DOI: 10.12890/2025_005565
When is a kidney biopsy indicated during the treatment of brain cancer?
Authors
catarina.ors@gmail.com
Keywords
Bevacizumab, anti-VEGF, thrombotic microangiopathy, glomerular microangiopathy, gliosarcomaAbstract
Introduction: Bevacizumab is a monoclonal antibody that targets vascular endothelial growth factor (VEGF) and is widely used in oncology for its anti-angiogenic properties. However, VEGF inhibition may result in significant nephrotoxicity, including thrombotic microangiopathy (TMA). While systemic TMA is well-described, isolated renal-limited TMA remains under recognised.
Case description: We present a 46-year-old woman with WHO grade IV IDH-wildtype EGFR-amplified gliosarcoma. She received second-line treatment with bevacizumab and, after 12 months of therapy, developed progressive hypertension and nephrotic-range proteinuria up to 6.2 g/day, with normal renal function and without anaemia or thrombocytopenia. A kidney biopsy revealed glomerular microangiopathy, and a diagnosis of bevacizumab-associated renal-limited TMA was established. Given the stability of the intracranial disease, the drug was discontinued with complete resolution of proteinuria after seven months.
Conclusion: Anti-VEGF therapy causes renal TMA and may present with nephrotic-range proteinuria associated with a pattern of glomerular microangiopathy. Recognising anti-VEGF-associated nephrotoxicity is essential in the differential diagnosis of proteinuria in cancer patients, and kidney biopsy is fundamental for guiding clinical decisions. Drug cessation led to the complete resolution of proteinuria.
References
- Estrada CC, Maldonado A, Mallipattu SK. Therapeutic inhibition of VEGF signaling and associated nephrotoxicities. J Am Soc Nephrol 2019;30:187–200. doi: 10.1681/ASN.2018080853
- Padilha WSC, Cesar BN, Pacheco ST, De Sousa AA, Ledesma FL, Malheiros DMAC, et al. Bevacizumab-associated thrombotic microangiopathy treated with eculizumab: a case report. Am J Case Rep 2023;24:e940906. doi: 10.12659/AJCR.940906
- Person F, Rinschen MM, Brix SR, Wulf S, Noriega MLM, Fehrle W, et al. Bevacizumab-associated glomerular microangiopathy. Mod Pathol 2019;32:684–700. doi: 10.1038/s41379-018-0186-4
- Shimamura Y, Maeda T, Takizawa H. Bevacizumab-induced thrombotic microangiopathy and nephrotic syndrome. Clin Exp Nephrol 2019;23:142–143. doi: 10.1007/s10157-018-1596-9
- Izzedine H, Escudier B, Lhomme C, Pautier P, Rouvier P, Gueutin V, et al. Kidney diseases associated with anti-vascular endothelial growth factor (VEGF): an 8-year observational study at a single center. Medicine (Baltimore) 2014;93:333–339. doi: 10.1097/MD.0000000000000207. Erratum in: Medicine (Baltimore) 2014;93:414.
- Hull KL, Adenwalla SF, Topham P, Graham-Brown MP. Indications and considerations for kidney biopsy: an overview of clinical considerations for the non-specialist. Clin Med (Lond) 2022;22:34–40. doi: 10.7861/clinmed.2021-0472
- Kavanagh D, Ardissino G, Brocklebank V, Bouwmeester RN, Bagga A, Ter Heine R, et al. Forum Participants. Outcomes from the International Society of Nephrology Hemolytic Uremic Syndromes International Forum. Kidney Int 2024;106:1038–1050. doi: 10.1016/j.kint.2024.09.012
- Kozak KR, Mahadevan A, Moody JS. Adult gliosarcoma: epidemiology, natural history, and factors associated with outcome. Neuro Oncol 2009;11:183–191. doi: 10.1215/15228517-2008-076
- Bollée G, Patey N, Cazajous G, Robert C, Goujon JM, Fakhouri F, et al. Thrombotic microangiopathy secondary to VEGF pathway inhibition by sunitinib. Nephrol Dial Transplant 2009;24:682–685. doi: 10.1093/ndt/gfn657
- Robinson CH, Hart-Matyas M, Morgenstern DA, Noone D, Campisi P. Renal implications of long-term systemic bevacizumab for recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol 2024;133:119–123. doi: 10.1177/00034894231184942
