Symptom Grade

Grade 1

Creatinine 1.5 x baseline or > ULN-1.5x ULN

Grade 2

Creatinine > 1.5 – 3x baseline or > 1.5 – 3x ULN

Grade 3

Creatinine > 3x baseline or > 3 – 6x ULN

Grade 4

Creatinine > 6x

Management escalation pathway

Continue ICPI Repeat creatinine weekly When worsening, manage as per criteria below Withhold ICPI; hydration and review creatinine in 48h72h; if not improving, discuss with nephrologist and need for biopsy and if attributed to irAE, initiate steroid

Oral prednisolone 1mg/kg

When returning to Grade 1 or baseline: restart ICPi

If on steroids, only once < 10mg prednisolone

If not attributes to irAE: continue ICPi

Withhold ICPI; admit patient for monitoring and fluid balance; repeat creatinine every 24h; early discussion with nephrologist and need for biopsy; when worsening. initiate i.v. (methyl)prednnisolone 2 mg/kg As per Grade 3; patient should be managed in hospital where renal replacement therapy is available

Assessment and Investigations

Review hydration status, As for Grade 2 medications, urine test, culture if urinary tract infection symptoms

Dipstick urine and send for protein assessment UPCR

If obstruction suspected: renal US +/- doppler to exclude obstructions or a clot

As above Renal ultrasound +/- doppler to exclude obstructions or a clot

If proteinuria: 24h collection or UPCR

Advise patient to notify if oliguric

As for Grade 2

Consider renal biopsy

As for Grade 2


US: Ultra Sound
ULN: Upper Limit of Normal
ICPi: Immune Checkpoint Blockade Inhibition
UPCR: Urine Protein to Creatinine Ratio
ANCA: Anti Neutrophil Cytoplasmic Antibody
CRP: C Reactive Protein
RF: Rheuma Factor
ACPA: Anti Citrullinated Protein Antibody
ESR: Erythrocyte Sedimentatio Rate