IgA Vasculitis Nephritis in a Patient With Alport Syndrome: An Association or a Just a Coincidence?

Introduction: Alport syndrome is a rare inherited disorder manifested by persistent microscopic hematuria, nephritis, sensorineural deafness, and ocular abnormalities. IgA nephropathy has been reported in a small percentage of patients with Alport syndrome, however, IgA vasculitis nephritis (IgA-VN) has not been reported. We report a rare case of Alport syndrome with crescentic IgA-VN. Case Description: A 48-year-old male with a history of deep vein thrombosis (on warfarin) was followed by nephrology clinic for chronic kidney disease (CKD). Due to concerns of risks associated with holding warfarin, genetic testing was done in lieu of kidney biopsy which was positive for a hemizygous pathogenic mutation in the X-linked COL4A5 gene for Alport Syndrome. He did not have any sensorineural deafness, ocular abnormalities, or a family history of kidney disease. He was admitted to the hospital for acute kidney injury (creatinine 14.6 mg/dL from a baseline of 2 mg/dL), nephrotic range proteinuria (microalbumin/creatinine ratio: 3,689 mg/g, normal < 200 mg/g) and microscopic hematuria. A full serological workup was unremarkable. He developed newonset bilateral lower extremity purpura which was biopsied showing leukocytoclastic IgA Vasculitis. Kidney biopsy showed IgA-dominant glomerulonephritis with 70% interstitial fibrosis and tubular atrophy, 80% crescents, and no electron microscopy findings suggestive of Alport Syndrome. Four days after the kidney biopsy, he was started on dialysis and immunosuppression (IV Methylprednisolone and Cyclophosphamide) after ruling out infection. He was discharged with a plan to continue immunosuppression and dialysis as an outpatient. Unfortunately, he developed COVID-19 prompting a delay in further immunosuppressive therapy. Discussion(s): Although extremely rare, mutations in the COL4A3, COL4A4, and COL4A5 genes have been implicated in cases of familial IgA Nephropathy and Alport Syndrome. We report a novel patient with IgA-VN and COL4A5 variant. It is unclear whether his underlying COL4A5 variant contributed to his severe presentation with IgAVN. Genome-wide association studies in patients with coexisting pathologies are needed to discover both diseases' possible common genetic connection.

COVID-19 in people living with diabetes: An international consensus.

The COVID-19 pandemic has added an enormous toll to the existing challenge of diabetes care world-wide. A large proportion of patients with COVID-19 requiring hospitalization and/or succumbing to the disease have had diabetes and other chronic conditions as underlying risk factors. In particular, individuals belonging to racial/ethnic minorities in the U.S. and other countries have been significantly and disproportionately impacted. Multiple and complex socioeconomic factors have long played a role in increasing the risk for diabetes and now for COVID-19. Since the pandemic began, the global healthcare community has accumulated invaluable clinical experience on providing diabetes care in the setting of COVID-19. In addition, understanding of the pathophysiological mechanisms that link these two diseases is being developed. The current clinical management of diabetes is a work in progress, requiring a shift in patient-provider interaction beyond the walls of clinics and hospitals: the use of tele-medicine when feasible, innovative patient education programs, strategies to ensure medication and glucose testing availability and affordability, as well as numerous ideas on how to improve meal plans and physical activity. Notably, this worldwide experience offers us the possibility to not only prepare better for future disasters but also transform diabetes care beyond the COVID-19 era.

Managing People with Diabetes Fasting for Ramadan During the COVID-19 Pandemic: A South Asian Health Foundation Update.

The month of Ramadan forms one of the five pillars of the Muslim faith. Adult Muslims are obligated to keep daily fasts from dawn to sunset, with exceptions. This year Ramadan is due to begin on 23 April 2020 and the longest fast in the UK will be approximately 18 hours in length. In addition, due to the often high-calorie meals eaten to break the fast, Ramadan should be seen as a cycle of fasting and feasting. Ramadan fasting can impact those with diabetes, increasing the risk of hypoglycaemia, hyperglycaemia and dehydration. This year, Ramadan will occur during the global COVID-19 pandemic. Reports show that diabetes appears to be a risk factor for more severe disease with COVID-19. In addition, the UK experience has shown diabetes and COVID-19 is associated with dehydration, starvation ketosis, diabetic ketoacidosis and hyperosmolar hyperglycaemic state. This makes fasting in Ramadan particularly challenging for those Muslims with diabetes. Here, we discuss the implications of fasting in Ramadan during the COVID-19 pandemic and make recommendations for those with diabetes who wish to fast.