal antibody that inhibits tumor necrosis factor-α and is used to treat a variety of autoimmune diseases, as well as steroid-refractory extrarenal immune-related adverse events. A strong biologic rationale exists for its use in patients with ICI-AKI, and case reports suggest some benefit in steroid-refractory ICI-AKI; however, there are no randomized clinical trial (RCT) data to guide the upfront use of infliximab in ICI-AKI.

This is a multi-center, 1:1 randomized pilot study examining the efficacy of infliximab in increasing the rate, speed, and durability of renal recovery when compared to standard of care prednisone which is current standard of care in patients receiving ICIs. The primary outcome is the rate of sustained renal recovery at 12 weeks. Key secondary outcomes include time-to-sustained renal recovery, time-to-ICI-AKI recurrence, and time-to-rechallenge with anti-cancer therapy. Additionally, we will characterize the safety profile of infliximab, as well a 6- vs. 2-week course of GCs, using the Glucocorticoid Toxicity Index.

Inclusion Criteria:

• Age ≥18 years.
• Acute kidney injury (AKI), defined as ≥1.5-fold increase in serum creatinine compared to baseline. Baseline is defined as the closest serum creatinine value prior to immune checkpoint inhibitor initiation (ICI).
• Receipt of ICI in the 180 days preceding AKI onset.
• AKI due to ICI-AIN, based on either a kidney biopsy or clinical adjudication by the treating team.
• Ability of the patient to understand the study and willingness to sign the written informed consent form.

Exclusion Criteria:

• Any condition requiring high dose glucocorticoids (GCs) (>10 mg/day prednisone equivalents) or other immunosuppressants, such as infliximab, tocilizumab, mycophenolate mofetil, B cell depletion, or calcineurin inhibitors, within 14 days preceding screening
• Evidence of any uncontrolled infection, including Tuberculosis (must have no evidence of active or latent TB determined by clinical history and negative interferon gamma release assay within the last 12 months or at screening); Hepatitis B (based on AntiSAg and HBV DNA negative within the last 12 months or at screening. Patients with Isolated Anti-HBcore positivity must agree to antiviral prophylaxis with entecavir for 6 months after receiving infliximab); Hepatitis C (must have no uncontrolled active infection evidenced by negative HCV antibody or HCV RNA within the last 12 months or at screening, and reflex testing must be performed for any patient with HCV antibody positivity); Patients with known HIV must be on stable disease antiretroviral therapy ≥12 weeks with a negative viral load [<50 copies/mL] at screening and CD4 count ≥ 350 cells/uL) measured within the last 12 months.
• History of hypersensitivity to infliximab or murine proteins.
• Moderate-severe (New York Heart Association class III/IV) heart failure or recent decompensation.
• Any active or uncontrolled hepatitis (immune-mediated, viral, or drug-induced) defined as AST or ALT > 3 × ULN or Total bilirubin > 1.5 × ULN in the 14 days preceding screening. (Participants with Gilbert syndrome can be enrolled with elevated total bilirubin if their direct bilirubin is not > ULN)
• History of demyelinating disease (e.g., multiple sclerosis) or optic neuritis.
• Uncontrolled or recurrent serious infections (e.g., untreated abscess, active sepsis), requirement for oral or intravenous antibiotics, at screening.
• Receipt of any live vaccine in the 28 days preceding screening
• Kidney biopsy showing primary lesion other than acute interstitial nephritis
• Life expectancy <12 weeks in the opinion of the investigator
• Unable to tolerate study procedures, including IV insertion.
• Contraindication to GCs, including but not limited to, uncontrolled diabetes mellitus with inability to safely manage expected steroid-induced hyperglycemia, severe and active psychiatric disease requiring ongoing titration of psychiatric medications, active peptic ulcer disease, severe osteoporosis or high fracture risk, or other investigator-determined conditions where systemic GC or infliximab would pose unacceptable risk in the judgment of the investigator.
• Vulnerable populations including children, prisoners, neonates and pregnant or breastfeeding patients