Immune checkpoint inhibitor usage in a sequential kidney transplant stage IV squamous cell carcinoma patient

Introduction: A cutaneous squamous cell carcinoma (cSCC) stage IV patient with a history of sequential kidney transplants was administered Cemiplimab (anti-PD-1) to treat his advanced cancer. The patient experienced an acute kidney injury (AKI) following initiation of Cemiplimab. The etiology of the AKI was acute tubular necrosis (ATN) due to atrial flutter with associated hypotension. Case Description: Kidney transplant rejection has been reported to be as high as 40% after exposure to immune checkpoint inhibitors; in this case, clinicians may prematurely discontinue immune checkpoint inhibitors (ICI) such as Cemiplimab in fear of graft loss. This case highlights that an individualized and comprehensive approach to finding the etiology of the AKI in patients treated with ICI is valuable for reducing the chance that stage IV cancer patients are taken off life-saving cancer treatment. The patient tested negative for donor specific antibodies during AKI although the patient has had two separate kidney transplants. Conclusions: Despite a significantly increased risk of alloimmunization, transplant patients with two separate kidney transplants should be given the opportunity to receive ICI therapy through an individualized patient outlook. To our knowledge, this case marks the first use of ICI in a patient with over 35 years of kidney transplant history and two sequential kidney transplants that did not result in ICI-mediated rejection.