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Li L, Zhou T, Lu Y, Chen J, Lei Y, Wu Q, Arnold J, Becich MJ, Bisyuk Y, Blecker S, Chrischilles E, Christakis DA, Geary CR, Jhaveri R, Lenert L, Liu M, Mirhaji P, Morizono H, Mosa ASM, Onder AM, Patel R, Smoyer WE, Taylor BW, Williams DA, Dixon BP, Flynn JT, Gluck C, Harshman LA, Mitsnefes MM, Modi ZJ, Pan CG, Patel HP, Verghese PS, Forrest CB, Denburg MR, Chen Y. Post-acute and Chronic Kidney Function Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Initiative. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.25.24309488. [PMID: 38978683 PMCID: PMC11230320 DOI: 10.1101/2024.06.25.24309488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
We investigated the risks of post-acute and chronic adverse kidney outcomes of SARS-CoV-2 infection in the pediatric population via a retrospective cohort study using data from the RECOVER program. We included 1,864,637 children and adolescents under 21 from 19 children's hospitals and health institutions in the US with at least six months of follow-up time between March 2020 and May 2023. We divided the patients into three strata: patients with pre-existing chronic kidney disease (CKD), patients with acute kidney injury (AKI) during the acute phase (within 28 days) of SARS-CoV-2 infection, and patients without pre-existing CKD or AKI. We defined a set of adverse kidney outcomes for each stratum and examined the outcomes within the post-acute and chronic phases after SARS-CoV-2 infection. In each stratum, compared with the non-infected group, patients with COVID-19 had a higher risk of adverse kidney outcomes. For patients without pre-existing CKD, there were increased risks of CKD stage 2+ (HR 1.20; 95% CI: 1.13-1.28) and CKD stage 3+ (HR 1.35; 95% CI: 1.15-1.59) during the post-acute phase (28 days to 365 days) after SARS-CoV-2 infection. Within the post-acute phase of SARS-CoV-2 infection, children and adolescents with pre-existing CKD and those who experienced AKI were at increased risk of progression to a composite outcome defined by at least 50% decline in estimated glomerular filtration rate (eGFR), eGFR <15 mL/min/1.73m2, End Stage Kidney Disease diagnosis, dialysis, or transplant.
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Affiliation(s)
- Lu Li
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Ting Zhou
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Yiwen Lu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiajie Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Yuqing Lei
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Qiong Wu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan Arnold
- Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Michael J. Becich
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yuriy Bisyuk
- Office of Research, University Medical Center New Orleans, New Orleans, LA
| | - Saul Blecker
- Department of Population Health, NYU Grossman School of Medicine
| | | | - Dimitri A Christakis
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, WA 98105, USA
| | - Carol Reynolds Geary
- Department of Pathology, Microbiology, and Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Leslie Lenert
- Biomedical Informatics Center, Medical University of South Carolina
| | - Mei Liu
- Department of Health Outcomes and Biomedical Informatics, University of Florida, College of Medicine
| | - Parsa Mirhaji
- Albert Einstein College of Medicine, Bronx, NY 10461
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children’s National Hospital, Washington DC
| | | | - Ali Mirza Onder
- Division of Pediatric Nephrology, Nemours Children’s Hospital, Wilmington, DE
| | - Ruby Patel
- Division of Pediatric Nephrology, Stanford Medicine Children’s Health, Palo Alto, CA
| | - William E. Smoyer
- Center for Clinical and Translational Research, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University
| | - Bradley W. Taylor
- Clinical and Translational Science Institute, The Medical College of Wisconsin, Milwaukee, WI 53226
| | | | - Bradley P. Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | - Caroline Gluck
- Nemours Children’s Health, Division of Pediatric Nephrology, Wilmington, DE
| | | | - Mark M Mitsnefes
- Cincinnati Children’s Hospital medical Center and University of Cincinnati
| | - Zubin J. Modi
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Cynthia G. Pan
- Department of Pediatrics, Section of Nephrology, Medical College of Wisconsin
| | - Hiren P. Patel
- Nationwide Children’s Hospital
- Ohio State University College of Medicine
| | - Priya S. Verghese
- Ann & Robert H Lurie Children’s Hospital
- Northwestern University, Feinberg School of Medicine
| | - Christopher B. Forrest
- Applied Clinical Research Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle R. Denburg
- Division of Pediatric Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Yong Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
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Özdemir Yalçınsoy K, Güngör A, Karakaya D, Özdal L, Kılıç M, Özdamar Erol Y, Çakar Özdal P. Tubulointerstitial Nephritis and Uveitis Syndrome During the COVID-19 Pandemic: A Case Series. Turk J Ophthalmol 2024; 54:5-10. [PMID: 38385308 PMCID: PMC10895161 DOI: 10.4274/tjo.galenos.2023.24280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/05/2023] [Indexed: 02/23/2024] Open
Abstract
Objectives To report the ocular findings, laboratory results, and management of patients with tubulointerstitial nephritis and uveitis syndrome (TINU), whose numbers increased during the 2019 coronavirus disease (COVID-19) pandemic. Materials and Methods Demographic characteristics, ophthalmic examination findings, laboratory results including polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), serum SARS-CoV-2 immunoglobulin G (IgG) antibody, and treatment of patients diagnosed with TINU between March 2020 and March 2022 were evaluated retrospectively. Results The study included 19 eyes of 10 patients (6 female/4 male). The mean age was 13.5±2.4 years (range: 8-16 years). The mean follow-up duration was 13.5±6.1 months (range: 6-24 months). All patients presented with anterior uveitis. Anterior uveitis was bilateral in 9 patients (90%) and unilateral in 1 patient (10%). Posterior segment findings were normal in 8 patients (80%), and bilateral optic disc edema was observed in only 2 patients (20%). None of the patients had a previous SARS-CoV-2 infection and/or vaccination history. The SARS-CoV-2 PCR test was negative in all patients at presentation. The SARS-CoV-2 IgG antibody test was reactive in 7 patients (70%). Recurrent uveitis developed in 8 patients (80%) during follow-up. Systemic immunomodulatory therapy was required for the control of ocular inflammation in 7 patients (70%) with severe uveitis flare-ups. Conclusion TINU is a multisystemic autoimmune disease, especially in response to environmental triggering factors such as viral infections. Although TINU is a rare disease, the number of cases increased during the COVID-19 pandemic. SARS-CoV-2 antibodies were detected at a significant rate of 70% in these patients, who did not have a history of SARS-CoV-2 infection and vaccination. Previous asymptomatic SARS-CoV-2 infection in children may be a triggering factor in the development of TINU.
