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Abstract: PO1487

COVID-19-Associated Collapsing Focal Segmental Glomerulosclerosis During Pregnancy in a Woman with Lupus Nephritis

Session Information

Category: Glomerular Diseases

  • 1202 Glomerular Diseases: Immunology and Inflammation

Authors

  • Santosh, Ramchandani, Lehigh Valley Health Network, Allentown, Pennsylvania, United States
  • Aown, Syed, Lehigh Valley Health Network, Allentown, Pennsylvania, United States
  • Maynard, Sharon E., Lehigh Valley Health Network, Allentown, Pennsylvania, United States
Introduction

Lupus nephritis (LN) is a common clinical entity in patients with systemic lupus erythematosus (SLE). LN is classified on the basis of renal biopsy findings. We present a woman with a history of LN who was diagnosed with COVID and AKI during pregnancy. Kidney biopsy showed collapsing FSGS and class V LN with APOL1 gene mutation.

Case Description

A 32-year-old G4P0212 African American female presented to a multidisciplinary Nephrology Maternal-Fetal Medicine program at 12 weeks gestation for management of LN in pregnancy. She was diagnosed with SLE at age 8, previously treated with rituximab and belimumab for rash, and other extrarenal manifestations. Three years prior, she was diagnosed with LN Class 3 + Class V treated with MMF with partial remission. She was switched from MMF to azathioprine at pregnancy diagnosis. She was diagnosed with COVID 4 days prior to the telemedicine office visit with GI symptoms and fever and admitted to the hospital. Her creatinine was 3.9 mg/dl, increased from the prior baseline of 1.3 mg/dl. Urinalysis showed proteinuria, and 24-hour urine collection contained 13.6 grams of protein. Her renal function continued to worsen despite intravenous fluid administration. Laboratory results included anti-Ds DNA titer 1:80, C3 61 mg/dl (90-180 mg/dL), and C4 34 mg/dl (10 -40 mg/dL). Kidney biopsy revealed class V LN and FSGS potentially related to COVID. As per biopsy finding and ethnicity, we sent APOL1 genetic analysis which came back positive. Treatment was started with IV steroids. The creatinine peaked at 4.7 mg/dl on hospital day 8 and subsequently improved. She did not require RRT and was continued on her maintenance IS. Unfortunately, she had fetal demise at 18 weeks 3 days of gestation with stable renal function.

Discussion

This is a case of COVID-associated FSGS in a pregnant woman with a history of LN. The initial impression included prerenal azotemia, LN flare, and COVID-associated kidney injury. Serologies were consistent with an LN flare, but renal biopsy showed both class 5 LN and FSGS potentially related to COVD. Kidney biopsy should be considered in pregnant patients with hematuria, proteinuria, to rule out alternative etiologies, even when LN is suspected on clinical grounds. The threshold of RRT is very narrow in pregnancy and requires increasing dialysis frequency for adequate pregnancy outcomes.