Lessons for the clinical nephrologist: recurrence of nephrotic syndrome induced by SARS-CoV-2
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LESSON FOR THE CLINICAL NEPHROLOGIST
Lessons for the clinical nephrologist: recurrence of nephrotic syndrome induced by SARS‑CoV‑2 Adrian A. N. Doevelaar1 · Bodo Hölzer1 · Felix S. Seibert1 · Frederic Bauer1 · Ulrik Stervbo2 · Benjamin J. Rohn1 · Panagiota Zgoura1 · Peter Schenker3 · Eva Vonbrunn4 · Kerstin Amann4 · Richard Viebahn3 · Nina Babel1,2 · Timm H. Westhoff1 Received: 5 August 2020 / Accepted: 28 August 2020 © The Author(s) 2020
Abstract SARS-CoV-2 is characterized by a multiorgan tropism including the kidneys. Recent autopsy series indicated that SARSCoV-2 can infect both tubular and glomerular cells. Whereas tubular cell infiltration may contribute to acute kidney injury, data on a potential clinical correlative to glomerular affection is rare. We describe the first case of nephrotic syndrome in the context of COVID-19 in a renal transplant recipient. A 35 year old male patient received a kidney allograft for primary focal segmental glomerulosclerosis (FSGS). Three months posttransplant a recurrence of podocytopathy was successfully managed by plasma exchange, ivIG, and a conversion from tacrolimus to belatacept (initial proteinuria > 6 g/l decreased to 169 mg/l). Six weeks later he was tested positive for SARS-CoV-2 and developed a second increase of proteinuria (5.6 g/l). Renal allograft biopsy revealed diffuse podocyte effacement and was positive for SARS-CoV-2 in RNA in-situ hybridation indicating a SARS-CoV-2 associated recurrence of podocytopathy. Noteworthy, nephrotic proteinuria resolved spontaneously after recovering from COVID-19. The present case expands the spectrum of renal involvement in COVID-19 from acute tubular injury to podocytopathy in renal transplant recipients. Thus, it may be wise to test for SARS-CoV-2 prior to initiation of immunosuppression in new onset glomerulopathy during the pandemic. Keywords SARS-CoV-2 · COVID-19 · Podocytopathy Abbreviations Covid-19 Coronavirus disease 2019 SARS-CoV-2 SARS Coronavirus 2 ACE2 Angiotensin-converting enzyme 2 Electronic supplementary material The online version of this article (https://doi.org/10.1007/s40620-020-00855-5) contains supplementary material, which is available to authorized users. * Timm H. Westhoff [email protected] 1
Medical Department 1, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Hölkeskampring 40, 44625 Herne, Germany
2
Center for Translational Medicine, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
3
Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
4
Department of Nephropathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
Case A 35-year old male patient of African origin with primary focal segmental glomerulosclerosis (FSGS) underwent successful renal transplantation in December 2019. After induction therapy with thymoglobuline, immunosuppression consisted of tacrolimus, mycophenolate mofetil, and prednisolone. 3 weeks af
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