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Affiliation(s)
- Kübra Özdemir Yalçınsoy
- University of Health Sciences Türkiye, Ulucanlar Eye Training and Research Hospital, Clinic of Ophthalmology, Ankara, Türkiye
| | - Anıl Güngör
- University of Health Sciences Türkiye, Ulucanlar Eye Training and Research Hospital, Clinic of Ophthalmology, Ankara, Türkiye
| | - Deniz Karakaya
- University of Health Sciences Türkiye, Ankara Dr. Sami Ulus Child Health and Diseases Training and Research Hospital, Clinic of Pediatric Nephrology, Ankara, Türkiye
| | - Levent Özdal
- University of Health Sciences Türkiye, Ankara City Hospital, Clinic of Urology, Ankara, Türkiye
| | - Meltem Kılıç
- University of Health Sciences Türkiye, Ankara City Hospital, Clinic of Ophthalmology, Ankara, Türkiye
| | - Yasemin Özdamar Erol
- University of Health Sciences Türkiye, Ulucanlar Eye Training and Research Hospital, Clinic of Ophthalmology, Ankara, Türkiye
| | - Pınar Çakar Özdal
- University of Health Sciences Türkiye, Ulucanlar Eye Training and Research Hospital, Clinic of Ophthalmology, Ankara, Türkiye
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El-Halaby H, Eid R, Elagamy A, El-Hussiny A, Moustafa F, Hammad A, Zeid M. A retrospective analysis of acute kidney injury in children with post-COVID-19 multisystem inflammatory syndrome: insights into promising outcomes. Ital J Pediatr 2024; 50:23. [PMID: 38317228 PMCID: PMC10845792 DOI: 10.1186/s13052-024-01598-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/21/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Acute kidney injury (AKI) in patients with multisystem inflammatory syndrome (MIS), COVID-19 related infection has been increasingly recognized with a paucity of data on AKI incidence, related mortality, and the requirement of renal replacement therapy in children with MIS (MIS-C). METHODS This is a retrospective study evaluating the prevalence, severity, management and outcomes of AKI in a cohort of Egyptian children with MIS-children (MIS-C) post-COVID infection. Patients were included if they met the criteria for MIS-C based on CDC guidelines. All patients were evaluated for AKI diagnosis and staging according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS Between March 2021 and June 2023, a total of 655 confirmed COVID-19 cases were admitted and then followed up in our hospital, of whom 138 (21%) were diagnosed with MIS-C. Fifty-one patients developed AKI associated with MIS-C post-COVID infection, 42 of whom were included in the analysis. Thirty-one patients had AKI in a formerly healthy kidney, of whom 51% (16 patients) were classified as KDIGO stage 3, 5 patients needed hemodialysis and 13 needed mechanical ventilation. Higher WBCs count, and serum ferritin on admission were associated with more severe AKI (KDIGO stage 3) (p = 0.04), while multivariate analysis showed high serum ferritin to be independent predictor of more severe AKI (p = 0.02). Two patients (2/31) died during hospital admission, while no residual renal impairment was reported at the time of discharge of patients with previously normal kidney functions. CONCLUSION More than one-third of patients with MIS-C develop AKI. Avoidance of nephrotoxic drugs, early recognition, and prompt management of AKI, including well-timed commencement of dialysis in MIS-C cases, is associated with favorable outcomes.
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Affiliation(s)
- Hanan El-Halaby
- Pediatric Critical Care Unit, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Riham Eid
- Pediatric Nephrology Unit, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Ahmed Elagamy
- Pediatric Critical Care Unit, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmed El-Hussiny
- Pediatric Critical Care Unit, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Fatma Moustafa
- Department of Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ayman Hammad
- Pediatric Nephrology Unit, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mayada Zeid
- Pediatric Infectious Diseases Unit, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Di Vincenzo F, Ennas S, Pizzoferrato M, Bibbò S, Porcari S, Ianiro G, Cammarota G. Henoch-schonlein purpura following exposure to SARS-CoV2 vaccine or infection: a systematic review and a case report. Intern Emerg Med 2024; 19:13-37. [PMID: 37500944 PMCID: PMC10827835 DOI: 10.1007/s11739-023-03366-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/03/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Henoch-Schonlein purpura (HSP) is an IgA-mediated systemic small-vessel vasculitis (IgAV) that typically presents with a variable tetrad of symptoms. HSP if often preceded by respiratory tract infections, vaccinations, drugs or malignancies. During the recent COVID-19 pandemic multiples cases of HSP have been described after both infection and vaccination for SARS-CoV2. This study aims to perform a systematic review of literature and describe an additional complicated case of de-novo HSP appeared after the administration of the third dose of a mRNA-SARS-CoV2 vaccination. METHODS Electronic bibliographic research was performed to identify all the original reports describing cases of de-novo HSP or IgAV appeared after respiratory infection or vaccine administration for SARS-CoV2. We included all case series or case reports of patients who respected our inclusion and exclusion criteria. RESULTS Thirty-eight publications met our pre-defined inclusion criteria, for an overall number of 44 patients. All patients presented with palpable purpura variable associated with arthralgia, abdominal pain or renal involvement. Increased levels of inflammation markers, mild leukocytosis and elevated D-dimer were the most common laboratory findings. Up to 50% of patients presented proteinuria and/or hematuria. Almost all skin biopsies showed leukocytoclastic vasculitis, with IgA deposits at direct immunofluorescence in more than 50% of cases. CONCLUSIONS Our results suggest that the immune response elicited by SARS-CoV2 vaccine or infection could play a role in the development of HSP. Current research suggests a possible role of IgA in immune hyperactivation, highlighted by early seroconversion to IgA found in some COVID-19 patients who develop IgA vasculitis.
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Affiliation(s)
- Federica Di Vincenzo
- UOC di Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, L. go A. Gemelli 8, Roma, Italia
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. go F. Vito 1, Roma, Italia
| | - Sara Ennas
- UOC di Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, L. go A. Gemelli 8, Roma, Italia
| | - Marco Pizzoferrato
- UOC di Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, L. go A. Gemelli 8, Roma, Italia.
| | - Stefano Bibbò
- UOC di Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, L. go A. Gemelli 8, Roma, Italia
| | - Serena Porcari
- UOC di Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, L. go A. Gemelli 8, Roma, Italia
| | - Gianluca Ianiro
- UOC di Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, L. go A. Gemelli 8, Roma, Italia
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. go F. Vito 1, Roma, Italia
| | - Giovanni Cammarota
- UOC di Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, L. go A. Gemelli 8, Roma, Italia
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. go F. Vito 1, Roma, Italia
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Wang Y, Yang L, Xu G. New-Onset Acute Interstitial Nephritis Post-SARS-CoV-2 Infection and COVID-19 Vaccination: A Panoramic Review. J Epidemiol Glob Health 2023; 13:615-636. [PMID: 37870719 PMCID: PMC10686899 DOI: 10.1007/s44197-023-00159-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/27/2023] [Indexed: 10/24/2023] Open
Abstract
The 2019 coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) has posed a considerable challenge to global healthcare. Acute interstitial nephritis (AIN) post SARS-CoV-2 infection and vaccination has been reported, but its clinical features and pathogenesis remained unclear. We reviewed so far the largest 22 cases of AIN post SARS-CoV-2 infection and 36 cases of AIN following COVID-19 vaccination. The onset of AIN was mainly related to messenger RNA vaccines (52.8%). Apart from fever, proteinuria (45.5%) was the main manifestation of AIN post SARS-CoV-2 infection, left acute kidney injury (AKI, 63.9%) in patients post COVID-19 vaccination. The potential mechanism of vaccination induced AIN was conjugating vaccines with proteins to form a hapten, which activated dendritic cells and promoted a cascade immunological reaction leading to AIN.
