Thrombotic Microangiopathy Triggered by COVID-19: Case Reports

Abstract

SARS-CoV-2 causes thrombotic microangiopathy (TMA) through the activation of an alternative and lectin complement pathway. TMA is one of the main reasons for acute kidney injury development in patients with COVID-19. In this study, we present 3 TMA cases with severe kidney injury triggered by SARS-CoV-2. In the absence of other TMA causes, we diagnosed the atypical hemolytic uremic syndrome, triggered by SARS-CoV-2 due to abnormal complement activation. Because of both coagulation factors activation, and the high level of D-dimer in patients with COVID-19, it is crucial to differentiate disseminated intravascular coagulation from TMA. The use of anticomplement therapies such as eculizumab should be considered in refractory cases of progressive COVID-19. Controlled clinical trials are required before a definitive statement can be made.

Osteonecrosis with Concomitant Bacterial Osteomyelitis of Both Hips and a Knee in a Post–COVID-19 Patient

“…Multiple reports have described hypercoagulability and thrombotic events in critically ill COVID-19 patients and in patients with elevated D-dimer levels 12,13 . There is evidence of disseminated intravascular coagulation (DIC), vascular endothelial damage, and thrombotic microangiopathy in COVID-19 1 .…”

COVID-19: A Rare Cause of Hemolytic Uremic Syndrome

“…The vasodilatory, anti-inflammatory and antithrombotic effects of nitric oxide are then lost [1]. This demonstrates how COVID-19 infection may cause kidney injury by inciting inflammation, complement activation, endothelial dysfunction, and thrombotic microangiopathy [8].…”

“…COVID-19 spike protein activates the alternative complement pathway by competing with complement factor H [2][3][4]6]. Complement cascade proteins also accumulate in the microvasculature of patients with COVID-19 [3,7,8]. Extensive complement activation causes MAC deposition on renal tubules.…”

“…Seven of the cases reported were initial presentations of aHUS, and two were relapses, as seen in our case. The treatment provided to these patients and the clinical outcome are summarized in Table 2 [ 3 , 6 , 8 , 13 , 14 ]. The treatment options included eculizumab or ravulizumab, a new complement component C5 inhibitor [ 15 ].…”

“…[3,6,8,13,14]. The treatment options included eculizumab or ravulizumab, a new complement component C5 inhibitor[15].…”