ABSTRACT
Introduction: Collapsing FSGS (cFSGS) is associated with viral infections including HIV, parvovirus B19 and CMV. Recent reports describe cFSGS in patients infected with coronavirus (COVID-19). While reports on idiopathic cFSGS suggest early institution of steroids improves renal outcomes, there are little data to guide treatment of cFSGS associated with infection. We present a case of AKI with severe abrupt nephrotic syndrome in a COVID-19 patient with cFSGS on biopsy and a rapid response to steroids. Case Description: A 51 y/o black woman with no known medical history presented with 8 days of fever and SOB. COVID-19 testing was positive. Admission serum creatinine (sCr) was 3.2 mg/dL with an albumin of 2.6 g/dL. A urinalysis showed moderate blood and 3+ protein on dipstick along with granular casts. A urine albumin:Cr (UAC) ratio was 0.19 g/g. Despite volume resuscitation, her sCr continued to rise. Workup included negative HIV, hepatitis panel, and parvovirus B19. ANA, ANCA, anti-dsDNA, C3, and C4 were neg/nl. On day 5, she was afebrile with resolution of her symptoms, but sCr was further elevated at 5.3 mg/dL and albumin was 1.1 g/dL. Repeat UAC ratio was elevated over lab measurable range. A biopsy showed cFSGS and ATN. She was started on 60mg of prednisone/day. Two weeks later, her sCr was 2.9 mg/dL, albumin 2.4 g/dL and her UAC ratio was 3.0 g/g (Fig 1). Discussion: The optimal treatment for viral related cFSGS is unknown. Because diffuse foot process effacement typically accompanies this lesion, it is tempting to give steroids. However, there is concern that this may exacerbate the infection, and cFSGS may improve along with clearance of the virus. Still, steroids may hasten recovery and reduce morbidity associated with the nephrotic syndrome. The rapid improvement inproteinuria despite an increase in GFR suggests that steroids played a role in the recovery. A randomized trial would be necessary.
ABSTRACT
Background: Severe coronavirus disease 2019 (COVID-19) not only causes acute pulmonary pathology leading to acute respiratory distress syndrome needing intubation, but also leads to acute kidney injury (AKI) requiring renal replacement therapy (RRT). Due to hemodynamic instability, these patients (pts) often need either continuous RRT (CRRT) or prolonged intermittent RRT (PIRRT). Accelerated Veno-Venous Hemodialysis (AVVHD), a form of PIRRT with typically 40-50 liter of dialysate used over 8-10 hours has been successfully used to treat hemodynamically unstable pts. In the past, we have published extracorporeal circuit clotting (ECC) to be low (5%) even without anticoagulation. However as hypercoagulability is extreme with COVID-19, we noticed a marked increase in ECC. Unfractionated heparin (UFH) was the initial anticoagulation of choice during the early phase of the pandemic but was ineffective in preventing ECC, prompting a trial of low molecular weight heparin (LMWH). Methods: We conducted a single-center retrospective study to evaluate the efficacy and safety of LMWH vs UFH in preventing ECC in pts with AKI due to COVID-19 who received AVVHD from 3/25/20 through 4/30/20 at a large academic medical center. Data collected included pt demographics, type of anticoagulation and thrombolytic use, treatment characteristics including clotting frequency as well as bleeding complications. ECC was defined as any event that required an unexpected interruption in treatment or the use of thrombolytics. Results: A total of 58 pts received 408 AVVHD treatments. The average pt age was 58 years, 65% were male, 66% were black and 69% were obese with body mass index >;30 kg/m2. 188/408 (46%) of AVVHD treatments received anticoagulation with UFH while 165/408 (40%) of treatments received LMWH. ECC occurred in 30% of AVVHD treatments who received UFH vs 15% in the LMWH group, a relative risk reduction of 50% (P = 0.001). 47.1% pts who were on UFH had ECC on the first RRT treatment compared to 13.6% on LMWH (P = 0.01). Only 1 pt experienced a major bleeding event in the UFH group and none with LMWH. Conclusions: Anticoagulation with LMWH is superior to UFH in reducing ECC in pts receiving AVVHD for AKI due to COVID-19 without an increased risk of bleeding.