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Erschienen in: BMC Nephrology 1/2022

Open Access 01.12.2022 | COVID-19 | Case report

IgA nephropathy relapse following COVID-19 vaccination treated with corticosteroid therapy: case report

verfasst von: Shota Watanabe, Shuling Zheng, Arash Rashidi

Erschienen in: BMC Nephrology | Ausgabe 1/2022

Abstract

Background

The flare of immune-mediated disease following coronavirus disease of 2019 (COVID-19) vaccination is a rare adverse event following immunization. De novo, as well as relapsing IgA nephropathy (IgAN) cases, have been reported following either mRNA-1273 (Moderna) or BNT162b2 (Pfizer-BioNTech) vaccination. To our knowledge, the majority of IgAN relapses did not result in severe acute kidney injury (AKI) and resolved spontaneously.

Case presentation

This is a case of a 54-year-old female with a previous diagnosis of IgAN who developed IgAN relapse following the second dose of Moderna vaccine. Gross hematuria developed 2 days after vaccination, which was accompanied by significant AKI. Kidney biopsy showed mild tubular atrophy and IgA staining in mesangium without crescent formation. Significant improvement in serum creatinine (Cr) was observed on day 10 after initiating prednisone. Cr came back to normal within 3 months after initiating corticosteroid.

Conclusion

COVID-19 vaccination is associated with a flare of IgAN that may cause significant AKI. Steroid therapy is associated with recovery. IgAN flare after COVID-19 vaccination should be closely monitored to elucidate any adverse effect associated with the novel vaccine.
Begleitmaterial
Hinweise

Supplementary Information

The online version contains supplementary material available at https://​doi.​org/​10.​1186/​s12882-022-02769-9.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abkürzungen
AKI
Acute kidney injury
COVID-19
Coronavirus disease of 2019
Cr
Creatinine
eGFR
Estimated glomerular filtration rate
HPF
High-power field
IgAN
IgA nephropathy
IMD
Immune-mediated disease
RBC
Red blood cell
SLE
Systemic lupus erythematous

Background

The flare of immune-mediated disease (IMD) following coronavirus disease of 2019 (COVID-19) vaccination is a rare adverse event following immunization. Previous studies reported flare-up of various IMDs, such as rheumatoid arthritis, systemic lupus erythematosus (SLE), Behcet’s disease, psoriasis, vasculitis, sarcoidosis, and multiple sclerosis [14]. De novo, as well as relapsing IgA nephropathy (IgAN) cases, have been reported following either mRNA-1273 (Moderna) or BNT162b2 (Pfizer-BioNTech) vaccination [510]. The majority of relapsed IgAN in previous reports did not result in severe acute kidney injury (AKI) and resolved without intervention (Table 1). However, Plasse et al. reported an IgAN relapse following the second dose of Pfizer vaccine, which caused significant AKI and subnephrotic range proteinuria. Kidney biopsy was not reported. AKI resolved 1 month after starting steroid therapy, and proteinuria returned to baseline level within 2 months [11]. Here we report an IgAN relapse with significant AKI after administration of Moderna vaccine, which resolved after initiating steroid therapy. Renal biopsy was performed to rule out other de-novo glomerulonephropathies.
Table 1
IgAN relapses following COVID-19 vaccination
Author
Age (Years)
Sex
Manufacture
Dose (1st/2nd)
Time between vaccine and onset (days)
Presentation
Pathology
Treatment
Response
Gul Rahim
52
F
Pfizer
2nd
 < 1
GH, AKI
N/A
None
Remission of GH in less than 1 week
Negrea
38
F
Pfizer
2nd
 < 1
GH, SRP
N/A
None
Remission of GH after 3 days
38
F
Pfizer
2nd
 < 1
GH
N/A
None
Remission of GH after 3 days
Perrin
22
M
Moderna
1st
2
GH
N/A
None
Remission of GH
41
F
Pfizer
1st
2
GH
N/A
None
Remission of GH
27
F
Pfizer
2nd
2
GH
N/A
None
Remission of GH
Plasse
N/A
N/A
Pfizer
2nd
5 to 6
GH, SRP, AKI
N/A
Corticosteroids
Remission of GH, AKI after 1 month, SRP within 2 months
N/A
N/A
Pfizer
2nd
1
GH
N/A
None
Remission of GH after 3 days
This Case
54
F
Moderna
2nd
2
GH, SRP, AKI
Active IgAN
Corticosteroids
Remission of GH after 2 days, AKI in 3 months
Abbreviations: AKI Acute Kidney Injury, GH Gross Hematuria, SRP Subnephrotic Range Proteinuria

