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Year : 2022  |  Volume : 16  |  Issue : 4  |  Page : 461-462

Unmasking of immunoglobulin a deposits posttransplant due to COVID-19 AKI-incidental or causal – A nephrologists' dilemma a case report

Department of Nephrology, Osmania Medical College, Hyderabad, Telangana, India

Date of Submission11-Jul-2020
Date of Acceptance30-Jun-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Manisha Sahay
Department of Nephrology, Osmania Medical College, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_78_20

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COVID-19 is a global pandemic with the chronically immunosuppressed transplant recipients being the most vulnerable both to infection as well as complications of COVID-19. Here, we report a case of live-related renal allograft recipient who presented with complaints of loose stools and new-onset graft dysfunction 2 years posttransplant. He tested positive for COVID-19 infection. On allograft biopsy, there were significant immunoglobulin A (IgA) deposits with no evidence of rejection or ATN or crescents or significant chronicity. The initial pretransplant biopsy of the recipient had revealed chronic glomerulonephritis with nil deposits. The donor had no evidence of hematuria or hypertension and had a preserved GFR. We, therefore, considered the possibility of the unmasking of IgA deposits posttransplantation diagnosed in a recipient with COVID-19 infection.

Keywords: AKI, COVID-19, graft dysfunction, immunoglobulin A nephropathy

How to cite this article:
Dogra L, Sahay M, Ismal K, Vali P S. Unmasking of immunoglobulin a deposits posttransplant due to COVID-19 AKI-incidental or causal – A nephrologists' dilemma a case report. Indian J Transplant 2022;16:461-2

How to cite this URL:
Dogra L, Sahay M, Ismal K, Vali P S. Unmasking of immunoglobulin a deposits posttransplant due to COVID-19 AKI-incidental or causal – A nephrologists' dilemma a case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 8];16:461-2. Available from: https://www.ijtonline.in/text.asp?2022/16/4/461/364626

  Introduction Top

COVID-19 is a global pandemic and has not spared any population, with the chronically immunosuppressed transplant recipients being the most vulnerable both to infection as well as complications of COVID-19. More than ever, a disease has evolved to involve such large populations in such a short time that without much knowledge and guidelines much is left to speculations of the treating physician. As of today, 44,675,733 COVID-19-positive patients are present in India alone.[1]

  Case Report Top

Here, we report a 21-year-old male, who first presented in April 2018 at 19 years of age, with signs and symptoms of uremia. He had no previous history attributable to renal disease. On evaluation, he was found to have a baseline serum creatinine of 9 mg/dl, hemoglobin of 9.6g/dl, and microscopic hematuria with moderate proteinuria (2 g/day). Renal imaging revealed bilaterally borderline kidneys with early corticomedullary differentiation loss. He was biopsied in view of presentation as rapidly progressive renal failure. Renal biopsy revealed chronic glomerulonephritis with nil deposits on IF. He was started on hemodialysis and then underwent a renal transplant in July 2018, with his mother being the donor. It was a haplomatch, ABO compatible renal transplant without induction, with no perioperative or postoperative complications, and an uncomplicated course till discharge on day 14 as per hospital protocol on triple immunosuppression (CMV D+/R+) with antiviral and co-trimoxazole prophylaxis. Baseline investigations of the donor (mother) were normal, with a Technitium-99m diethylenetriaminepentaacetic acid (DTPA) Glomerular filtration rate (GFR) of 84 ml/min/m2. She was normotensive, nondiabetic and blood and urine chemistries were normal.

The patient was on regular follow-up on triple IS. He developed posttransplant diabetes mellitus 12 months posttransplant and was started on insulin therapy for the same. His baseline creatinine was 1.4 mg/dl 2 years posttransplant.

In June 2020, he presented with new-onset graft dysfunction with loose stools. Baseline investigations revealed normal blood counts with mild lymphopenia (white blood count of 10,200/cumm and absolute lymphocyte count of 2040/cumm) and rising serum creatinine (4 mg/dl at admission).

