Glomerular basement membrane nephritis: crescentic renal inflammation and immunosuppressive intervention in the time of the severe acute respiratory syndrome coronavirus 2 pandemic
Authors: Silke R. Brix, Rachel B. Jones, David R.W. Jayne
Journal: Kidney International (2021)

The diagnosis and management of autoimmune disorders is challenging in the current pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Here, we describe the case of a patient with anti–glomerular basement membrane (GBM) disease complicated by a SARS-CoV-2 infection to highlight the importance of appropriate immunosuppression and individualized care in respect of these 2 disease processes. The 44-year-old Caucasian male presented to the emergency department with palpitations and a new tickling cough. He displayed tachycardia, lymphopenia (0.21 × 109/L), and a positive rapid test for SARS-CoV-2. He recently had been diagnosed with anti-GBM glomerulonephritis (GN), causing an acute kidney injury. He was receiving alternate-day plasma exchange, oral glucocorticoids, and i.v. cyclophosphamide pulses to preserve kidney function. His chest radiography did not reveal any pneumonic consolidation. He was admitted to the hospital and commenced on remdesivir. He did not develop more severe symptoms of pneumonitis typical for SARS-CoV-2. After 5 days of remdesivir treatment, he was discharged and his plasma exchange and cyclophosphamide therapies were restarted while he remained SARS-CoV-2 polymerase chain reaction (PCR)–positive. SARS-CoV-2 PCR became undetectable after a total of 31 days, and SARS-CoV-2 antibodies were detected (Figure 1). The current pandemic is a global health threat and a great challenge to vasculitis and GN care. Here, we describe a SARS-CoV-2 infection in a vasculitis patient in which the viral infection remained mild despite aggressive immunotherapy. A registry of SARS-CoV-2 infection in patients with immune-mediated kidney diseases proposed a higher mortality in GN patients.1Waldman M. Soler M.J. Garcia-Carro C. et al.Results from the IRoc-GN international registry of patients with COVID19 and glomerular disease suggest close monitoring.Kidney Int. 2021; 99: 227-237Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Waldman et al. detected a higher rate of acute kidney injury and a more pronounced hypoalbuminaemia in 40 GN patients as potential causes for the adverse outcome, while the immunotherapy did not correlate with mortality. Risk stratification in SARS-CoV-2 disease is evolving.2Williamson E.J. Walker A.J. Bhaskaran K. et al.Factors associated with COVID19 related death using OpenSAFELY.Nature. 2020; 584: 430-436Crossref PubMed Scopus (4037) Google Scholar, 3Lee L.Y. Cazier J.P. Angelis V. et al.COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study.Lancet. 2020; 395: 1919-1926Abstract Full Text Full Text PDF PubMed Scopus (846) Google Scholar, 4Ellinghaus D. Degenhardt F. Bujanda L. et al.On behalf of the Severe COVID-19 GWAS groupGenomwide Association Study of Severe COVID-19 With Respiratory Failure.N Engl J Med. 2020; 383: 1522-1534Crossref PubMed Scopus (1313) Google Scholar SARS-CoV-2 vaccination will be the most important step toward protecting immune-compromised patients. In the presence of scarce resources, equitable and effective risk–benefit allocation will be vital, prioritizing vulnerable patients. Timing immunotherapy with vaccination and determining vaccination response will be crucial. Concurrent SARS-CoV-2 infection should not prevent delivery of effective immunomodulatory therapy in patients with severe autoimmune diseases, essential for the protection and recovery of vital organ function.