Article Figures & Data
Figures
- Figure 1.
Kidney biopsy findings in patients with COVID-19. (A) Light microscopy demonstrates a lesion of collapsing glomerulopathy characterized by hyperplasia of glomerular epithelial cells and collapse of the underlying glomerular capillaries. Jones methanamine silver. Magnification, ×600. (B) Diffuse foot process effacement and endothelial TRIs (arrow and inset) in a patient with minimal change disease. Electron micrograph. Magnification, ×8000. (C) Subepithelial electron dense deposits in PLA2R-associated membranous glomerulopathy. Electron micrograph. Magnification, ×15,000. (D) Multiple glomeruli with circumferential cellular crescents (arrows) in a patient with class 4+5 lupus nephritis. Periodic acid–Schiff. Magnification, ×100. (E) A glomerulus compressed by a crescent with global linear GBM staining for IgG in a patient with anti-GBM nephritis. Immunofluorescence for IgG. Magnification, ×400. (F) Tubular simplification and focal shedding of degenerating epithelial cells into the tubular lumina in a patient with isolated ATI. Hematoxylin and eosin. Magnification, ×400. (G) Severe lymphocytic tubulitis in a patient with acute T cell–mediated rejection. Periodic acid–Schiff. Magnification, ×600. (H) ISH for the virus by automated method showing undetectable viral RNA in the kidney (inset shows positive lung control). Automated ISH with hematoxylin counterstain. Magnification, ×400.
Tables
Pt Age Sex Race Comorbidities IS Temperature, °C SpO2 on RA BP Edema COVID-19 Manifestations Renal Presentation/Biopsy Indications 1 46 M B OSA, obesity (BMI=44) N 37.1 94 144/100 Y Cough, fever, sore throat AKI, NS 2 62 M B HTN, prostate carcinoma N 37.2 98 126/79 Y Fever, myalgia, weakness AKI on CKD, NS 3 62 M B HTN, DM, prostate carcinoma N 36.8 91 122/82 N Fever, hypoxemia, bilateral perihilar and basilar infiltrates on CXR AKI, NRP 4 57 M B HTN, untreated hepatitis C virus N 38.1 97 173/92 N Flu-like symptoms with ground glass opacities and patchy consolidation on CXR AKI on CKD, NRP 5 61 M B HTN, obesity (BMI=31.1) N 38.5 99 134/79 N Cough, fever AKI, NRP 6 25 M B Obesity (BMI=32.2) N 38.5 95 117/79 Y Cough, fever, myalgia, infiltrates on CXR AKI, NS 7 43 F B DM, HLD, streptococcal infection, obesity (BMI=52.5) N 37.6 96 107/67 N Cough, fever, sore throat, weakness, patchy LUL infiltrates on CXR AKI 8 28 M B None N 38.6 96 (on O2) 143/62 N Cough, fever, hypoxemia, bilateral infiltrates on CXR, elevated troponin and CPK AKI 9 67 M W HTN, gout, history of tobacco use, obesity (BMI=34.9) N 36.5 95 135/75 N Cough, diarrhea, lethargy, multifocal infiltrates on CXR AKI on CKD 10 51 M B HTN, DSA+ OHTx for NICM 1 yr ago, atrial fibrillation, CVA, BPH, HLD Y 36.8 96 117/81 N Predominantly nausea, vomiting, abdominal pain, with cough AKI on CKD 11 72 M W HTN, DM, HLD, gout, spinal stenosis, atrial fibrillation N 36.8 97 (on O2) 125/73 Y Cough, pleural effusion on CT NS 12 70 F B