# ICI-Associated AKI: Suspect AIN, Do Not Assume It

Do not label every creatinine rise as ICI nephritis or every biopsy pattern as inevitable. The explanation must fit the full clinical picture.

![Infographic: ICI-Associated AKI: Suspect AIN, Do Not Assume It](https://urinenephrology.org/visual-reference/images/mastery-ici-diagnosis.png?v=20261003c)

## Loss of immune restraint

Checkpoint inhibitors can provoke immune-mediated kidney injury. Acute interstitial nephritis is an important pattern, but other causes of AKI remain common.

## Review the timeline

Cancer therapy, other immune adverse events, acid suppressants, antibiotics, NSAIDs, dehydration, and infection all inform the differential.

## Do not diagnose from pyuria alone

Compare creatinine with baseline and assess perfusion, infection, obstruction, recent contrast, other drugs, urine sediment, and protein quantity. Pyuria or an extrarenal immune adverse event supports suspicion but does not prove ICI-AIN. Heavy proteinuria or RBC casts should redirect attention toward a glomerular lesion.

## Use tissue to avoid the wrong treatment

When competing causes remain plausible and the result would change steroids or cancer therapy, discuss kidney biopsy with oncology and nephrology. Tubular injury, AIN, TMA, and GN have different implications. Document why empirical treatment or biopsy is preferred in this patient.

## Coordinate oncology and nephrology

Balance kidney recovery, diagnostic confidence, cancer control, and treatment toxicity. Review unnecessary potential nephritogenic drugs.

## Avoid categorical shortcuts

Do not label every creatinine rise as ICI nephritis or every biopsy pattern as inevitable. The explanation must fit the full clinical picture.

## Source lessons

- [ici diagnosis pathology](https://urinenephrology.org/mastery/onconephrology/ici-diagnosis-pathology.html)
- [ici nephrotoxicity](https://urinenephrology.org/mastery/onconephrology/ici-nephrotoxicity.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.