ABSTRACT
Introduction: Inclusion of patients with kidney disease in COVID vaccine trials remains low. It is important to report association of disease exacerbation so that patients may undergo post vaccination monitoring. We hereby present a case of worsening IgA nephropathy temporarily associated with COVID vaccination Case Description: 63-year-old Hispanic female with past medical history of hypertension, psoriatic arthritis presented to the hospital with gross hematuria for 6 weeks starting 3 days after 2nd dose of Pfizer COVID vaccine. Her PCP had sent her to ER 5 days after onset of hematuria as had noted a creatinine (Cr) of 1.6 with 3+ protein and >20 RBCs on urinalysis suspicious for nephritic syndrome. On review she had serum Cr of 0.5 about 4 months ago with no proteinuria or hematuria before. In the ER she was given antibiotics for urinary tract infection and outpatient referral for nephrology. She could not make the outpatient appointment and with continued gross hematuria for a month, she presented to the ER again where she was noted to have Cr of 10 mg/dl and urine protein:cr ratio of 7.3gm/gm. Renal imaging including CT urogram was normal. Renal biopsy showed IgA nephropathy, M1S0E0T1C1 with a fibrocellular crescent and acute tubular necrosis likely secondary to lyzed red cells in setting of multiple RBC casts in the tubules. She was put on 250 mg Solumedrol for 3 doses followed by 1 mg/kg of Prednisone with eventual downtrend in Cr to 4.5 in 15 days. Discussion: There have been 2 cases reported in literature with known IgA nephropathy who developed gross hematuria post COVID 19 vaccination. SARS-COV 2 vaccines use nucleoside modified purified mRNA which does elicit higher neutralizing antibody titre and strong cluster of differentiation response leading to production of several proinflammatory cytokines. Thus, there is a concern that vaccines might exacerbate immune mediated glomerular diseases. IgA1 is involved in the pathogenesis of IgA nephropathy and patients with IgA nephropathy have higher than normal IgA1 response to other vaccines like influenza. Also while studying the antibody response to COVID 19 illness patients with IgA nephropathy are known to express higher IgA response compared to IgG and IgM along with reports of concurrent worsening of the glomerulonephritis. Nephrologists should closely follow patients with IgA nephropathy to establish the frequency of disease activation post vaccination.