ABSTRACT
Introduction: Renal disease in COVID-19 is often due to acute tubular injury but can include multiple glomerular lesions such as collapsing glomerulopathy. This is the first reported case of COVID-19-associated PGNMID. Case Description: A 71-year-old woman with normal baseline creatinine (Cr) was admitted with COVID-19 and discharged on oxygen and dexamethasone (Dex). She improved but returned a month later with edema and nausea. She was found to have nephrotic syndrome, hematuria, and AKI (peak Cr 8.5 mg/dL) requiring HD. Kidney biopsy revealed PGNMID with clonal IgG3-kappa. SPEP, serum free light chains (sFLC), 24h urine UPEP, bone marrow biopsy with flow cytometry, fat pad biopsy, and PET-CT were negative for monoclonal immunoglobulin (Ig) or cell line, amyloid, or malignancy. Though symptoms had long since resolved, she was still PCR-positive for SARS-CoV-2 on nasal swab. Upon discharge she was given cyclophosphamide (Cy). Her renal function improved (Cr 2.5) and she came off HD 2 weeks later. Her outpatient oncologist opted not to continue therapy. However, 2 months later she was readmitted with nausea, dyspnea, and anasarca with recurrent AKI (Cr 6.7) and nephrotic syndrome. HD was restarted. Repeat kidney biopsy [Figure] was noted to be a carbon copy of the first. SPEP, spot UPEP, and sFLC were again negative. She was started on Cy, bortezomib, and Dex with similar partial response (Cr <2.5). Discussion: PGNMID is a rare type of monoclonal gammopathy of renal significance (MGRS) that often has no detectable extrarenal monoclonal Ig or cell line. MGRS and PGNMID, though usually not postinfectious, have been reported with other viruses (e.g., viral hepatitis, parvovirus-B19). However, though causality is unclear, this is the first case of MGRS reported in association with COVID-19.
ABSTRACT
Background: Vaccination is considered safe in patients with chronic kidney disease. However, given the ability to activate the immune system, immunizations carry a risk of inducing inflammatory disease flares. The mass vaccination for SARS-CoV-2 provides a unique opportunity to investigate potential vaccine-associated glomerular diseases. Methods: Kidney biopsies from patients who presented with acute kidney injury (AKI) and/or nephritic/nephrotic syndrome within three weeks of SARS-CoV-2 vaccination were included in the study (n=16). Kidney biopsies were reviewed at a single center and clinical information was provided from nephrologists for clinicopathologic correlation. Results: Sixteen patients with a new onset of kidney disease or flare within 3 weeks of SARS-CoV-2 vaccination were identified and all had glomerular disease on biopsy. Eleven patients had two vaccine doses prior to symptom onset. The patient cohort included 6 males and 10 females, with a mean age of 58 years. Biopsy diagnoses included IgA nephropathy (n=7), minimal change disease (n=4), ANCA-associated glomerulonephritis (n=3), membranous glomerulopathy (n=1), and diffuse lupus nephritis (n=1). Thirteen patients had co-morbid medical conditions, including hypertension (n=10), diabetes mellitus (n=4), autoimmune disease (n=5), and chronic kidney disease (n=4). The most common clinical presentation was AKI with concurrent nephritic or nephrotic syndrome (n=9), followed by nephritic syndrome with preserved kidney function (n=5), nephrotic syndrome with preserved kidney function (n=1), and isolated hematuria (n=1). Three patients with AKI required dialysis. A majority of patients had an elevated serum creatinine (mean 3.4 mg/dL), 14 had proteinuria (nephrotic range in 4), 11 had hematuria, and 10 had hypoalbuminemia (mean 2.9 g/dL). Six patients had antinuclear antibodies and 4 had a positive ANCA serology at the time of biopsy. Clinical follow-up is ongoing. Conclusions: IgA nephropathy, minimal change disease, ANCA-associated glomerulonephritis, membranous glomerulopathy, and lupus nephritis were identified with temporal association with SARS-CoV-2 vaccination. In the setting of mass vaccination, causality is unclear, but a new onset of glomerular disease should be monitored as a potential adverse event.