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Affiliation(s)
- Yu Wang
- Department of Nephrology, Donghu District, the Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Nanchang, 330006, Jiangxi, China
| | - Ling Yang
- Department of Health Management Medicine, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Gaosi Xu
- Department of Nephrology, Donghu District, the Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Nanchang, 330006, Jiangxi, China.
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García-Fernández S, Fernández-Morán E, López-Martínez C, Vivanco-Allende B, Costales-Álvarez C, Ordóñez-Álvarez FA. Tubulointerstitial nephritis and uveitis syndrome and SARS-CoV-2 infection in an adolescent: just a coincidence in time? Pediatr Nephrol 2023; 38:4203-4207. [PMID: 37130974 PMCID: PMC10153047 DOI: 10.1007/s00467-023-05950-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/05/2023] [Accepted: 03/06/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Despite recent well-established kidney tropism of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), usually presenting as acute kidney injury (AKI), there are few published cases with SARS-CoV-2-related tubulointerstitial nephritis (TIN). We report an adolescent with TIN and delayed association with uveitis (TINU syndrome), where SARS-CoV-2 spike protein was identified in kidney biopsy. CASE-DIAGNOSIS/TREATMENT A 12-year-old girl was assessed for a mild elevation of serum creatinine detected during the evaluation of systemic manifestations including asthenia, anorexia, abdominal pain, vomiting, and weight loss. Data of incomplete proximal tubular dysfunction (hypophosphatemia and hypouricemia with inappropriate urinary losses, low molecular weight proteinuria, and glucosuria) were also associated. Symptoms had initiated after a febrile respiratory infection with no known infectious cause. After 8 weeks, the patient tested positive in PCR for SARS-CoV-2 (Omicron variant). A subsequent percutaneous kidney biopsy revealed TIN and immunofluorescence staining with confocal microscopy detected the presence of SARS-CoV-2 protein S within the kidney interstitium. Steroid therapy was started with gradual tapering. Ten months after onset of clinical manifestations, as serum creatinine remained slightly elevated and kidney ultrasound showed mild bilateral parenchymal cortical thinning, a second percutaneous kidney biopsy was performed, without demonstrating acute inflammation or chronic changes, but SARS-CoV-2 protein S within the kidney tissue was again detected. At that moment, simultaneous routine ophthalmological examination revealed an asymptomatic bilateral anterior uveitis. CONCLUSIONS We present a patient who was found to have SARS-CoV-2 in kidney tissue several weeks following onset of TINU syndrome. Although simultaneous infection by SARS-CoV-2 could not be demonstrated at onset of symptoms, since no other etiological cause was identified, we hypothesize that SARS-CoV-2 might have been involved in triggering the patient's illness.
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Affiliation(s)
| | - Eva Fernández-Morán
- Department of Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Cecilia López-Martínez
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Centro de Investigación Biomédica En Red–Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Blanca Vivanco-Allende
- Department of Pathology, Hospital Universitario Central de Asturias, Oviedo, Spain
- Departamento de Cirugía y Especialidades Médico-Quirúrgicas, Área de Anatomía Patológica, Universidad de Oviedo, Oviedo, Spain
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Baek HS, Cho MH. Kidney complications associated with COVID-19 infection and vaccination in children and adolescents: a brief review. Clin Exp Pediatr 2023; 66:424-431. [PMID: 37402469 PMCID: PMC10556799 DOI: 10.3345/cep.2023.00738] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has spread considerably across the globe, affecting numerous children and adolescents besides adults. Despite its relatively lower incidence rates in children and adolescents than in adults, some infected children and adolescents exhibit a severe postinflammatory response known as multisystem inflammatory syndrome in children, followed by acute kidney injury, a common complication. Meanwhile, few reports have been available regarding kidney complications such as idiopathic nephrotic syndrome and other glomerulopathies associated with COVID-19 infection and vaccination in children and adolescents. However, the morbidity and mortality of these complications are not exceptionally high; more importantly, causality has yet to be clearly established. Finally, vaccine hesitancy in these age groups should be addressed, considering the strong evidence of COVID-19 vaccine safety and efficacy.
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Affiliation(s)
- Hee Sun Baek
- Department of Pediatrics, Yeungnam University, College of Medicine, Daegu, Korea
| | - Min Hyun Cho
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
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Orsi SM, Pepino C, Rossoni L, Serafino M, Caorsi R, Volpi S, Palmeri S, Faragli A, Lugani F, Bigatti C, Ghiggeri GM, Verrina EE, La Porta E, Angeletti A. Case Report: Multisystem inflammatory syndrome in children with associated proximal tubular injury. FRONTIERS IN NEPHROLOGY 2023; 3:1194989. [PMID: 37675350 PMCID: PMC10479668 DOI: 10.3389/fneph.2023.1194989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/30/2023] [Indexed: 09/08/2023]
Abstract
Introduction SARS-CoV-2 infection in the pediatric population can be associated with a multiorgan inflammatory syndrome called children's multisystem inflammatory syndrome (MIS-C). The kidneys can be affected by a broad spectrum of possible injuries, whose pathogenetic mechanisms are still unclear.Case report: We report the case of a 5-year-old boy with severe cardiac involvement in the context of MIS-C. After two weeks of hospitalization, an abdominal ultrasound showed massive bladder "debris", followed by the onset of normoglycemic glycosuria. Over time, there was a progressive increase in glycosuria, and the presence of a mat of amorphous phosphate crystals was evidenced on urinary sediment. Together with the findings of hypo-uricemia, increased urinary uric acid, and globally increased urinary amino acids, a clinical picture of kidney proximal tubular damage with secondary Fanconi-like syndrome took shape. Discussion This case report describes the case of a patient with MIS-C with cardiac and kidney involvement characterized by proximal tubular damage, which slowly improved but still persisted at the 8-month follow-up. The pathogenesis of the damage is unclear and probably multifactorial.
