Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jun 16, 2021; 9(17): 4415-4422
Published online Jun 16, 2021. doi: 10.12998/wjcc.v9.i17.4415
Efficacy of artificial liver support system in severe immune-associated hepatitis caused by camrelizumab: A case report and review of the literature
You-Wen Tan, Li Chen, Xing-Bei Zhou
You-Wen Tan, Li Chen, Xing-Bei Zhou, Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang 212003, Jiangsu Province, China
Author contributions: Tan YW and Chen L designed the research; Zhou XB collected and analyzed the data, and drafted the manuscript; Tan YW wrote and revised the manuscript; all authors have read and approved the final version to be published.
Informed consent statement: Informed consent was obtained from the patient.
Conflict-of-interest statement: All authors have no conflict of interest related to the manuscript.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: You-Wen Tan, MD, Chief Doctor, Professor, Department of Hepatology, The Third Hospital of Zhenjiang Affiliated Jiangsu University, No. 300 Danjiamen, Runzhou District, Zhenjiang 212003, Jiangsu Province, China. tyw915@sina.com
Received: February 4, 2021
Peer-review started: February 4, 2021
First decision: February 24, 2021
Revised: February 27, 2021
Accepted: March 25, 2021
Article in press: March 25, 2021
Published online: June 16, 2021
Processing time: 111 Days and 8.4 Hours
Abstract
BACKGROUND

Immune checkpoint inhibitors (ICIs) can lead to immune-related hepatitis (IRH) and severe liver damage, which is life-threatening in the absence of specific treatment.

CASE SUMMARY

A 75-year-old man was admitted to our hospital complaining of loss of appetite, yellow urine, and abnormal liver function for the past 2 wk. Three months prior to admission, he was treated with two rounds of capecitabine in combination with camrelizumab for lymph node metastasis of esophageal cancer. Although liver function was normal before treatment, abnormal liver function appeared at week 5. Capecitabine and camrelizumab were discontinued. Ursodeoxycholic acid and methylprednisolone 40 mg daily were administered. Liver function continued to deteriorate. Prothrombin time and international normalized ratio were 19 s and 1.8, respectively. The patient was diagnosed with acute liver failure. A pathological analysis of liver biopsy indicated a strongly positive immunohistochemical staining of T8+ cells, thereby suggesting that drug-induced liver injury was related to IRH caused by camrelizumab. Subsequently, we performed sequential dual-molecule plasma adsorption system (DPMAS) treatment with plasma exchange (PE). After two rounds of treatment, the patient's appetite significantly improved, the yellow color of urine reduced, and liver function improved (total bilirubin level decreased) after five rounds of treatment. Liver function normalized 4 wk after discharge.

CONCLUSION

The use of sequential DPMAS with PE can reduce liver injury and systemic toxic reactions by clearing inflammatory mediators and harmful substances from blood, and regulate immune cell activity, which may be effective in the treatment of severe ICI-induced IRH.

Keywords: Plasma exchange; Dual plasma molecular adsorption system; Immune checkpoint inhibitors; Immune-associated hepatitis; Case report

Core Tip: Immune checkpoint inhibitors can lead to immune-associated hepatitis and severe liver damage that can be life-threatening without specific treatment. Corticosteroids and immunosuppressants do not show sufficient sensitivity and their use often leads to serious complications such as severe secondary infections. Here we report a case of severe liver damage caused by death protein 1 inhibitors and the first use of dual-molecule plasma adsorption combined with plasma exchange to achieve satisfactory results. In addition, the clinical biochemical indicators in this case were sufficient for diagnosing acute liver failure, while pathology provided an accurate diagnosis. Pathological diagnosis is a very important diagnostic tool for severe liver injury.