Renal Thrombotic Microangiopathy in Concurrent COVID-19 Vaccination and Infection

Abstract

We report on the development of nephrotic proteinuria and microhematuria, with histological features of renal thrombotic microangiopathy (TMA), following the first dose of BNT162b2 COVID-19 vaccine (Pfizer-BioNTech) and COVID-19 diagnosis. A 35-year-old previously healthy man was admitted at our hospital due to the onset of foamy urine. Previously, 40 days earlier, he had received the first injection of the vaccine, and 33 days earlier, the RT-PCR for SARS-CoV-2 tested positive. Laboratory tests showed nephrotic proteinuria (7.9 gr/day), microhematuria, serum creatinine 0.91 mg/dL. Kidney biopsy revealed ultrastructural evidence of severe endothelial cell injury suggestive of a starting phase of TMA. After high-dose steroid treatment administration, complete remission of proteinuria was achieved in a few weeks. The association of COVID-19 with renal TMA has been previously described only in patients with acute renal injury. Besides, the correlation with COVID-19 vaccine has not been reported so far. The close temporal proximity (7 days) between the two events opens the question whether the histological findings should be ascribed to COVID-19 itself or to vaccine injection.

New-Onset and Relapsed Kidney Histopathology Following COVID-19 Vaccination: A Systematic Review

“…A 35-year-old previously healthy male patient presenting with nephrotic-range proteinuria and microscopic hematuria following the first dose of the Pfizer-BioNTech vaccine was reported by De Fabritiis et al [43], with the final histopathological diagnosis found to be renal thrombotic microangiopathy (renal TMA). The patient had a positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction (SARS-CoV-2 PCR) test seven days after receiving his vaccine prior to the onset of urinary abnormalities.…”

New-Onset Kidney Diseases after COVID-19 Vaccination: A Case Series

“…However, the pathophysiologic mechanism of TMA after COVID-19 vaccination has not yet been clarified. Fabritiis et al also reported a case of TMA after the BNT162b2 vaccination [17]. In this case, foamy urine was observed 5 weeks after the second dose of vaccination, and complete remission was achieved after steroid pulse therapy and high-dose steroid therapy.…”

Thrombosis post-mRNA-based SARS-CoV-2 vaccination (BNT162b2) – Time to think beyond thrombosis with thrombocytopenia syndrome (TTS)

“…There are 16 cases of ITP, 12 cases of TTP reactivation, 11 cases of suspected intracerebral hemorrhage (ICH), 6 cases of cerebral venous sinus thrombosis, 1 case of pulmonary embolism, 1 case of renal thrombotic microangiopathy, a case of ST-elevation myocardial infarction (STEMI), 1 case of stroke, 1 case of central retinal artery occlusion, and a case of lower limb DVT associated with BNT162b2( Fig. 1 ) [ [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] ]. The STEMI reported in an elderly gentleman with multiple cardiovascular and pro-thrombotic risk factors 30mins post first dose of BNT162b2 is attributed to vaccination-induced “Kounis syndrome” or allergic myocardial infarction likely secondary to mast cell activation from an allergic or anaphylactoid reaction [ 11 ].…”