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Kidney Week

Abstract: PO0126

Cryoglobulinemia in the Setting of COVID-19 AKI

Session Information

Category: Coronavirus (COVID-19)

  • 000 Coronavirus (COVID-19)

Authors

  • Ward, Emily Louise, University of Louisville, Louisville, Kentucky, United States
  • Garg, Gunjan, University of Louisville, Louisville, Kentucky, United States
Introduction

COVID19 is due to SARS-CoV-2 a single stranded RNA virus with respiratory and epithelial cell targets. As COVID19 has reached pandemic proportions, complicating AKI is common. Pathogenesis is varied and multifactorial but acute tubular injury is most common. Glomerular pathology is possible but not well defined.

Case Description

66YOM with HTN, Stage III CKD, & COVID19 hypoxemic respiratory failure complicated by AKI & nephritic syndrome. Cr peaked at 5mg/dL. He required CRRT for volume overload & acidosis. Labs showed low C3 & type I cryoglobulinemia. IgGλ monoclonal protein on SPEP. Extensive cryoglobulinemic GN on renal bx with IgGλ immunofluorescence. Negative Congo red stain. Microtubular deposits indicative of cryoglobulins on EM.

He received pulsed solumedrol then 5 sessions of PLEX. Renal recovery with good urine output, dialysis discontinued. Cr down to 2.2mg/dL post PLEX.

Discussion

Cryoglobulinemia is due to cold immunoglobulin precipitation. Type I is associated with malignancy or hematologic disease and Types II & III have infectious triggers. Our patient had Type I IgGλ cryoglobulinemia without evidence of malignancy. BM bx had 10% abnormal plasma cells, perhaps due to plasma cell dyscrasia of cryoglobulinemia.

A prior case series reported COVID19 incident MGUS. Patients had monoclonal IgGλ or IgGκ but no mentioned renal injury. They hypothesized gammopathy due to immune hyperactivation. Expounding, our patient's renal manifestations fit a Hemophagocytic Lymphohistiocytosis pattern so we hypothesize they are due to COVID19 associated hyperinflammation and cytokine release.

Our case illustrates the benefit of biopsy to identify additional treatment options and the reality that timely biopsy can't always be safely obtained. In COVID19 patients respiratory or hematologic status can make biopsy unsafe which may limit defining associated glomerular pathology.