A Case Series on Glomerular Disease Manifesting for the First Time after Covid 19 Vaccination

ABSTRACT

BACKGROUND: Different vaccines have been developed against SARS nCoV 19 and deployed in mass immunization campaigns across the world. In India, Covishield (ChAdOx1 nCoV-19) manufactured by Serum Institute of India) and Covaxin (BBV152) manufactured by Bharat Biotech are two such vaccines that have been made available. The former is a replication-deficient adenovirus vaccine while the latter is an inactivated whole virion vaccine. There has been many case reports of new onset or relapse of glomerular disease occurring after Covid-19 vaccination. This is attributed to heighten off target effect of immune response of the vaccine. AIM OF THE STUDY We present a case series of four patients where glomerular disease manifested for the first time after Covid-19 vaccination in our center. METHOD(S) We have included in our case series those patients whose clinical features manifested for the first time within 1 month of Covid-19 vaccination and whose renal biopsy showed glomerular pathology. RESULT(S) Case 1 A 12-year-old male presented to us with abrupt onset of edema leading to anasarca on 30/4/2022. He had received first dose of Covid-19 vaccine (Covaxin) on 26/4/2022. His labs showed urine protein of 3+ and nil RBC, serum creatinine 0.7 mg/dl, serum albumin 1.9 mg/dl, and dyslipidemia (total cholesterol 378 mg/dl, triglycerides 191 mg/ dl). He underwent renal biopsy in view of nephrotic syndrome. It was suggestive of minimal change disease. He was started on prednisolone at 2 mg/kg/day. Case 2 A 39-year-old female presented to us with abrupt onset of maculopapular rash, fever, and bilateral lower limb swelling on 25/1/2022. She had received second dose of Covid-19 vaccine (Covishield) on the same day in the morning. She was found to have hypertension with BP of 160/100 mm Hg. Her labs showed urine protein of 2+ and 18-20 RBC/high power field, serum creatinine 1.9 mg/dl, serum albumin 3.7 mg/dl, negative ANA and ANCA, and normal complement levels. She underwent renal biopsy in view of renal failure with active urinary sediments. It was suggestive of focal and segmental glomerulosclerosis (FSGS). Case 3 A 37-year-old male patient with history of hypertension (on irregular treatment) presented to us with history of gross hematuria without passage of clots in May 2022 about three days after receiving booster dose of Covishield vaccine. He did not have edema, rash, joint pain, or decreased urine output. His labs showed urine protein of 2+ and 5-6 RBC/high power field, serum creatinine 2.0 mg/dl, serum albumin 4.0 mg/dl, negative ANA and ANCA, and normal complement levels. He underwent renal biopsy in view of renal failure with active urinary sediments. It was suggestive of IgA nephropathy (M1E0S1T1C0). Case 4 An 18-year-old female with family history of nail patella syndrome presented to us with history of abrupt onset of edema of both lower limbs on 21/11/2021. She also had rash at the time of presentation. She had received first dose of Covid-19 vaccine (Covaxin) on 20/11/2021. Her labs showed urine protein of 2+ and numerous RBC/high power field, serum creatinine 1.4 mg/dl, serum albumin 2.98 mg/dl, negative ANA, and dsDNA and low complement levels (C3 14.1 mg/dl, C4 10.1 mg/dl both being low). She underwent renal biopsy in view of renal failure with active urinary sediments. It was suggestive of membranoproliferative glomerulonephritis (MPGN). She was started on prednisolone at 1 mg/kg/day. CONCLUSION(S) Different vaccines have different mechanisms of action, but their target remains the spike protein of the SARS Cov2 virus. Glomerular disease has mostly been reported with mRNA-based vaccines. Here we have reported glomerular disease occurring in close temporal relation to Covishield and Covaxin which have different mechanism of action. There have been reports of IgA nephropathy, minimal change disease and FSGS which manifested soon after vaccination. MPGN after Covid-19 vaccination is rarely seen. Thus, this case series shows that post- Covid vaccination glomerular disease can have varied pathologies.