De novo collapsing glomerulopathy in a pediatric kidney transplant recipient with COVID‐19 infection

• Published in: Pediatric transplantation 2021-06, Vol.25 (4), p.e14013-n/a
• Main Authors: Levenson, Emma, Shepherd, Tara N., Aviles, Diego, Craver, Randall, Ehlayel, Abdulla, Love, Gordon L., Simms, K'Joy, Straatmann, Caroline, Ashoor, Isa F.
• Format: Article
• Language: English
• Subjects: acute kidney injury; Autoimmune diseases; Biopsy; Children; Chronic infection; Corticosteroids; COVID; COVID-19; Epithelium; glomerular disease; Graft rejection; Immunosuppression; Immunosuppressive agents; Infections; Intravenous administration; Kidney diseases; kidney transplant; Kidney transplantation; Kidney transplants; Nephrotic syndrome; Pandemics; Pediatrics; Severe acute respiratory syndrome coronavirus 2
• ISSN: 1397-3142; 1399-3046
• DOI: 10.1111/petr.14013

The negative impact of COVID‐19 on adults with underlying chronic kidney disease, including kidney transplant recipients, has been well documented. Children have a less severe presentation and better prognosis compared to adults. However, little is known regarding the spectrum of COVID‐19 infection in children and adolescents with underlying autoimmune disorders necessitating solid organ transplant and long‐term immunosuppressive therapy. Case Report. An adolescent male developed end‐stage kidney disease secondary to microscopic polyangiitis requiring a living‐donor kidney transplant. Six years later, he developed antibody‐mediated rejection of his kidney transplant. During his rejection treatment course, he contracted SARS‐CoV‐2 and developed new‐onset nephrotic syndrome with severe acute kidney injury. Kidney transplant biopsy revealed de novo collapsing focal segmental glomerulosclerosis on a background of chronic active antibody mediated rejection. Immunostaining for SARS‐CoV‐2 on the biopsy specimen demonstrated positive staining of the proximal tubular epithelium consistent with intra‐renal viral infection. Pulse corticosteroids, intravenous immunoglobulin, and temporary reduction of anti‐metabolite therapy resulted in successful recovery with return of graft function back to pre‐infection baseline. This case highlights the clinical conundrum of treating kidney transplant recipients with active rejection in the midst of the COVID‐19 pandemic. Pediatric kidney transplant recipients can develop severe COVID‐19‐related kidney complications. Judicious immunosuppression modulation is necessary to balance infection and rejection risk.