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Affiliation(s)
- Silvia Maria Orsi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Carlotta Pepino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Lisa Rossoni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Margherita Serafino
- Department of Pediatric Cardiology and Cardiac Surgery, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Caorsi
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Stefano Volpi
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Serena Palmeri
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alessandro Faragli
- Department of Internal Medicine and Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Francesca Lugani
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina Bigatti
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Enrico Eugenio Verrina
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Dialysis Unit, Department of Pediatric, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Edoardo La Porta
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Dialysis Unit, Department of Pediatric, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Angeletti
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Avramescu M, Isnard P, Temmam S, Chevalier A, Bastard P, Attia M, Berthaud R, Fila M, Dossier C, Hogan J, Ulinski T, Leguevaques D, Louillet F, Casado EM, Halimi JM, Cloarec S, Zaloszyc A, Faudeux C, Rousset-Rouvière C, Clavé S, Harambat J, Rollot E, Simon T, Nallet-Amate M, Ranchin B, Bacchetta J, Porcheret F, Bernard J, Ryckewaert A, Jamet A, Fourgeaud J, Da Rocha N, Pérot P, Kuperwasser N, Bouazza N, Rabant M, Duong Van Huyen JP, Robert MP, Zuber J, Casanova JL, Eloit M, Sermet-Gaudelus I, Boyer O. Acute tubulointerstitial nephritis with or without uveitis: a novel form of post-acute COVID-19 syndrome in children. Kidney Int 2023; 103:1193-1198. [PMID: 36918081 PMCID: PMC10008186 DOI: 10.1016/j.kint.2023.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/13/2023]
Affiliation(s)
- Marina Avramescu
- Pediatric Nephrology, Maladies REnales Héréditaires de l'Enfant et de l'Adulte (MARHEA) Reference Center, Institut National de la Santé Et de la Recherche Médicale (INSERM) U1163, Imagine Institute, Paris Cité University, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Pierre Isnard
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France; Université de Paris, Institut National de la Santé Et de la Recherche Médicale (INSERM) U1151, Centre National de la Recherche Scientifique (CNRS) Unité Mixte de Recherche (UMR) 8253, Institut Necker Enfants Malades, Département « Croissance et Signalisation », Paris, France
| | - Sarah Temmam
- Pathogen Discovery Laboratory, Department of Virology, Institut Pasteur, Paris, France
| | - Agnès Chevalier
- Department of Pediatric Nephrology, Arnaud-de-Villeneuve Hospital, University Hospital of Montpellier, Montpellier, France
| | - Paul Bastard
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé Et de la Recherche Médicale (INSERM) U1163, Imagine Institute, Necker-Enfants Malades Hospital, Paris, France; Paris Cité University, Paris, France; St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, New York, USA; Department of Pediatrics, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Mikael Attia
- Molecular Genetics of RNA Viruses, Department of Virology, Institut Pasteur, Centre National de la Recherche Scientifique (CNRS) Unité Mixte de Recherche (UMR) 3569, Paris, France
| | - Romain Berthaud
- Pediatric Nephrology, Maladies REnales Héréditaires de l'Enfant et de l'Adulte (MARHEA) Reference Center, Institut National de la Santé Et de la Recherche Médicale (INSERM) U1163, Imagine Institute, Paris Cité University, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Marc Fila
- Department of Pediatric Nephrology, Arnaud-de-Villeneuve Hospital, University Hospital of Montpellier, Montpellier, France
| | - Claire Dossier
- Department of Pediatric Nephrology, Robert Debré Hospital, Paris Cité University, Paris, France
| | - Julien Hogan
- Department of Pediatric Nephrology, Robert Debré Hospital, Paris Cité University, Paris, France
| | - Tim Ulinski
- Department of Pediatric Nephrology, Armand Trousseau Hospital, Paris, France
| | - Damia Leguevaques
- Department of Pediatric Nephrology, Centre Hospitalier Régional Universitaire (CHRU) de Lille, Lille, France
| | | | | | - Jean-Michel Halimi
- Department of Adult Nephrology, Centre Hospitalier Régional Universitaire (CHRU) de Tours, Tours, France
| | - Sylvie Cloarec
- Department of Pediatric Nephrology, Clocheville Hospital, Centre Hospitalier Régional Universitaire (CHRU) de Tours, Tours, France
| | - Ariane Zaloszyc
- Department of Pediatric Nephrology, centre Hospitalier Universitaire (CHU) de Strasbourg, Strasbourg, France
| | - Camille Faudeux
- Department of Pediatrics, Pediatric Nephrology Unit, L'Archet Hospital, University Hospital of Nice, Nice, France
| | - Caroline Rousset-Rouvière
- Department of Multidisciplinary Pediatrics, Pediatric Nephrology Unit, Assistance Publique - Hôpitaux de Marseille (APHM), Marseille, France
| | - Stéphanie Clavé
- Department of Multidisciplinary Pediatrics, Pediatric Nephrology Unit, Assistance Publique - Hôpitaux de Marseille (APHM), Marseille, France
| | - Jérôme Harambat
- Department of Pediatrics, Pediatric Nephrology Unit, SoRare Reference Center, Bordeaux University Hospital, Bordeaux, France
| | - Edouard Rollot
- Department of Pediatrics, Pediatric Nephrology Unit, SoRare Reference Center, Bordeaux University Hospital, Bordeaux, France
| | - Thomas Simon
- Department of Pediatric Nephrology, SoRare Reference Center, Toulouse University Hospital, Toulouse, France
| | | | - Bruno Ranchin
- Department of Pediatric Nephrology, centre Hospitalier Universitaire (CHU) de Lyon, Lyon, France
| | - Justine Bacchetta
- Department of Pediatric Nephrology, centre Hospitalier Universitaire (CHU) de Lyon, Lyon, France
| | | | - Josselin Bernard
- Pediatric Department, Nantes University Hospital, Nantes, France
| | - Amélie Ryckewaert
- Department of Pediatric Nephrology, centre Hospitalier Universitaire (CHU) de Rennes, Rennes, France
| | - Anne Jamet
- Department of Clinical Microbiology, Necker Enfants-Malades Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Jacques Fourgeaud
- Department of Clinical Microbiology, Necker Enfants-Malades Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris Cité University, Paris, France
| | - Nicolas Da Rocha
- Pathogen Discovery Laboratory, Department of Virology, Institut Pasteur, Paris, France
| | - Philippe Pérot
- Pathogen Discovery Laboratory, Department of Virology, Institut Pasteur, Paris, France
| | - Nicolas Kuperwasser
- Paris Cité University, Institut National de la Santé Et de la Recherche Médicale (INSERM) U1151, Centre National de la Recherche Scientifique (CNRS) Unité Mixte de Recherche (UMR) 8253, Necker Enfants Malades Institute, Department « Croissance et Signalisation », Paris, France
| | - Naïm Bouazza
- Equipe Associée (EA) 7323, Université Paris, Pharmacologie et évaluations thérapeutiques chez l'enfant et la femme enceinte, Paris, France; Unité de Recherche Clinique, Hôpital Tarnier, Paris, France; Centre d'Investigation Clinique (CIC)-1419 Institut National de la Santé Et de la Recherche Médicale (Inserm), Cochin-Necker, Paris, France
| | - Marion Rabant
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Jean-Paul Duong Van Huyen
- Department of Pathology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Matthieu P Robert
- Department of Ophthalmology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris Cité University, Paris, France
| | - Julien Zuber
- Department of Nephrology and Kidney Transplantation, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris Cité University, Paris, France
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé Et de la Recherche Médicale (INSERM) U1163, Imagine Institute, Necker-Enfants Malades Hospital, Paris, France; Paris Cité University, Paris, France; St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, New York, USA
| | - Marc Eloit
- Pathogen Discovery Laboratory, Department of Virology, Institut Pasteur, Paris, France
| | - Isabelle Sermet-Gaudelus
- Department of Pediatric Pulmonology and Allergology, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Olivia Boyer
- Pediatric Nephrology, Maladies REnales Héréditaires de l'Enfant et de l'Adulte (MARHEA) Reference Center, Institut National de la Santé Et de la Recherche Médicale (INSERM) U1163, Imagine Institute, Paris Cité University, Necker-Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.
