A case of gross hematuria and IgA nephropathy flare-up following SARS-CoV-2 vaccination
Authors: Shab E Gul Rahim, Jonathan T. Lin, John C. Wang
Journal: Kidney International (2021)

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).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 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.2Lambert E.M. Liebling A. Glusac E. Antaya R.J. Henoch-Schonlein purpura following a meningococcal vaccine.Pediatrics. 2003; 112: e491Crossref PubMed Scopus (27) Google Scholar,3McNally 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: 313-315Crossref PubMed Scopus (19) Google ScholarTable 1Patient symptoms and details of workupPatient characteristicDataYear of IgAN diagnosis2017Exacerbations since diagnosis1. April 2019 following URI2. June 2019 following shingles vaccineCurrent treatmentLisinoprilBaseline Cre0.7–0.8 g/dlLast urine microalbumin/Cre before exacerbation (2020)633.1 mg/gBaseline always <1000 mg/g, except exacerbationsUrine microalbumin/Cre 48 h after Pfizer second dose2411.3 mg/gGross hematuria/RBCs in urineYes/yesOther symptomsFever, myalgias, body aches, lower back pain bilaterallyUrine microalbumin/Cre 5 d after Pfizer second dose1441 mg/gHematuria 5 d after Pfizer second doseResolvedCre, creatinine; IgAN, IgA nephropathy; RBC, red blood cell; URI, upper respiratory tract infection. Open table in a new tab 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.4Hasan 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/ciaa1496Google Scholar 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. 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 Is COVID-19 vaccination unmasking glomerulonephritis?Kidney InternationalVol. 100Issue 2PreviewWe read with great interest the reports of macroscopic hematuria occurring hours following coronavirus disease 2019 (COVID-19) vaccination in patients with known IgA nephropathy (IgAN).1,2 We report 2 previously healthy individuals who presented with macroscopic hematuria shortly after COVID-19 vaccination and were diagnosed with IgAN and crescentic glomerulonephritis, respectively. 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 IgA nephropathy presenting as macroscopic hematuria in 2 pediatric patients after receiving the Pfizer COVID-19 vaccineKidney InternationalVol. 100Issue 3PreviewWith great interest, we read the recent reports of IgA nephropathy (IgAN) flare-up presenting as macroscopic hematuria, following the second dose of coronavirus disease 2019 (COVID-19) vaccination in adult patients.1–4 The US Food and Drug Administration granted an emergency use authorization for the Pfizer–BioNtech COVID-19 vaccination in December 2020 for individuals aged ≥16 years; the emergency use authorization was recently expanded to include children aged 12 to 15 years on May 10, 2021. Herein, we report 2 pediatric patients with IgAN presenting with macroscopic hematuria <24 hours after Pfizer COVID-19 vaccination. Full-Text PDF Histologic correlates of gross hematuria following Moderna COVID-19 vaccine in patients with IgA nephropathyKidney InternationalVol. 100Issue 2PreviewWe read with interest the recent reports of gross hematuria occurring in 4 patients with IgA nephropathy shortly following the second dose of mRNA vaccine for coronavirus disease 2019 (COVID-19).1–3 These include 2 cases following the Moderna vaccine1 and 2 following the Pfizer BioNTech vaccine.2,3 As only 1 of these patients had a postvaccination biopsy performed,3 we report the biopsy findings in 2 additional patients who underwent their first kidney biopsy due to the development of gross hematuria shortly following the second dose of the Moderna vaccine for COVID-19. Full-Text PDF Acute kidney injury with gross hematuria and IgA nephropathy after COVID-19 vaccinationKidney InternationalVol. 100Issue 4PreviewThe 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.1–3 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. Full-Text PDF Letter regarding: "A Case of Gross Hematuria and IgA Nephropathy Flare-Up Following SARS-CoV-2 Vaccination"Kidney International ReportsVol. 6Issue 8PreviewWe 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.1–3 Full-Text PDF Open AccessCOVID-19 vaccination followed by activation of glomerular diseases: does association equal causation?Kidney InternationalVol. 100Issue 5PreviewTo date, >4 billion doses of the various severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines have been administered worldwide in response to the coronavirus disease 2019 (COVID-19) pandemic. Even as widespread vaccination campaigns have contributed to declining case rates, adverse events are appearing beyond those originally reported in the clinical trials of vaccine efficacy and safety. Of particular relevance to the kidney is the increasing number of reports of de novo or reactivation of glomerular diseases (Table 11–25). Full-Text PDF