Case presentation

A 54-year-old, Caucasian female with history of IgAN after strep throat infection that was diagnosed with renal biopsy in 2006. Other significant co-morbidity includes obesity (BMI 31.6), hypertension, and GERD. She had no prior documented infection with COVID-19. She was on enalapril 20 mg daily, hydrochlorothiazide 12.5 mg daily, and propranolol 120 mg daily. Her baseline creatinine level (Cr) was 1.2 (eGFR 46 mL/min/1.73m2). Urinalysis was positive for 2 + protein, 3 + blood, and red blood cell (RBC) 15 /high-power field (HPF). The total urine protein to Cr ratio was 1.03.
Two days after receiving the second Moderna vaccine, she developed gross hematuria that resolved spontaneously after 2 days. Vital sign upon examination: body temperature 36.5 °C, blood pressure 122/88 mmHg, heart rate 78 beats/minute. Physical exam was unremarkable without lower extremity edema. Follow-up Cr increased to 3.04 (eGFR 16 mL/min/1.73m2) approximately one week after vaccination. The urinalysis showed 1 + protein, 3 + blood, RBC 50/ HPF. The total urine protein to Cr ratio was 0.67. The renal ultrasound was unremarkable. Repeat kidney biopsy showed mild interstitial fibrosis and tubular atrophy without crescent formation (Fig. 1a). Immunofluorescence analysis showed weak IgA staining in mesangium (Fig. 1b). IgG staining was negative (Fig. 1c). Electron microscopy revealed some mesangial electron-dense deposits (Fig. 1d). Differential diagnosis included IgAN relapse, other de-novo glomerulonephropathies, urinary tract hemorrhage with obstruction, and urinary tract infection, among other causes of hematuria and AKI; however, given her history and kidney biopsy result, IgAN relapse was thought to be the most likely cause.
She was started on prednisone 60 mg daily. Cr level improved to 1.9 after 10 days, at which point prednisone was decreased to 40 mg daily. Thereafter prednisone was tapered down gradually over 2 months. Serum Cr recovered to 1.07 approximately 3 months after starting the steroid therapy. Patient tolerated the treatment without significant adverse effect.

Discussion

Here we report a case of IgAN relapse with significant AKI following COVID-19 vaccination that resolved after initiating steroid therapy. In accord with previously reported cases, gross hematuria occurred within a week after vaccination and resolved without intervention. The natural course of AKI due to IgAN following COVID-19 vaccination is unknown, but this case took a longer period for AKI to resolve compared to the case reported by Plasse et al. [11]. The efficacy of steroid therapy remains inconclusive; nevertheless, AKI seems to be reversible as in the cases thar are not related to COVID-19 vaccination. The previous retrospective study conducted by Kveder et al. in 2009, involving 584 adult patients, showed that all cases of AKI associated with IgAN and macroscopic hematuria resolved at a median follow-up of 15 months regardless of treatment status [12].
The pathogenesis of IgAN flare-up after COVID-19 vaccination is yet to be elucidated. The RNA vaccine has been shown to elicit antigen-specific, CD4+ and CD8+ T-cell responses producing multiple cytokines, including Interferon-ɣ, Tumor necrosis factor-α, and Interleukin-2 in animal studies [13]. A previous study showed early serum IgA rise after COVID-19 vaccination [14]. Hyperresponsiveness of IgA1 antibody was documented among those who developed IgAN flare following flu vaccine [15]. Similarly, COVID-19 vaccination may induce IgAN flare via IgA1 hyperresponsiveness to systemic cytokine.

Conclusion

IgAN relapse with significant AKI is associated with COVID-19 vaccination, and systemic steroid therapy is associated with recovery. IgAN exacerbation after COVID-19 vaccination should be closely monitored to elucidate any adverse effect related to the novel vaccine.

Acknowledgements

The part of this manuscript has been presented as a poster presentation during Kidney Week 2021 organized by American Society of Nephrology.

Declarations

Ethics approval was waived as consent for publication was obtained from the patient in this case report.
Written consent for publication has been obtained from the patient.

Competing interests

The authors declare that they have no competing interests.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Anhänge

Supplementary Information

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Metadaten
Titel
IgA nephropathy relapse following COVID-19 vaccination treated with corticosteroid therapy: case report
verfasst von
Shota Watanabe
Shuling Zheng
Arash Rashidi
Publikationsdatum
01.12.2022
Verlag
BioMed Central
Schlagwörter
COVID-19
COVID-19-Impfung
Erschienen in
BMC Nephrology / Ausgabe 1/2022
Elektronische ISSN: 1471-2369
DOI
https://doi.org/10.1186/s12882-022-02769-9

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