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10
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Sakhinia F, Brice V, Ollerenshaw R, Gajendran S, Ashworth J, Shenoy M. Tubulointerstitial nephritis and uveitis in children during the COVID-19 pandemic: report of four cases. J Nephrol 2023; 36:1451-1455. [PMID: 36848016 PMCID: PMC9969945 DOI: 10.1007/s40620-022-01564-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 12/25/2022] [Indexed: 03/01/2023]
Abstract
Tubulointerstitial nephritis and uveitis (TINU) is a rare autoimmune disorder often triggered by drugs and infections. Since the onset of the COVID-19 pandemic, we have observed an unusual cluster of paediatric cases. Four children (3 females) were diagnosed with TINU (median age 13 years) following a kidney biopsy and ophthalmologic assessment. Presenting symptoms included abdominal pain (3 cases), fatigue, weight loss and vomiting (2 cases). At presentation, median eGFR was 50.3 ml/min/1.73m2 (range 19.2-69.3). Anaemia was common (3 cases) with median haemoglobin of 10.45 g/dL (range 8.4-12.1). Two patients were hypokalaemic and 3 had non-hyperglycaemic glycosuria. Median urine protein:creatinine ratio was 117 mg/mmol (range 68-167). SARS-CoV-2 antibodies were detected in 3 cases at presentation. All were asymptomatic for COVID-19 with a negative PCR. Kidney function improved following high-dose steroids. However, disease relapse was observed during steroid tapering (2 cases) and upon discontinuation (2 cases). All patients responded well to further high dose steroids. Mycophenolate mofetil was introduced as a steroid-sparing agent. At latest follow up (range 11-16 months), median eGFR was 109.8 ml/min/1.73m2. All four patients continue on mycophenolate mofetil, with 2 patients applying topical steroids for uveitis. Our data suggest that SARS-CoV-2 infection might be a trigger for TINU.
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Affiliation(s)
- Faezeh Sakhinia
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK.
| | - Vicky Brice
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Rebecca Ollerenshaw
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sellathurai Gajendran
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Jane Ashworth
- Department of Paediatric Ophthalmology, Manchester Royal Eye Hospital, Manchester, UK
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
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11
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Nikolaishvili M, Pazhava A, Di Lernia V. Viral Infections May Be Associated with Henoch-Schönlein Purpura. J Clin Med 2023; 12:697. [PMID: 36675626 PMCID: PMC9862009 DOI: 10.3390/jcm12020697] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
Henoch-Schönlein purpura or IgA vasculitis is the most common type of pediatric vasculitis that may affect adults as well. It is classified as a type of small-vessel vasculitis. It can cause cutaneous and systemic symptoms with a minority of patients developing kidney failure. Little is known about the specific pathophysiology of this disorder, except that it is believed to occur in individuals with abnormally glycosylated IgA1. Serum aberrant IgA1 may form large antigen-antibody complexes which, due to a defective clearance, are able to deposit in the small vessels of the skin, kidney, gut, and joints. A variety of factors, including infectious agents, drugs, and vaccines, have been identified as potential triggers. The majority of cases are preceded by upper respiratory tract infections, and seasonal variations suggest a link with many pathogens. The etiologic agent most frequently associated with IgA vasculitis historically have been group A β-hemolytic streptococcus and common respiratory tract viruses. However, during the current coronavirus pandemic, SARS-CoV-2 infection was identified as a main trigger factor. In addition, IgA vasculitis has been observed following COVID-19 immunization. This review provides insights into the state of the art on the relationship between viral infections, viral vaccines, and Henoch-Schönlein purpura.
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Affiliation(s)
- Mariam Nikolaishvili
- Faculty of Medicine, Ivane Javakhishvil Tbilisi State University, 0179 Tbilisi, Georgia
| | - Ani Pazhava
- American MD Program, Tbilisi State Medical University, 0186 Tbilisi, Georgia
| | - Vito Di Lernia
- Dermatology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
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12
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Kim GH, Jun JB. Altered Serum Uric Acid Levels in Kidney Disorders. Life (Basel) 2022; 12:1891. [PMID: 36431026 PMCID: PMC9692609 DOI: 10.3390/life12111891] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/07/2022] [Accepted: 11/13/2022] [Indexed: 11/17/2022] Open
Abstract
Serum uric acid levels are altered by kidney disorders because the kidneys play a dominant role in uric acid excretion. Here, major kidney disorders which accompany hyperuricemia or hypouricemia, including their pathophysiology, are discussed. Chronic kidney disease (CKD) and hyperuricemia are frequently associated, but recent clinical trials have not supported the pathogenic roles of hyperuricemia in CKD incidence and progression. Diabetes mellitus (DM) is often associated with hyperuricemia, and hyperuricemia may be associated with an increased risk of diabetic kidney disease in patients with type 2 DM. Sodium-glucose cotransporter 2 inhibitors have a uricosuric effect and can relieve hyperuricemia in DM. Autosomal dominant tubulointerstitial kidney disease (ADTKD) is an important hereditary kidney disease, mainly caused by mutations of uromodulin (UMOD) or mucin-1 (MUC-1). Hyperuricemia and gout are the major clinical manifestations of ADTKD-UMOD and ADTKD-MUC1. Renal hypouricemia is caused by URAT1 or GLUT9 loss-of-function mutations and renders patients susceptible to exercise-induced acute kidney injury, probably because of excessive urinary uric acid excretion. Hypouricemia derived from renal uric acid wasting is a component of Fanconi syndrome, which can be hereditary or acquired. During treatment for human immunodeficiency virus, hepatitis B or cytomegalovirus, tenofovir, adefovir, and cidofovir may cause drug-induced renal Fanconi syndrome. In coronavirus disease 2019, hypouricemia due to proximal tubular injury is related to disease severity, including respiratory failure. Finally, serum uric acid and the fractional excretion of uric acid are indicative of plasma volume status; hyperuricemia caused by the enhanced uric acid reabsorption can be induced by volume depletion, and hypouricemia caused by an increased fractional excretion of uric acid is the characteristic finding in syndromes of inappropriate anti-diuresis, cerebral/renal salt wasting, and thiazide-induced hyponatremia. Molecular mechanisms by which uric acid transport is dysregulated in volume or water balance disorders need to be investigated.
