Letter regarding: “A Case of Gross Hematuria and IgA Nephropathy Flare-Up Following SARS-CoV-2 Vaccination”

Abstract

We have followed with interest reports of female patients (n=4) with indolent IgA nephropathy, evidenced by normal kidney function and microscopic hematuria without proteinuria at baseline, presenting after a second dose of the Pfizer-BioNTech (n=2) or Moderna (n=2) SARS-CoV-2 mRNA vaccine with self-limited gross hematuria.1Negrea L. Rovin B.H. Gross hematuria following vaccination for severe acute respiratory syndrome coronavirus 2 in 2 patients with IgA nephropathy.Kidney Int. 2021; 99: 1487Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 2Rahim S.E.G. Lin J.T. Wang J.C. A case of gross hematuria and IgA nephropathy flare-up following SARS-CoV-2 vaccination.Kidney Int. 2021; 100: 238Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 3Tan H.Z. Tan R.Y. Choo J.C.J. et al.Is COVID-19 vaccination unmasking glomerulonephritis? Kidney Int.https://doi.org/10.1016/j.kint.2021.05.009Google Scholar With the hope of spurring continued discussion of best management in patients with more aggressive IgA nephropathy at baseline, we share 4 additional cases of IgA nephropathy and/or IgA vasculitis flairs temporally associated with Moderna SARS-CoV-2 mRNA vaccination (Table 1).Table 1Patient clinical characteristicsPatientAge, yrSexMHMedicationsEvidence of systemic IgA vasculitis before vaccinationTemporal relation of gross hematuria to Moderna SARS-CoV-2 mRNA vaccinationBaseline (hematuria / uPCR / SCr)Presentation (hematuria / uPCR / SCr)Evidence of systemic IgA vasculitis after vaccinationBiopsyTreatmentFollow-up 1 mo post second dose (hematuria / uPCR / SCr)122FNoneNone since episodic steroids for IgA vasculitis at age 10 yrYes48 h after second dose4–10 / neg / 0.80>50 / 0.40 / 0.80NoNoNone0–3 / 0.27 / 0.80 (hematuria returned to baseline)239FNoneNoneNo48 h after second dose0–3 / neg / no baseline>50 / 0.90 / 0.80NoNoNone0 / below detection / 0.80 (hematuria and proteinuria returned to baseline)350MHTNNoneNo24 h after second dose11–25 / 2.40 / 1.17>50 / 3.56 / 1.54NoYes, kidneyRAASi11–25 / 2.20 / 1.24 (hematuria and proteinuria returned to baseline; SCr improving but above baseline)467MHTNRAASiNo1 mo after first dose0–3 / 0.05 / 1.20>50 / 2.10 / 2.90Yes, bilateral lower extremity maculopapular rashYes, skinSteroid0–3 / 0.09 / 1.40 (hematuria and proteinuria returned to baseline; SCr improving but above baseline)F, female; HTN, hypertension; M, male; neg, negative; MH, medical history; RAASi, renin-angiotensin-aldosterone system inhibition; SCr, serum creatinine (in mg/dL); uPCR, urine protein-to-creatinine ratio.Hematuria is expressed as number of red blood cells per high-powered field on urinalysis. None of the patients had episodes of gross hematuria before vaccination, and none were known to have been infected with SARS-CoV-2, although serologic testing before vaccination was not performed. Open table in a new tab F, female; HTN, hypertension; M, male; neg, negative; MH, medical history; RAASi, renin-angiotensin-aldosterone system inhibition; SCr, serum creatinine (in mg/dL); uPCR, urine protein-to-creatinine ratio. Hematuria is expressed as number of red blood cells per high-powered field on urinalysis. None of the patients had episodes of gross hematuria before vaccination, and none were known to have been infected with SARS-CoV-2, although serologic testing before vaccination was not performed. Patients 1 and 2 are both women with normal kidney function who developed gross hematuria and mild proteinuria without rise in serum creatinine within 48 hours of a second vaccine dose. By 1 week and sustained through at least 1-month follow-up, both had complete resolution of hematuria and no additional flairs without intervention. In contrast, patients 3 and 4 are both men with chronic kidney disease and mild proteinuria at baseline, who developed not only gross hematuria but also significant proteinuria and kidney function decline. Owing to persistent kidney dysfunction, 3 months after second vaccine dose, patient 3 underwent a kidney biopsy, showing an active and chronic IgA nephropathy with 13% active crescents. As his kidney function and proteinuria showed improvement, patient 3 declined immunosuppressive therapy and was treated with angiotensin-converting enzyme inhibition and close follow-up. Patient 4 developed gross hematuria followed by lower extremity rash 1 month after his first vaccine dose (5 days before second dose); skin biopsy showed IgA vasculitis. Cutaneous but not renal symptoms of IgA vasculitis worsened though 10 days after second vaccine dose, and he received a 1-week course of prednisone 40 mg daily, with resolution of rash and improved renal function. These cases highlight that in the absence of intervention, COVID-19 vaccine–associated IgA nephropathy and IgA vasculitis flairs may improve spontaneously; however, important questions remain regarding utility and risks of immunosuppressants or subsequent vaccine doses. All the authors declared no competing interests. A case of gross hematuria and IgA nephropathy flare-up following SARS-CoV-2 vaccinationKidney InternationalVol. 100Issue 1PreviewWe read with great interest the report of Negrea and Rovin of 2 cases of IgA nephropathy with gross hematuria following the Moderna vaccine for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).1 We also cared for a 52-year-old Asian female with prior biopsy-proven IgA nephropathy who developed gross hematuria within 24 hours of receiving a second dose of the Pfizer vaccine. Table 1 summarizes clinical data. Her workup was notable for proteinuria of 4.2 g/g of creatinine with serum creatinine at baseline. Full-Text PDF