Acute Kidney Injury and Electrolyte Abnormalities After Chimeric Antigen Receptor T-Cell (CAR-T) Therapy for Diffuse Large B-Cell Lymphoma

Am J Kidney Dis. 2020 Jul;76(1):63-71. doi: 10.1053/j.ajkd.2019.10.011. Epub 2020 Jan 20.


Rationale & objective: Cytokine release syndrome is a well-known complication of chimeric antigen receptor T-cell (CAR-T) therapy and can lead to multiorgan dysfunction. However, the nephrotoxicity of CAR-T therapy is unknown. We aimed to characterize the occurrence, cause, and outcomes of acute kidney injury (AKI), along with the occurrence of electrolyte abnormalities, among adults with diffuse large B-cell lymphoma receiving CAR-T therapy.

Study design: Case series.

Setting & participants: We reviewed the course of 78 adults receiving CAR-T therapy with axicabtagene ciloleucel or tisagenlecleucel at 2 major cancer centers between October 2017 and February 2019. Baseline demographics, comorbid conditions, medications, and laboratory values were obtained from electronic health records. AKI was defined using KDIGO (Kidney Disease: Improving Global Outcomes) criteria. The cause, clinical course, and outcome of AKI events and electrolyte abnormalities in the first 30 days after CAR-T infusion were characterized using data contained in electronic health records.

Results: Among 78 patients receiving CAR-T therapy, cytokine release syndrome occurred in 85%, of whom 62% were treated with tocilizumab. AKI occurred in 15 patients (19%): 8 had decreased kidney perfusion, 6 developed acute tubular necrosis, and 1 patient had urinary obstruction related to disease progression. Those with acute tubular necrosis and obstruction had the longest lengths of stay and highest 60-day mortality. Electrolyte abnormalities were common; hypophosphatemia, hypokalemia, and hyponatremia occurred in 75%, 56%, and 51% of patients, respectively.

Limitations: Small sample size; AKI adjudicated by retrospective chart review; lack of biopsy data.

Conclusions: In this case series of patients with diffuse large B-cell lymphoma receiving CAR-T therapy, AKI and electrolyte abnormalities occurred commonly in the context of cytokine release syndrome.

Keywords: Chimeric antigen receptor T-cell (CAR-T); acute kidney injury (AKI); adverse event; case series; cytokine release syndrome; diffuse large B-cell lymphoma (DLBCL); electrolyte abnormalities; hypokalemia; hyponatremia; hypophosphatemia; immunotherapy; nephrotoxicity; pre-renal azotemia; renal failure.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Acute Kidney Injury / blood*
  • Acute Kidney Injury / etiology
  • Acute Kidney Injury / immunology
  • Aged
  • Female
  • Humans
  • Immunotherapy, Adoptive / adverse effects*
  • Immunotherapy, Adoptive / trends
  • Lymphoma, Large B-Cell, Diffuse / blood*
  • Lymphoma, Large B-Cell, Diffuse / immunology
  • Lymphoma, Large B-Cell, Diffuse / therapy*
  • Male
  • Middle Aged
  • Water-Electrolyte Balance / physiology
  • Water-Electrolyte Imbalance / blood*
  • Water-Electrolyte Imbalance / etiology
  • Water-Electrolyte Imbalance / immunology