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Affiliation(s)
- Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Jae-Bum Jun
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul 04763, Republic of Korea
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13
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Bronz G, Faré PB, Lava SAG, Bianchetti MG, Simonetti GD, Scoglio M, Beretta-Piccoli BT, Agostoni C, Milani GP. Coronavirus disease 2019, vaccination against coronavirus and immunoglobulin A-mediated diseases: systematic literature review. J Autoimmun 2022; 132:102899. [PMID: 36108473 PMCID: PMC9393156 DOI: 10.1016/j.jaut.2022.102899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/14/2022] [Accepted: 08/14/2022] [Indexed: 11/16/2022]
Abstract
Coronavirus disease 2019 (COVID-19) and vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been associated with autoimmune phenomena. However, the interplay between COVID-19 or vaccination against SARS-CoV-2 and Berger glomerulonephritis or Henoch-Schönlein vasculitis, two diseases mediated by immunoglobulin A, has never been comprehensively investigated. Therefore, we carried out a systematic review of the literature on this topic. Following databases were used: Google Scholar, Excerpta Medica and the United States National Library of Medicine. Eighty-seven patients with immunoglobulin A-mediated diseases associated with SARS-CoV-2 infection or vaccination against coronavirus were sorted out (53% males, 47% females; 34 17-51 years of age, median and interquartile range): 47 cases of Berger glomerulonephritis and 40 of Henoch-Schönlein vasculitis. Approximately 50% (N = 24) of Berger glomerulonephritis and 10% (N = 4) of Henoch-Schönlein vasculitis patients presented with a pre-existing history of immunoglobulin A-mediated disease. Almost all cases of Berger glomerulonephritis were vaccine-associated (N = 44; 94%), while most cases of Henoch-Schönlein vasculitis were infection-associated (N = 23; 57%). Among vaccine-associated immunoglobulin A diseases, about 90% were associated to mRNA-based vaccines. Our analysis supports the hypothesis that COVID-19 and vaccination against SARS-CoV-2 may trigger or exacerbate an immunoglobulin A-mediated diseases.
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Affiliation(s)
- Gabriel Bronz
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Pietro B Faré
- Division of Infectious Diseases, Department of Medicine, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland; Heart Failure and Transplantation, Department of Paediatric Cardiology, Great Ormond Street Hospital, London, United Kingdom
| | - Mario G Bianchetti
- Family Medicine, Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland; Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Giacomo D Simonetti
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Martin Scoglio
- Family Medicine, Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | | | - Carlo Agostoni
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, Milan, Italy
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, Milan, Italy
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14
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Liao TH, Wu HC, Liao MT, Hu WC, Tsai KW, Lin CC, Lu KC. The Perspective of Vitamin D on suPAR-Related AKI in COVID-19. Int J Mol Sci 2022; 23:10725. [PMID: 36142634 PMCID: PMC9500944 DOI: 10.3390/ijms231810725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 01/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has claimed the lives of millions of people around the world. Severe vitamin D deficiency can increase the risk of death in people with COVID-19. There is growing evidence that acute kidney injury (AKI) is common in COVID-19 patients and is associated with poorer clinical outcomes. The kidney effects of SARS-CoV-2 are directly mediated by angiotensin 2-converting enzyme (ACE2) receptors. AKI is also caused by indirect causes such as the hypercoagulable state and microvascular thrombosis. The increased release of soluble urokinase-type plasminogen activator receptor (suPAR) from immature myeloid cells reduces plasminogen activation by the competitive inhibition of urokinase-type plasminogen activator, which results in low plasmin levels and a fibrinolytic state in COVID-19. Frequent hypercoagulability in critically ill patients with COVID-19 may exacerbate the severity of thrombosis. Versican expression in proximal tubular cells leads to the proliferation of interstitial fibroblasts through the C3a and suPAR pathways. Vitamin D attenuates the local expression of podocyte uPAR and decreases elevated circulating suPAR levels caused by systemic inflammation. This decrease preserves the function and structure of the glomerular barrier, thereby maintaining renal function. The attenuated hyperinflammatory state reduces complement activation, resulting in lower serum C3a levels. Vitamin D can also protect against COVID-19 by modulating innate and adaptive immunity, increasing ACE2 expression, and inhibiting the renin-angiotensin-aldosterone system. We hypothesized that by reducing suPAR levels, appropriate vitamin D supplementation could prevent the progression and reduce the severity of AKI in COVID-19 patients, although the data available require further elucidation.
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Affiliation(s)
- Tzu-Hsien Liao
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan
| | - Hsien-Chang Wu
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Min-Tser Liao
- Department of Pediatrics, Taoyuan Armed Forces General Hospital Hsinchu Branch, Hsinchu City 300, Taiwan
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Wan-Chung Hu
- Department of Clinical Pathology and Medical Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan
| | - Kuo-Wang Tsai
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan
| | - Ching-Chieh Lin
- Department of Chest Medicine, Taoyuan Armed Forces General Hospital Hsinchu Branch, Hsinchu City 300, Taiwan
| | - Kuo-Cheng Lu
- Division of Nephrology, Department of Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan
- Division of Nephrology, Department of Medicine, Fu-Jen Catholic University Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City 242, Taiwan
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15
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Storrar J, Kudose S, Woywodt A. Have we missed AINything? Acute interstitial nephritis in SARS-CoV-2 infection and vaccination. Clin Kidney J 2022; 15:1643-1652. [PMID: 35999962 PMCID: PMC9213847 DOI: 10.1093/ckj/sfac147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Acute interstitial nephritis (AIN), defined by the presence of interstitial inflammation accompanied by tubulitis, is an often overlooked cause of acute kidney injury (AKI). It is now well established that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can cause a wide variety of kidney injuries, most commonly acute tubular injury and collapsing glomerulopathy. In comparison, AIN is rarely documented in association with SARS-CoV-2 both anecdotally and in larger series of autopsy or biopsy studies. In this issue of the Journal, León-Román describe five cases of AIN in patients with a history of coronavirus disease 2019 (COVID-19) and highlight AIN as a possibly under-reported or ignored facet of renal disease associated with SARS-CoV-2. They describe three scenarios in which AIN can be seen: (i) SARS-CoV-2 infection after diagnosis of AIN, (ii) AIN followed by SARS-CoV-2 infection in the same admission and (iii) Severe SARS-CoV-2 and AIN possibly associated with SARS-CoV-2 itself. Overall, AIN remains rare in SARS-CoV-2 and causality is difficult to ascertain. Interestingly, AIN is not only seen in association with the disease itself but also with SARS-CoV-2 vaccination. This scenario is equally rare and causality is no less difficult to prove. A history of preceding SARS-CoV-2 infection and vaccination should be actively sought when patients present with otherwise unexplained AIN.
