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Kidney Week

Abstract: PO0297

AKI and Collapsing Focal Segmental Glomerulosclerosis in an Immunocompetent Patient with Cytomegalovirus and COVID-19 Infection

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Ray, Milton, Harlem Hospital Center, New York, New York, United States
  • Jain, Sudhanshu, Harlem Hospital Center, New York, New York, United States
  • Andrabi, Suhaib A., Harlem Hospital Center, New York, New York, United States
  • Ramos, Marco, Harlem Hospital Center, New York, New York, United States
Introduction

Collapsing Glomerulopathy is a morphological variant of focal segmental glomerulosclerosis (FSGS) characterized by rapidly progressive renal failure and nephrotic range proteinuria. CMV-associated renal infections are usually seen in post-transplant and immunocompromised patients. We present a case of severe collapsing FSGS and acute CMV infection in an immunocompetent host.

Case Description

A 19-year-old woman with HbSS sickle cell disease and infrequent vaso occlusive crisis was hospitalized with febrile illness.

During hospitalization she developed non-oliguric acute kidney injury (AKI) and volume overload and started on intermittent hemodialysis.

Chest x-ray showed cardiomegaly, pulmonary venous congestion, infiltrates and bilateral pleural effusions. 24h Urine protein was 17,291 mg/24h. Urine and serum myoglobin were elevated. Relevant investigations include positive CMV IgM , CMV PCR 7000 international unit(s)/ml, positive mycoplasma IgM. SARS-CoV-2 RT-PCR & NAT were negative but antibodies were positive.

A diagnosis of COVID associated Multisystem inflammatory syndrome in children (MIS-C) was made and she received methylprednisolone.
She received piperacillin/tazobactam, azithromycin, ganciclovir, meropenem, and linezolid for CMV infection and pneumonia.

Renal biopsy revealed collapsing FSGS, moderate and acute tubular injury, interstitial edema, focal tubular microcysts and podocyte effacement.

Renal function improved after ganciclovir therapy and hemodialysis was discontinued. Prednisone and losartan were started for persistent proteinuria.

Discussion

Active CMV infection in immunocompetent hosts is uncommon. The mechanism of CMV associated with collapsing FSGS is unclear as direct viral infection is not always seen on biopsy.

CMV is not routinely tested for in immunocompetent patients and should be considered in AKI and nephrotic syndrome with multi-system involvement. Our patient had lung infiltrates and rhabdomyolysis which could be explained by CMV infection.

Anti-viral therapy may be effective. As opposed to primary collapsing FSGS steroids are not routinely needed. Some patients have persistent proteinuria and nephrotic syndrome may respond to steroids, with tacrolimus in refractory cases.
It is unclear if prior COVID infection or MIS-C contributed to activation of CMV infection and FSGS.