We read with interest the reports of relapsing glomerular diseases after coronavirus disease 2019 (COVID-19) vaccination [1, 2]. We describe two cases of minimal change disease (MCD) relapses and one case of gross haematuria with acute kidney injury (AKI) in immunoglobulin A (IgA) nephropathy following COVID-19 vaccination.
A 42-year-old Chinese woman and 30-year-old Malay man with biopsy-proven MCD diagnosed in October 2020 and January 2021, respectively, achieved complete remission following a tapering course of prednisolone. Both presented with lower limb swelling and frothy urine within 2 weeks of their second COVID-19 vaccine. Clinically, there was no evidence of concurrent infection or malignancy. There were no new medications. Repeat kidney biopsies were not performed. These were their first disease relapses. They subsequently achieved remission within 2 weeks of restarting prednisolone monotherapy. The third case was a 26-year-old man with suspected IgA nephropathy whose proteinuria was adequately managed with losartan. He presented with fever, gross haematuria, worsening proteinuria (rise in urine protein creatinine ratio from 74 to 174 mg/mmol) and AKI (rise in serum creatinine from 75 to 143 µmol/L) 1 day after his second dose of COVID-19 vaccination. Kidney biopsy revealed histological findings suggestive of IgA nephropathy with acute tubular injury. Details of these cases are presented in Table 1.
Table 1.
Clinical details of the three cases
| Case 1 | Case 2 | Case 3 | |
|---|---|---|---|
| Date of diagnosis (biopsy proven) | 8 October 2020 | 21 January 2021 | 3 August 2021 |
| Histological diagnosis | Minimal change disease | Minimal change disease | IgA nephropathy |
| Therapy and duration | oral prednisolone; tapered over 27 weeks | oral prednisolone; tapered over 2 months | – |
| Type of vaccine | Moderna COVID-19 vaccine | Pfizer-BioNTech COVID-19 vaccine | Pfizer-BioNTech COVID-19 vaccine |
| Vaccination dates | 25 May 2021, 2 July 2021 | 12 June 2021, 17 July 2021 | 8 July 2021, 30 July 2021 |
| Time period between second dose of vaccination and onset of symptoms of new disease activity (days) | 11 | 7 | 1 |
| Time period between last dose of prednisolone and onset of symptoms of new disease activity (months) | 3 | 4 | – |
| Laboratory findings upon clinical presentation of first disease relapse | |||
| Serum creatinine at presentation (µmol/L) | 54 | 64 | 143 |
| Serum albumin at presentation (g/L) | 40 | 17 | 40 |
| Urine protein creatinine ratio (mg/mmol) | 413 | 142 | 74 |
| 24-h urine protein (g/day) | 4.23 | 0.75 | – |
| Urine microscopy (white blood cells/red blood cells/epithelial cells per high-power field) | 0/0/2 | 5/0/0 | >100 red blood cells in the field |
| Medications (at presentation) | Atorvastatin 40 mg every night, cholecalciferol 1000 units twice daily, calcium carbonate 450 mg/vitamin D 200 IU 1 tablet twice daily, omeprazole 40 mg twice daily | Budesonide/formoterol turbuhaler 1 puff twice daily, salbutamol 100 µg 1–2 puffs 6-hourly as needed for breathlessness (asthma) | Losartan 50 mg twice daily, omega-3 fish oil 1 g twice daily |
| SARS-CoV-2 spike quantitative antibody (U/mL) | >250 | >250 | >250 |
There is a possible role of T-cell-mediated immune dysregulation precipitated by mRNA vaccination leading to glomerular disease flares [3]. Further research is warranted in this area. Adequate patient counselling and monitoring for early relapse should be vigilantly practised by managing nephrologists following COVID-19 vaccination.
Contributor Information
Leanne Ca-Yin Leong, Fast and Chronic Programmes, Alexandra Hospital, Singapore; Division of Nephrology, Department of Medicine, National University Hospital, Singapore.
Wei-Zhen Hong, Fast and Chronic Programmes, Alexandra Hospital, Singapore; Division of Nephrology, Department of Medicine, National University Hospital, Singapore.
Priyanka Khatri, Fast and Chronic Programmes, Alexandra Hospital, Singapore; Division of Nephrology, Department of Medicine, National University Hospital, Singapore.
PATIENT CONSENT
We obtained informed consent from the patients to publish their cases.
CONFLICT OF INTEREST STATEMENT
The authors declare that there is no conflict of interest.
REFERENCES
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