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Affiliation(s)
- Joshua Storrar
- Department of Nephrology, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Salford, UK
| | - Satoru Kudose
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, NY, NY, USA
| | - Alexander Woywodt
- Department of Nephrology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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16
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Daneshgar N, Liang PI, Michels CJ, Nester CM, Harshman LA, Dai DF. Case Report: Clinical and Pathological Findings of a Recurrent C3 Glomerulopathy With Superimposed Membranoproliferative Glomerulonephritis Pattern and Cryoglobulinemia Associated With COVID-19. Front Pediatr 2022; 10:827466. [PMID: 35311055 PMCID: PMC8931284 DOI: 10.3389/fped.2022.827466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/31/2022] [Indexed: 02/05/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) may cause a wide spectrum of kidney pathologies. The impact of COVID-19 is unclear in the context of the complement system abnormalities, including C3 glomerulopathy (C3G). In this report, we describe a young adult receiving a kidney transplant for C3 glomerulopathy (C3G), a disorder of the alternative complement pathway. The patient developed a recurrent C3G ~7 months after transplantation. His post-transplant course was complicated by SARS-CoV-2 infection. There was a progression of glomerulonephritis, characterized by de novo immune-complex mediated membranoproliferative glomerulonephritis pattern of injury with crescentic and necrotizing features, along with positive immunoglobulins, persistent IgM staining and the presence of cryoglobulinemia. COVID-19 may have aggravated the inherent complement dysregulation and contributed to cryoglobulinemia observed in this patient. Our study of 5 sequential kidney allograft biopsy series implicates that COVID-19 in this patient promoted a superimposed immune complex-mediated glomerulonephritis with membranoproliferative glomerulonephritis (MPGN) pattern and cryoglobulinemia, which was a potentiating factor in allograft loss. This work represents the first report of cryoglobulinemic GN after COVID-19.
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Affiliation(s)
- Nastaran Daneshgar
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Peir-In Liang
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Christina J. Michels
- Division of Pediatric Nephrology, University of Iowa Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, United States
| | - Carla M. Nester
- Division of Pediatric Nephrology, University of Iowa Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, United States
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Lyndsay A. Harshman
- Division of Pediatric Nephrology, University of Iowa Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, United States
| | - Dao-Fu Dai
- Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
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17
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Cyclophosphamide/methylprednisolone/prednisone. REACTIONS WEEKLY 2022. [PMCID: PMC8933155 DOI: 10.1007/s40278-022-11746-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gambella A, Barreca A, Biancone L, Roccatello D, Peruzzi L, Besso L, Licata C, Attanasio A, Papotti M, Cassoni P. Spectrum of Kidney Injury Following COVID-19 Disease: Renal Biopsy Findings in a Single Italian Pathology Service. Biomolecules 2022; 12:298. [PMID: 35204798 PMCID: PMC8961620 DOI: 10.3390/biom12020298] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 02/04/2023] Open
Abstract
The onset of coronavirus disease (COVID-19) as a pandemic infection, has led to increasing insights on its pathophysiology and clinical features being revealed, such as a noticeable kidney involvement. In this study, we describe the histopathological, immunofluorescence, and ultrastructural features of biopsy-proven kidney injury observed in a series of SARS-CoV-2 positive cases in our institution from April 2020 to November 2021. We retrieved and retrospectively reviewed nine cases (two pediatric and seven adults) that experienced nephrotic syndrome (six cases), acute kidney injury (two cases), and a clinically silent microhematuria and leukocyturia. Kidney biopsies were investigated by means of light microscopy, direct immunofluorescence, and electron microscopy. The primary diagnoses were minimal change disease (four cases), acute tubular necrosis (two cases), collapsing glomerulopathy (two cases), and C3 glomerulopathy (one case). None of the cases showed viral or viral-like particles on ultrastructural analysis. Novel and specific histologic features on kidney biopsy related to SARS-CoV-2 infection have been gradually disclosed and reported, harboring relevant clinical and therapeutic implications. Recognizing and properly diagnosing renal involvement in patients experiencing COVID-19 could be challenging (due to the lack of direct proof of viral infection, e.g., viral particles) and requires a proper integration of clinical and pathological data.
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Affiliation(s)
- Alessandro Gambella
- Pathology Unit, Department of Medical Sciences, University of Turin, Via Santena 7, 10126 Turin, Italy; (A.G.); (A.A.)
| | - Antonella Barreca
- Pathology Unit, “Città della Salute e della Scienza di Torino” University Hospital, Via Santena 7, 10126 Turin, Italy;
| | - Luigi Biancone
- Division of Nephrology Dialysis and Transplantation, AOU Città della Salute e della Scienza di Torino, Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Dario Roccatello
- CMID, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Nephrology and Dialysis Unit (ERK-Net Member), San Giovanni Bosco Hub Hospital, University of Turin, 10144 Turin, Italy;
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy;
| | - Luca Besso
- Division of Nephrology and Dialysis, AO S. Croce e Carle di Cuneo, 12100 Cuneo, Italy;
| | - Carolina Licata
- Division of Nephrology and Dialysis, ASL TO4, 10073 Ciriè, Italy;
| | - Angelo Attanasio
- Pathology Unit, Department of Medical Sciences, University of Turin, Via Santena 7, 10126 Turin, Italy; (A.G.); (A.A.)
| | - Mauro Papotti
- Pathology Unit, Department of Oncology, University of Turin, Via Santena 7, 10126 Turin, Italy;
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, Via Santena 7, 10126 Turin, Italy; (A.G.); (A.A.)
