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Abstract: PO1545

Primary Membranous Nephropathy Flare After COVID-19 Vaccination

Session Information

Category: Glomerular Diseases

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Liang, Kelly V., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
  • Kurtz, Elizabeth C., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
  • Pittappilly, Matthew, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
  • Ahmad, Syeda B., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
  • Minervini, Marta I., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
Introduction

Primary membranous nephropathy (MN) is most commonly due to phospholipase A2 receptor antibodies (PLA2R Ab). It is unclear whether the COVID-19 vaccine can trigger flares of glomerular diseases such as primary MN. We present a patient with MN and metastatic breast cancer who developed nephrotic syndrome after receiving her second mRNA-1273 COVID-19 vaccine with positive PLA2R Ab by ELISA suggesting MN flare.

Case Description

A 62 year old female with history of Stage IIIB T3N3M1 ER/PR positive HER-2 negative metastatic left breast invasive ductal carcinoma, hypertension, hyperlipidemia, and primary MN presented with bilateral leg edema, dyspnea, and proteinuria 2 weeks after COVID-19 vaccination. She had previous proteinuria of 7029 mg/24hr in August 2018 with PLA2R Ab 128 RU/mL in October 2018. She underwent modified radical mastectomy in September 2018 followed by adjuvant chemotherapy in November 2018, after which PLA2R Ab decreased to <2 RU/mL in February 2019 and urine protein/Cr ratio (UPCR) decreased to 1094 mg/g Cr in April 2019. She was diagnosed with metastatic breast cancer and started anastrazole transiently. She received mRNA-1273 COVID-19 vaccines in late January and February 2021. In March 2021, she presented with bilateral leg edema, dyspnea, and bilateral pleural effusions. Urinalysis had >1000 protein, 24hr urine protein 11.2 g, Cr 1.6 mg/dL, and PLA2R Ab 787 RU/mL. Renal biopsy showed immune complex-mediated glomerulopathy with positive PLA2R, consistent with primary MN stage II-III. Glomerular basement membrane deposits were strongly positive for IgG4. Electron microscopy showed numerous subepithelial and occasional intramembranous electron-dense immune-type deposits. She was treated with lisinopril and furosemide followed by rituximab in May 2021. Prior to rituximab PLA2R Ab was 342 RU/mL and UPCR was 8671 mg/g Cr.

Discussion

There is insufficient data on the risk of flare after COVID-19 vaccine in glomerular diseases. There have been a few case reports of primary MN and minimal change disease after COVID-19 vaccine as well as MN after influenza vaccine. Our case of primary MN flare after COVID-19 vaccine adds support to a potential association between SARS-CoV-2 antigens and loss of tolerance to the PLA2R antigen. Close follow-up of patients with primary MN and other glomerular diseases after COVID-19 vaccination is warranted.