Case descriptionA 29-year-old South Asian male presented with fever, myalgia and lower limb swelling of 3 days duration. Four weeks prior to presentation, he had been diagnosed with COVID-19 infection and was treated symptomatically in the community isolation facility.He was diagnosed to have nephrotic syndrome with proteinuria of 8.71 g/24 h and serum albumin of 22 g/L. He also had acute kidney injury with peak serum creatinine of 145 µmol/L, estimated glomerular filtration rate (eGFR) of 65 mL/min per 1.73 m 2 . Urinalysis revealed few dysmorphic red blood cells and presence of white blood cells. Antinuclear antibody, anti-double stranded DNA, antineutrophil cytoplasmic antibodies were negative. Hepatitis B, Hepatitis C and HIV screens were negative and ultrasound imaging showed normal kidneys.Kidney biopsy showed 28 glomeruli with diffusely thickened capillary walls. Some glomeruli displayed segmental increases in mesangial cells amid expanded mesangial matrix. Masson-silver stains showed tiny fuchsinophilic subepithelial deposits and fine vacuolization of tangentially sectioned portions of the glomerular basement membranes (Fig. 1). Immunofluorescence showed 3 + finely granular staining for IgG along glomerular capillary walls, with focal weak segmental staining for anti-phospholipase A2 receptor (PLA2R) regarded as of uncertain significance (Fig. 2).Electron microscopy revealed thickened glomerular basement membranes and subepithelial electron dense deposits.

BackgroundEnd stage renal disease (ESRD) is on the rise globally. Varicella infection among adult patients with ESRD has been reported to lead to multiple complications and even death. While varicella vaccination has been recommended in paediatric renal patients; recommendation on varicella vaccination among adult patients with ESRD remained sparse. This review is aimed at evaluating the impact of varicella infection among adult patients with ESRD and make a recommendation for vaccination.MethodsThree databases (PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched in April 2018 with keywords ‘varicella, chronic kidney failure, chronic kidney disease, renal replacement therapy, kidney transplantation, end stage renal disease, end stage renal failure, chicken pox, vaccine, vaccination and complications’.Results29 articles were selected for review. The studies were mainly case reports, and they included measured outcomes: prevalence of seronegativity, impact (morbidity, length of stay, and mortality) of varicella among patients with ESRD, seroconversion rates and safety of varicella vaccination. The prevalence of seronegativity among varicella-infected ESRD adults was found to be at 42 to 100%. Nineteen deaths were reported. At least 54 patients have had complications from varicella infection. Seroconversion rate post vaccination was found to be around 64–94%.ConclusionVaricella is associated with significant morbidity and mortality rates in adult patients with ESRD. Varicella vaccination should be considered for the vulnerable, seronegative patients.

BackgroundCrescent formation generally reflects severe glomerular injury. There is sparse literature on post-infectious glomerulonephritis (PIGN) with crescents in adults. This retrospective study looked at nine such cases to see if there is a correlation between the severity of presentation, steroid treatment, histological severity and outcome.MethodsBiopsy reports of all the adults who underwent kidney biopsy from February 2010 to June 2014 in a tertiary care hospital were screened and all the cases with the diagnosis of PIGN with crescents were selected. Clinical presentation, laboratory data, histology, treatment and outcome were analysed.ResultsSix patients had evidence of recent/current infection, but all except two were non-streptococcal. The mean creatinine was 360.67 μmol/L (range 70.72–770.85) and the mean estimated glomerular filtration rate (MDRD eGFR) was 30.28 mL/min/1.73 m2 (range 6.4–111.1) on presentation. All five patients who were treated with steroids had an excellent response. Among the four patients who did not receive steroids, two were left with significant renal impairment (mean MDRD eGFR 23.5 mL/min/1.73 m2) at a mean follow-up of 15.5 months (range 10–21). The mean percentage of glomeruli with crescents was 36.13% (range 11.76–100) and except in one, there was no tubular atrophy or interstitial fibrosis and none had glomerulosclerosis. None of the patients progressed to end-stage renal disease.ConclusionNon-streptococcal infections are more common precipitants. There was no correlation between histological and clinical severity. Patients treated with steroids had better renal outcomes.

AimClinical presentation and course of Immunoglobulin A nephropathy vary by ethnicity and geography and significance of extracapillary proliferation or crescents (IgAN‐C) in Southeast Asia is not well described. We aimed to describe the clinical course of IgAN‐C in Singapore.MethodsRetrospective cohort study of adult biopsy‐proven IgAN diagnosed between February 2011 and October 2016 in 2 hospital‐based nephrology units. Outcome was chronic kidney disease (CKD) progression, defined as reduction in eGFR ≥50% or end stage renal failure (ESRF).ResultsOne hundred and forty‐five patients were studied. Among individuals with IgAN‐C (n = 44, 30%), 38 patients had cellular or fibrocellular crescents in 1 to 25% of the glomeruli and 6 had crescents in >25%. Median eGFR was 54 (33, 83) mL/min/1.73 m2. Compared to IgAN without crescents, IgAN‐C had greater proteinuria (median 2.9 [1.4, 5.4] g/g vs 1.9 [1.1, 3.6] g/g, P = .03) and more had endocapillary hypercellularity (96% vs 39%, P < .001). IgAN‐C were also more likely to receive immunosuppressants (66% vs 43%, P = .01) such as prednisolone (63% vs 38%, P = .006) and cyclophosphamide (12% vs 2%, P = .03).Median follow up was 27 (12, 46) months. IgAN‐C were more likely to achieve proteinuria reduction ≥50% at 6 months (66% vs 44%, P = .03). CKD progression within 12 months was not different among those with and without crescents (13% vs 10% respectively, P = .73). However, immunosuppressant treatment of IgAN‐C was associated with reduced ESRF (0 vs 20%, P = .03).ConclusionImmunosuppressants may attenuate the risk of ESRF in IgAN‐C.

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