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Pathology findings in pediatric patients with COVID-19 and kidney dysfunction. Pediatr Nephrol 2022; 37:2375-2381. [PMID: 35166918 PMCID: PMC8853278 DOI: 10.1007/s00467-022-05457-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is seen in one-fifth of pediatric patients with COVID-19 requiring hospital admission, and is associated with increased morbidity, mortality, and residual kidney impairment. The majority of kidney pathology data in patients with COVID-19 is derived from adult case series and there is an overall lack of histologic data for most pediatric patients with COVID-19. METHODS We assembled a multi-institutional cohort of five unvaccinated pediatric patients with COVID-19 and associated kidney dysfunction with available histology. RESULTS Three complex patients with current or prior SARS-CoV-2 infection had multifactorial thrombotic microangiopathy with clinical features of hemolytic uremic syndrome (in two) or disseminated intravascular coagulation (in one); one died and another developed chronic kidney disease stage 5. Two with recently preceding SARS-CoV-2 infection presented with nephrotic syndrome; one had IgA vasculitis and one had minimal change disease. Within a short follow-up time, none has returned to baseline kidney function. CONCLUSION Although uncommon, COVID-19-associated kidney injury can have significant morbidity in the unvaccinated pediatric and adolescent population. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Niel O, Florescu C. IgA nephropathy presenting as rapidly progressive glomerulonephritis following first dose of COVID-19 vaccine. Pediatr Nephrol 2022; 37:461-462. [PMID: 34786589 PMCID: PMC8594861 DOI: 10.1007/s00467-021-05351-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Olivier Niel
- Pediatric Nephrology, Centre Hospitalier de Luxembourg, 5 rue Barblé, L1210, Luxembourg, Luxembourg. .,Faculty of Science, Technology and Medicine, University of Luxembourg, 2 Avenue de l'Université, L4365, Esch-sur-Alzette, Luxembourg.
| | - Cosmin Florescu
- National Center of Pathology, Laboratoire National de Santé, 1 rue Rech, L3555 Dudelange, Luxembourg
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Azukaitis K, Besusparis J, Laurinavicius A, Jankauskiene A. Case Report: SARS-CoV-2 Associated Acute Interstitial Nephritis in an Adolescent. Front Pediatr 2022; 10:861539. [PMID: 35498789 PMCID: PMC9047909 DOI: 10.3389/fped.2022.861539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/18/2022] [Indexed: 12/03/2022] Open
Abstract
Acute interstitial nephritis (AIN) has been recently recognized as one of the infrequent kidney involvement phenotypes among adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Although SARS-CoV-2 associated intrinsic kidney disease has been scarcely reported in children, only one case of AIN temporally associated with the infection has been described in the pediatric population so far. We presented a case of a 12-year old boy who presented with fatigue, anorexia, and polydipsia following an RT-PCR that confirmed SARS-CoV-2 infection seven weeks prior to admission. Initial workup revealed increased serum creatinine (235 μmol/L), glucosuria, low-molecular-weight proteinuria, mild leukocyturia, and microhematuria with hyaline and granular casts on microscopy. Antibodies against the SARS-CoV-2 S protein receptor-binding domain confirmed prior infection with high titers. Kidney biopsy showed diffuse active interstitial nephritis with negative immunofluorescence and positive immunohistochemistry for SARS-CoV-2 in the inflammatory cells within the interstitium. Electron microscopy revealed several SARS-CoV-2-like particles. Kidney function continued to deteriorate despite several days of supportive therapy only (peak serum creatinine 272 μmol/L); thus, treatment with methylprednisolone pulse-dose therapy was initiated and was followed by oral prednisolone with gradual tapering. Kidney function completely recovered after 3 weeks post-discharge and remained normal after 11 weeks of follow-up (last estimated glomerular filtration rate 106 ml/min/1.73 m2) with only residual microhematuria. Our case adds to the emerging evidence of SARS-CoV-2 as a potential etiological agent of AIN in children and also suggests that interstitial kidney injury may result from secondary inflammatory damage. Epidemiological history, serologic testing, and SARS-CoV-2 detection in biopsy should be considered in the work-up of children with AIN of unknown etiology.
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Affiliation(s)
- Karolis Azukaitis
- Clinic of Pediatrics, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Justinas Besusparis
- Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Arvydas Laurinavicius
- Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Augustina Jankauskiene
- Clinic of Pediatrics, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Sirufo MM, Raggiunti M, Magnanimi LM, Ginaldi L, De Martinis M. Henoch-Schönlein Purpura Following the First Dose of COVID-19 Viral Vector Vaccine: A Case Report. Vaccines (Basel) 2021; 9:vaccines9101078. [PMID: 34696186 PMCID: PMC8539285 DOI: 10.3390/vaccines9101078] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 01/03/2023] Open
Abstract
A 76 year-old female came to our observation one week after the vaccination with ChAdOx1 nCoV-19 AZD1222 for the onset of purpuric rash on her gluteal and legs regions associated with coxalgia and episodes of macrohaematuria. Henoch-Schönlein purpura (HSP) was diagnosed on the basis of the revised criteria developed by the European League Against Rheumatism, the Paediatric Rheumatology International Trials Organization, and the Paediatric Rheumatology European Society (EULAR/PRINTO/PRES). HSP is a common IgA-mediated small vessel vasculitis, typical of childhood, that affects several systems and is characterized by a tetrad of dermatological, abdominal, joint, and renal manifestations. The Etiology of HSP is not completely understood, but it was observed following upper respiratory tract infections, medications, vaccinations, and malignancies. HSP has previously been reported following immunization with various vaccines, mostly within 12 weeks post, suggesting a possible correlation. To our knowledge, this is the first report of the possible association between COVID-19 ChAdOx1 nCoV-19 AZD1222 and the onset of HSP in a previously healthy woman. No similar cases were reported amongst 23.848 participants in the ChAdOx1 nCoV-19 AZD1222 trial.
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Affiliation(s)
- Maria Maddalena Sirufo
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (M.M.S.); (M.R.); (L.M.M.); (L.G.)
- Allergy and Clinical Immunology Unit, AUSL 04 Teramo, 64100 Teramo, Italy
| | - Martina Raggiunti
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (M.M.S.); (M.R.); (L.M.M.); (L.G.)
- Allergy and Clinical Immunology Unit, AUSL 04 Teramo, 64100 Teramo, Italy
| | - Lina Maria Magnanimi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (M.M.S.); (M.R.); (L.M.M.); (L.G.)
| | - Lia Ginaldi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (M.M.S.); (M.R.); (L.M.M.); (L.G.)
- Allergy and Clinical Immunology Unit, AUSL 04 Teramo, 64100 Teramo, Italy
| | - Massimo De Martinis
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (M.M.S.); (M.R.); (L.M.M.); (L.G.)
- Allergy and Clinical Immunology Unit, AUSL 04 Teramo, 64100 Teramo, Italy
- Correspondence:
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