To the editor:
We 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. Of note, SARS-CoV-2 antibody testing prior to vaccination was negative, and she developed no symptoms after the first vaccine dose. Repeated testing within 1 week demonstrated resolution of hematuria and improving proteinuria. Interestingly, she developed gross hematuria following the first shot of the Shingrix vaccine 2 years prior but no symptoms following annual influenza vaccinations. The IgA nephropathy flare in our patient following the second SARS-CoV-2 vaccine dose without known prior exposure to SARS-CoV-2 suggests it was mediated by a delayed-type hypersensitivity reaction. Vasculitis flare-ups following vaccinations have been reported in the past.2 , 3
Table 1.
Patient symptoms and details of workup
| Patient characteristic | Data |
|---|---|
| Year of IgAN diagnosis | 2017 |
| Exacerbations since diagnosis | 1. April 2019 following URI 2. June 2019 following shingles vaccine |
| Current treatment | Lisinopril |
| Baseline Cre | 0.7–0.8 g/dl |
| Last urine microalbumin/Cre before exacerbation (2020) | 633.1 mg/g Baseline always <1000 mg/g, except exacerbations |
| Urine microalbumin/Cre 48 h after Pfizer second dose | 2411.3 mg/g |
| Gross hematuria/RBCs in urine | Yes/yes |
| Other symptoms | Fever, myalgias, body aches, lower back pain bilaterally |
| Urine microalbumin/Cre 5 d after Pfizer second dose | 1441 mg/g |
| Hematuria 5 d after Pfizer second dose | Resolved |
Cre, creatinine; IgAN, IgA nephropathy; RBC, red blood cell; URI, upper respiratory tract infection.
Our patient’s symptoms improved within a week without any intervention aside from continued renin-angiotensin-aldosterone system blockade. It has been reported that severe coronavirus disease 2019 (COVID-19) illnesses can trigger an IgA response in the bronchial mucosa.4 However, it is unclear how a nonmucosal vaccine triggers this response. We suggest that nephrologists closely follow their patients after COVID-19 vaccination to evaluate for varying degrees of flares, particularly after the second dose of an mRNA vaccine without prior exposure to SARS-CoV-2.
References
- 1.Negrea L., Rovin B.H. Gross hematuria following vaccination for severe acute respiratory syndrome coronavirus 2 in 2 patients with IgA nephropathy. Kidney Int. 2021;99:1487. doi: 10.1016/j.kint.2021.03.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Lambert E.M., Liebling A., Glusac E., Antaya R.J. Henoch-Schonlein purpura following a meningococcal vaccine. Pediatrics. 2003;112:e491. doi: 10.1542/peds.112.6.e491. [DOI] [PubMed] [Google Scholar]
- 3.McNally A., McGregor D., Searle M., et al. Henoch-Schönlein purpura in a renal transplant recipient with prior IgA nephropathy following influenza vaccination. Clin Kidney J. 2013;6:313–315. doi: 10.1093/ckj/sft029. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Hasan Ali O., Bomze D., Risch L., et al. Severe coronavirus disease 2019 (COVID-19) is associated with elevated serum immunoglobulin (Ig) A and antiphospholipid IgA antibodies [e-pub ahead of print]. Clin Infect Dis. https://doi.org/10.1093/cid/ciaa1496 Accessed September 20, 2020. [DOI] [PMC free article] [PubMed]