Corticosteroid treatment in a case of COVID-19-associated collapsing FSGS

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 albuminCr (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.