Nephrotic syndrome with sunitinib-associated focal segmental glomerulosclerosis in a patient with renal carcinoma: partial reversibility after dose adjustment

Case Report.

Abstract

Introduction: Vascular endothelial growth factor (VEGF) is produced by podocytes and helps maintain the endothelial structure and the glomerular filtration barrier. Inhibition of VEGF, used in cancer treatment with sunitinib, can cause kidney side effects. These include high blood pressure, proteinuria, and sometimes structural damage such as focal segmental glomerulosclerosis.

Case report: A 78-year-old woman with a history of high blood pressure, asthma, hypothyroidism, and deep vein thrombosis. In November 2022, an active bone lesion was detected in the left femur. The biopsy confirmed metastatic tubular clear cell adenocarcinoma, consistent with a primary renal tumor. A right radical nephrectomy was performed, and palliative treatment with Sunitinib was initiated, later adjusted to a schedule of 2 weeks on treatment and 1 week off due to toxicity. The patient also received cervical radiotherapy and placement of a prosthesis in the left femur. During oncological follow-up, progressive edema and anasarca were observed. Renal biopsy reported lesions with focal and segmental glomerulosclerosis.

Treatment: Treatment was started with valsartan 80 mg QD, intravenous furosemide, and subsequently rotated to indapamide, statin, and sodium glucose cotransporter inhibitor type 2 with dapaglifozin 10 mg once daily. The dose of sunitinib was decreased to 50% (25 mg once daily).

Evolution: A favorable evolution of the clinical picture was evidenced with progressive improvement of peripheral edema, decreased proteinuria, and azotemia.

Conclusions: In this case of glomerulopathy induced by VEGF inhibitors, the use of ARBs II and SGLT2 inhibitors may contribute to preserving renal function and promoting the continuity of cancer treatment.