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      Newly-diagnosed immunoglobulin A nephropathy with increased plasma galactose-deficient-IgA 1 antibody associated with mRNA COVID-19 vaccination: a case report

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          Abstract

          Newly-diagnosed or relapses of immunoglobulin A nephropathy (IgAN) have been associated with COVID-19 vaccination in the literature. Most reported cases were mild clinical diseases characterized by microscopic haematuria and do not require dialysis treatment. This current case report describes a 55-year-old male patient that presented to the emergency department with acute kidney injury after receiving the first dose of the mRNA-1273 COVID-19 vaccine. After admission, his renal function deteriorated rapidly, and then he developed uraemic encephalopathy. He underwent emergency haemodialysis with a rapid improvement in his mental status. Renal biopsy showed newly-diagnosed IgA nephropathy along with markedly elevated plasma level of galactose-deficient-IgA 1 (Gd-IgA 1) antibody. The patient did not receive immunosuppressive treatment and is now dialysis-free. Immune activation is considered an essential factor in developing or exacerbating IgAN following COVID-19 vaccination. This current case report demonstrates that elevated Gd-IgA 1 antibody may be the potential mechanistic link between COVID-19 vaccination and IgAN.

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          Oxford Classification of IgA nephropathy 2016: an update from the IgA Nephropathy Classification Working Group.

          Since the Oxford Classification of IgA nephropathy (IgAN) was published in 2009, MEST scores have been increasingly used in clinical practice. Further retrospective cohort studies have confirmed that in biopsy specimens with a minimum of 8 glomeruli, mesangial hypercellularity (M), segmental sclerosis (S), and interstitial fibrosis/tubular atrophy (T) lesions predict clinical outcome. In a larger, more broadly based cohort than in the original Oxford study, crescents (C) are predictive of outcome, and we now recommend that C be added to the MEST score, and biopsy reporting should provide a MEST-C score. Inconsistencies in the reporting of M and endocapillary cellularity (E) lesions have been reported, so a web-based educational tool to assist pathologists has been developed. A large study showed E lesions are predictive of outcome in children and adults, but only in those without immunosuppression. A review of S lesions suggests there may be clinical utility in the subclassification of segmental sclerosis, identifying those cases with evidence of podocyte damage. It has now been shown that combining the MEST score with clinical data at biopsy provides the same predictive power as monitoring clinical data for 2 years; this requires further evaluation to assess earlier effective treatment intervention. The IgAN Classification Working Group has established a well-characterized dataset from a large cohort of adults and children with IgAN that will provide a substrate for further studies to refine risk prediction and clinical utility, including the MEST-C score and other factors.
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            IgA nephropathy.

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              COVID-19 vaccination and glomerulonephritis

              Background MRNA COVID-19 vaccine is more effective than traditional vaccines due to superior immune activation. However, the impact of mRNA COVID-19 vaccine on triggering de novo/relapsing glomerulonephritis (GN) is limited. We report a case series of patients who developed new or relapsing GN post vaccination. Method We evaluated baseline characteristics, vaccine type and clinical outcomes of 13 patients from our institution who had a new diagnosis or relapse of their GN post mRNA COVID-19 vaccination. Results Of 13 patients, 8 patients were newly diagnosed GNs and 5 patients had relapse. Median age was 62 years (range 19-83 years). Autoimmune disease (38%) was the most prevalent underlying disease followed by cancer (23%). Majority of patients were white male. IgA nephropathy (IgAN) was the most common GN in our series (5 patients, 38%) followed by membranous nephropathy (MN) (3 patients, 23%). One patient with IgAN had evidence of IgA deposits prior to vaccination suggesting that the immune activation following vaccination triggered a flare of the disease. Our case series also included the first case report of tip-variant focal segmental glomerulosclerosis, NELL-1 associated MN, and atypical anti-GBM nephritis. Seventy seven percent developed acute kidney injury with the majority being KDIGO stage 1 (67%). Outcome are favorable with 80% responding to therapy. Conclusions New cases and relapse of GN can present shortly after mRNA COVID-19 vaccination. New cases of IgAN may result from unmasking of undiagnosed IgAN due to robust immune activation rather than development of new deposits.
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                Author and article information

                Journal
                J Int Med Res
                J Int Med Res
                IMR
                spimr
                The Journal of International Medical Research
                SAGE Publications (Sage UK: London, England )
                0300-0605
                1473-2300
                October 2022
                19 October 2022
                : 50
                : 10
                : 03000605221129674
                Affiliations
                [1 ]Department of Critical Care Medicine, Far Eastern Memorial Hospital, New Taipei City
                [2 ]Department of Medicine, Far Eastern Memorial Hospital, New Taipei City
                [3 ]Department of Anatomical Pathology, Far Eastern Memorial Hospital, New Taipei City
                [4 ]Department of Medical Research, Far Eastern Memorial Hospital, New Taipei City
                [5 ]Division of Nephrology, Department of Medicine, National Taiwan University Hospital, Taipei
                [6 ]Graduate Institute of Medicine and Graduate Programme in Biomedical Informatics, Yuan Ze University, Taoyuan
                [7 ]Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei
                Author notes
                [*]

                These authors contributed equally to this work.

                [*]Yen-Ling Chiu, Department of Medical Research, Far-Eastern Memorial Hospital. No.21, Section 2, Nanya S Road, Banciao District, New Taipei City 10051 (220). Email: yenling.chiu@ 123456gmail.com
                Author information
                https://orcid.org/0000-0003-4504-5571
                Article
                10.1177_03000605221129674
                10.1177/03000605221129674
                9585566
                36262058
                048d9a5f-41d1-4145-acc5-fcb44ad01103
                © The Author(s) 2022

                Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 8 March 2022
                : 5 September 2022
                Funding
                Funded by: Far Eastern Memorial Hospital, Taiwan;
                Award ID: FEMH-2019-C-023
                Funded by: Ministry of Science and Technology, Taiwan, FundRef https://doi.org/10.13039/501100004663;
                Award ID: MOST 109-2314-B-418 -011 -MY3
                Categories
                Case Reports
                Custom metadata
                ts2

                acute kidney injury,immunoglobulin a nephropathy,covid-19 vaccination,galactose-deficient iga1,case report

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