key: cord-0728369-a8ry8ai9
authors: Sethi, Sanjeev; D’Costa, Mathew R.; Hermann, Sandra M.; Nasr, Samih H.; Fervenza, Fernando C.
title: Immune-complex glomerulonephritis following COVID-19 infection
date: 2021-02-12
journal: Kidney Int Rep
DOI: 10.1016/j.ekir.2021.02.002
sha: 95bf0b77976d25a2d6906de2e20c32962c3aa948
doc_id: 728369
cord_uid: a8ry8ai9

nan

Acute kidney injury is frequently present in Sars CoV-2 infection . 1 In addition, many COVID-19 positive patients also develop proteinuria and collapsing glomerulopathy. [2] [3] [4] We recently encountered a kidney biopsy showing an immune complex-glomerulonephritis (GN) following a recent COVID-19 infection. To the best of our knowledge, an immune-complex glomerulonephritis (GN) has not been described in the setting of COVID-19 infection.

A 25-year old young white woman with a history of genetic FSGS secondary to a SMARCAL1 gene mutation and baseline serum creatinine of 0.98 mg/dl, serum albumin 3.5 g/dl, proteinuria of 3.7g/24h and a creatinine clearance of 83 ml/min/1.73m 2 , was admitted on 11/7/2020 to our hospital with diarrhea secondary to Shiga toxin-producing E coli O157:H7, associated hemolytic uremic syndrome (HUS), seizures, encephalopathy, and acute kidney injury requiring hemodialysis from admission to 11/16/20. On admission, she was also found to be positive for Sars CoV-2 (COVID-19). Laboratory results are presented on Table 1 . Due to the severity of her HUS she received two doses of eculizumab 900 mg IV, one week apart. She was discharged on 12/4/20 and seen in clinic on 12/9/20. Her creatinine had decreased to 2.4 mg/dl, but serum albumin had decreased to 2.5 g/dl and proteinuria had increased to 13 g/24h.

Due to the unusual course of her renal disease, a kidney biopsy was performed.

The kidney biopsy showed a membranoproliferative (MPGN) pattern of injury. There were 14 glomeruli present, of which 6 (43%) were globally sclerosed. The glomeruli showed both mesangial and endocapillary hypercellularity, with lobular accentuation of the glomerular capillary tufts. The capillary walls were thickened and showed double contour formation. In some of the loops large wire-loop type subendothelial deposits and intraluminal hyaline immune microthrombi were present. There was no evidence of crescents, fibrinoid necrosis or thrombosis. The tubulointerstitium showed acute tubular injury and moderate interstitial 

The patient was treated with methylprednisolone 750 mg IV, followed by oral prednisone 50 mg a day, and oral mycophenolate mofetil 500 mg twice daily. However, when seen in clinic on J o u r n a l P r e -p r o o f 1/6/21 her serum creatinine had increased to 3.2 mg/dL, serum albumin was 2.3 g/dL, and proteinuria was 7.2 g/24 hours (Table 1 ). The short term follow-up does not allow us to fully ascertain the response to immunosuppression therapy. Panel B. Immunofluorescence microscopy shows bright staining for all immunoglobulins and complement proteins. Immunofluorescence studies showing bright 3+ granular staining for IgG, IgA, IgM, C1q, C3, C4d, kappa and lambda light chains.

Acute kidney injury in patients hospitalized with COVID-19

Postmortem Kidney Pathology Findings in Patients with COVID-19

COVAN is the new HIVAN: the re-emergence of collapsing glomerulopathy with COVID-19

Kidney Biopsy Findings in Patients With COVID-19, Kidney Injury, and Proteinuria

Membranoproliferative Glomerulonephritis: A New Look at an Old Entity

Histopathologic and Ultrastructural Findings in Postmortem Kidney Biopsy Material in 12 Patients with AKI and COVID-19

COVID-19-Associated Kidney Injury: A Case Series of Kidney Biopsy Findings

Kidney Biopsy Findings in Patients with COVID-19

HIV-associated immune complex glomerulonephritis with "lupus-like" features: a clinicopathologic study of 14 cases

The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection

Clinical characteristics and outcomes of HIVassociated immune complex kidney disease

Differentiating Primary, Genetic, and Secondary FSGS in Adults: A Clinicopathologic Approach

Teaching points 1. Immune-complex/Ig-mediated GN with a membranoproliferative pattern of injury are usually secondary to infections, autoimmune diseases and monoclonal gammopathy 2. Infections include hepatitis C, HIV, and autoimmune diseases include lupus. 3. Acute tubular injury and collapsing glomerulopathy have been described in COVID-19 infection. 4. COVID-19 infection may also present with an immune complex-mediated GN.