Acute kidney injury with gross hematuria and IgA nephropathy after COVID-19 vaccination
Authors: Richard Plasse, Robert Nee, Sanh Gao, Stephen Olson
Journal: Kidney International (2021)

The mRNA coronavirus disease 2019 (COVID-19) vaccines induce an IgG response that prevents people from contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Interestingly, there are now at least 6 cases of gross hematuria reported in patients with a history of biopsy-proven IgA nephropathy (IgAN), involving both mRNA vaccines.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, 3Perrin P. Bassand X. Benotmane I. Bouvier N. Gross hematuria following SARS-CoV-2 vaccination in patients with IgA nephropathy.Kidney Int. 2021; 100: 466-468Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar All of the previous patients were treated with supportive therapy with rapid resolution of hematuria and no acute kidney injury (AKI). It has been reported in preclinical trials that nasal shedding of SARS-CoV-2 still occurred after vaccination with both mRNA vaccines, suggesting a lack of a mucosal IgA response.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,4Bleier B.S. Ramanathan Jr., M. Lane A.P. COVID-19 vaccines may not prevent nasal SARS-CoV-2 infection and asymptomatic transmission.Otolaryngol Head Neck Surg. 2021; 164: 305-307Crossref PubMed Scopus (103) Google Scholar We also cared for 2 patients who had prior biopsy-proven IgAN, who developed gross hematuria after their second dose of the Pfizer vaccine, without a preceding COVID-19 infection. Table 1 outlines the clinical data. Our first patient presented 5 days after his second dose, with nonspecific myalgias, chills, headache, dysuria, and gross hematuria within 24 hours of initial symptoms. Previous IgAN flares in this patient were precipitated by upper respiratory infections and were limited to gross hematuria with no AKIs and no requirement for steroids in the past. His postvaccine workup was notable for AKI, with a serum creatinine level of 3.53 mg/dl and a urine protein–creatinine ratio of 3.0. He was empirically started on steroids with recovery to baseline renal function at 1 month and recovery to baseline proteinuria within 2 months. Our second patient developed gross hematuria within 24 hours of receiving his second dose. His hematuria resolved after 3 days with supportive therapy only. To our knowledge, we are the first to report an IgAN flare that has led to an AKI that resolved with steroid therapy. We agree that it is not clear how a nonmucosal immune challenge led to an IgAN exacerbation; however, the delayed-type hypersensitivity reactions seen in our patients suggest a cell-mediated immune response, not an antibody response. We offer further evidence that patients with IgAN warrant close monitoring after receiving their second mRNA vaccine dose.Table 1Patient characteristics, treatment, and symptomsPatient characteristicsPatient 1Patient 2Year of IgAN diagnosis20182020Exacerbations since diagnosis1. February 2019: UPCR 3.2 after URI;None2. February 2020: UPCR 2.6 after URICurrent treatmentLisinopril and prednisoneLisinoprilBaseline serum creatinine level, mg/dl0.81.0Peak serum creatinine level after COVID-19 vaccine, mg/dl3.531.16Last UPCR (gm/g) before COVID-19 vaccine1.560.61Last UACR (mg/g) before COVID-19 vaccineNA341Gross hematuriaYesYesOther symptomsFevers, chills, body aches, dysuriaBody achesUPCR (gm/g) after COVID-19 vaccine4.970.92UACR (mg/g) after COVID-19 vaccine3160320Hematuria 5 days after COVID-19 vaccinePresentResolvedCOVID-19, coronavirus disease 2019; IgAN, IgA nephropathy; NA, not applicable; UACR, urine albumin–creatinine ratio; UPCR, urine protein–creatinine ratio; URI, upper respiratory infection. Open table in a new tab COVID-19, coronavirus disease 2019; IgAN, IgA nephropathy; NA, not applicable; UACR, urine albumin–creatinine ratio; UPCR, urine protein–creatinine ratio; URI, upper respiratory infection. The views expressed in this chapter are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or US government. The authors are military service members. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that "Copyright protection under this title is not available for any work of the United States Government." Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties. 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 Gross hematuria following vaccination for severe acute respiratory syndrome coronavirus 2 in 2 patients with IgA nephropathyKidney InternationalVol. 99Issue 6PreviewSeveral of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines use a nucleoside-modified, purified mRNA lipid nanoparticle-encapsulated platform. Compared with traditional inactivated viral and adjuvanted protein vaccines, this RNA platform elicits far higher neutralizing antibody titers, stronger antigen-specific cluster of differentiation (CD) 4+ and CD8+ T-cell responses, and stronger germinal center B and TFH cell activation in experimental animals.1 The activated CD4+ and CD8+ T cells produce several proinflammatory cytokines, including interferon-γ and tumor necrosis factor-α. Full-Text PDF Gross hematuria following SARS-CoV-2 vaccination in patients with IgA nephropathyKidney InternationalVol. 100Issue 2PreviewAfter the publication of the 2 letters by Negrea and Rovin1 and Rahim et al.,2 we herein describe 3 additional patients with IgA nephropathy (IgAN) who developed gross hematuria after receiving severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA-based vaccines. The clinical data of our cases are summarized in Table 1. In line with the 3 previously reported cases, patient 1 had normal kidney function. However, patients 2 and 3 were treated with kidney transplantation (KT) and hemodialysis, respectively. Full-Text PDF Distinct glomerular disease association after vaccination with BNT162b2 and mRNA-1273: a VigiBase analysisKidney InternationalVol. 101Issue 2PreviewWith the worldwide rollout of coronavirus disease 2019 (COVID-19) vaccines, numerous reports of de novo or relapsing glomerular diseases have been published recently.1–4 It has been stressed that associations between vaccination efforts and the onset of disease do not prove causation, but the administration of vaccines and the induction of an immune response might trigger disease activity. Of note, most cases appear to be either IgA nephropathy (IgAN) or minimal change disease,1 with around 30 cases each reported to date. Full-Text PDF