Would you offer adjuvant immunotherapy in a patient with high risk RCC with new/worsening post-op renal dysfunction and CrCl<30?

My preference in situations like this is to stabilize the renal function first. I am comfortable treating the patient with adjuvant pembrolizumab with a CrCl <30 mL/min but it should be stabilized first. That will make it easier to diagnose potential irAEs as compared to starting adjuvant treatment now in the setting of some ongoing, worsening comorbid condition such as heart failure or whatever is driving the worsening renal function.

This has not been extensively studied, but a few case series suggest it is safe to use checkpoint inhibitors in patients with significant organ dysfunction such as ESRD (Bekku et al., PMID 37278602, Johnson et al., PMID 28241095, Li et al., PMID 35626064).

My major concern is that the patient has very limited ...