A Case of Membranous Nephropathy Post SARS-CoV-2 Vaccination

ABSTRACT

Introduction: Emergency use authorization and mass vaccination programs worldwide have lowered the burden of the COVID-19 pandemic. Vaccine complications not previously seen in clinical studies continue to manifest. We present a case of membranous nephropathy (MN) following the SARS-CoV-2 vaccination with successful treatment. Case Description Our patient is a 58-year-old woman with past medical history of hypothyroidism seen at a nephrology clinic for evaluation of new onset symptoms of dyspnea, severe bilateral pedal edema, and proximal muscle weakness for 4 months. The patient had 3+ proteinuria and microscopic hematuria on urinalysis obtained by primary care provider. She also had a rapid decline in serum albumin to 2.2 g/dL and new onset hypercholesteremia at 415 mg/dL. Before initial presentation, she had normal labs and no symptoms. Upon presentation to our nephrology clinic, the patient had proteinuria of 2,360 mg/day on a 24-hour urine collection, random urine protein-to-creatinine ratio (UPCR) of 5,459 mg/g and random urine albumin-to-creatinine ratio (UACR) of 3,539 mg/g. She had no risk factors for chronic kidney disease. The only recent change in the health management of the patient was the administration of two doses of the SARS-CoV-2 vaccine several weeks prior to presenting with her initial symptoms 4 months ago. The phospholipase A2 receptor (PLA2R) antibody was elevated at 287 IU/mL. Serological tests for other sources of proteinuria were negative. Renal biopsy performed was consistent with primary MN. The patient was started on rituximab infusion given 2 weeks apart based on Mentor Trial. Additional treatment included apixaban, sulfamethoxazole/ trimethoprim DS, losartan, and L-carnitine. After two doses of rituximab, she had resolution of dyspnea, pedal edema and muscle weakness. Repeat labs revealed UPCR to 1000 mg/g, UACR to 629 mg/g, improvement of PLA2R to 8 IU/mL. Our patient achieved immunological remission and partial clinical remission. Discussion(s) This case illustrates a potential association of the SARS-CoV-2 vaccination and autoimmune mimicry leading to MN. We hope that this will help clinicians become aware of a potential complication not widely recognized and an effective management strategy. We hope further investigations of this possible association are performed as more cases are discovered.