Tacrolimus levels were 6 ng/ml. Imaging findings of the graft were also normal. The stool examination was normal for routine examination. He deteriorated further with serum creatinine rising to 6mg/dl. He received one session of hemodialysis and underwent a renal biopsy. Renal biopsy revealed immunoglobulin A (IgA) deposits with only mild IFTA (20%) and no crescents or tubular injury and no evidence of rejection with a negative C4d stain. Further evaluations to rule out other causes of rejection (including DSA) and graft dysfunction (Cytomegalovirus and BK virus) were normal. COVID-19 testing was done though he was largely asymptomatic for COVID-19-specific symptoms except for loose stools and was found to be positive.[2],[3] He had no history of travel or exposure to a known COVID-19 case. The patient was shifted to a COVID-designated hospital for further management. Renal dysfunction improved in 4 weeks and creatinine came to baseline. He did not require oxygen or ventilatory support and was managed symptomatically.

  Discussion Top

COVID-19 is an RNA virus and has seven strains detected which affect humans. Usual presentation of COVID-19 is with influenzas such as illness and most patients recover uneventfully. The estimated mortality of COVID infection is between 1% and 6% and people with severe disabilities, morbidities, and those on immunosuppression are at higher risk.[1]

On retrospective evaluation, we hypothesize that this patient at first presentation had IgA nephropathy (IgAN) as the cause of his ESRD. Only once he had COVID-19 disease, these deposits were unmasked. Contrary to this, the possibility of passively acquiring these deposits from the donor (mother) kidney, however, looks less likely as the mother had no hypertension or hematuria and had a normal GFR for age. Furthermore, on the biopsy of the transplanted kidney, there was no evidence of significant chronicity. In the absence of a noninvasive marker of IgAN and that the donor cannot be subjected to an unwanted invasive renal biopsy, it remains difficult to prove or refute our assumption.

This case had a few more atypical features other than just the appearance of IgA deposits; first that this patient had significant kidney injury stage 3 (AKIN 3) in the absence of any significant tubular injury or markers of chronicity. This may be attributed to the focal nature of the biopsy sample though the number of glomeruli was appropriate. Furthermore, apart from COVID-19, he did not have any other apparent cause of AKI on biopsy in the form of crescents, rejection, etc., Furthermore, COVID-19 AKI is not described in patients who were mildly ill. Therefore, transplant recipients on immunosuppression may have an atypical presentation of COVID-19 disease.[4] The other possibility is that the AKI may have been due to volume depletion due to COVID-19-related gastroenteritis and the presence of significant IgA deposits was incidental. Whether the IgA came from the donor is difficult to say as the donor was asymptomatic and did not have any hematuria or proteinuria. Furthermore, whether the native kidney disease of the recipient was IgA can only be presumed as pretransplant biopsy did not show IgA.

Other researchers too have documented atypical presentations of COVID-19 in patients on potent IS and transplant recipients. Guillen et al. reported a case of posttransplant COVID-19 with gastrointestinal manifestations only.[5]

This case report is intriguing by the new appearance of IgA deposits in a posttransplant case with COVID-19, which has not been described earlier. Furthermore, it is a reminder to be vigilant and consider COVID testing in any patient who presents with a nonspecific illness or graft dysfunction which cannot be explained by conventional thinking. Utility of a 0 h implantation donor kidney biopsy seems enticing in case, however, cannot be recommended until more evidence accrues.

Declaration of patient consent

The authors certify that patient consent has been taken for participation in the study and for the publication of clinical details and images. The patient understands that the names and initials would not be published, and all standard protocols will be followed to conceal their identity.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

MOHFW, GOI. Available from: https://www.mohfw.gov.in. [Last accessed on 2022 Dec 09].  Back to cited text no. 1
Gao QY, Chen YX, Fang JY. 2019 Novel coronavirus infection and gastrointestinal tract. J Dig Dis 2020;21:125-6.  Back to cited text no. 2
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 3
Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, et al. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci 2020;63:706-11.  Back to cited text no. 4
Guillen E, Pineiro GJ, Revuelta I, Rodriguez D, Bodro M, Moreno A, et al. Case report of COVID-19 in a kidney transplant recipient: Does immunosuppression alter the clinical presentation? Am J Transplant 2020;20:1875-8.  Back to cited text no. 5


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