HTN, CAD, PVD, cervical carcinoma, GERD, HLD, obesity (BMI=39.4) N 38.1 92 118/58 Y Cough, fever, shortness of breath AKI, NRP 13 27 F A SLE with class 2 lupus nephritis Y 36.9 93 130/80 Y Cough, fever, shortness of breath, hypoxemia, bilateral infiltrates on CXR, required intubation and ICU admission AKI, NS 14 48 F B GERD, history of tobacco use, obesity N 37.6 98 185/80 N Cough, myalgia, infiltrates on CXR AKI 15 54 M W ESKD secondary to IgAN s/p DSA+ LURTx 1 mo ago, HTN, obesity (BMI=30.7) Y 36.8 99 116/75 N Asymptomatic AKI 16 22 M B ESKD likely secondary to PLA2R+ MGN s/p DDRTx 2 years ago, HTN Y 37.7 95 178/127 N Cough, fever, bilateral infiltrates on CXR, required intubation and ICU admission CKD 17 54 F H ESKD secondary to PCKD s/p DDRTx 2 months ago, HTN Y 98.8 100 104/70 N Fever, dry throat AKI BP is in millimeters of Hg. Pt, patient; IS, immunosuppression at presentation; SpO2, oxygen saturation (percentage); RA, room air; M, man; B, black; OSA, obstructive sleep apnea; BMI, body mass index; N, no; Y, yes; NS, nephrotic syndrome; HTN, hypertension; AKI on CKD, AKI superimposed on CKD; DM, diabetes mellitus; CXR, chest x-ray; NRP, nephrotic-range proteinuria; F, woman; HLD, hyperlipidemia; LUL, left upper lobe; O2, oxygen; CPK, creatine phosphokinase; W, white; DSA, donor-specific antibody; OHTx, orthotopic heart transplantation; NICM, nonischemic cardiomyopathy; CVA, cerebrovascular accident; BPH, benign prostatic hyperplasia; CT, computed tomography; CAD, coronary artery disease; PVD, peripheral vascular disease; GERD, gastroesophageal reflux disease; A, Asian; ICU, intensive care unit; IgAN, IgA nephropathy; s/p, status post; LURTx, living unrelated renal transplantation; MGN, membranous glomerulopathy; DDRTx, deceased donor renal transplantation; H, Hispanic; PCKD, polycystic kidney disease.
- Table 2.
Laboratory findings and follow-up information in patients with COVID-19 who underwent kidney biopsy
Pt Baseline sCr Renal Function at Presentation Complete Blood Counts Other Laboratory Tests Follow-Up Information sCr Dialysis Urine Prot sAlb Urine RBC Hgb WBC Plt Duration, d Therapy Outcome 1 1.1 12.5 Y 5.8 3.1 2 16.6 7.7 242 LDH 1504 U/L, ESR>130 mm/h, hsCRP 49.4 mg/L ferritin 1147 ng/ml, IL-6 12 pg/ml, IL-2R 1530 pg/ml 24 Tocilizumab, steroids Dialysis dependent with sCr 14.2 mg/dl, UPCR 10.2 g/g, repeat COVID-19 negative 2 2 10.7 N 12.1 3.1 0–5 14.2 7.1 (with lymphopenia) 235 ESR 125 mm/h, ferritin 340.3 ng/ml 30 None sCr 3.8 mg/dl, UACR 5.5 g/g, repeat COVID-19 negative 3 1 11.6 N 19 2.4 11.7 14.4 (with lymphopenia) 355 ESR 130 mm/h, CRP 232 mg/L, ferritin 5000 ng/ml 12 Steroids, hydroxychloroquine, ceftriaxone, doxycycline sCr 2.3 mg/dl, UPCR 4 g/g, decreased ferritin, ESR, IL-6 4 1.1 4.9 N 6.2 2.5 0 9.8 7 257 elevated ESR, CRP 11.1 mg/L, ferritin 907 ng/ml, elevated IL-6 and d-dimer, CK 3200 U/L, +HCV Ab 11 Azithromycin, ceftriaxone sCr 4.9 mg/dl, UPCR 4.1 g/g, repeat COVID-19 negative 5 Normal 15 Y 9 2.5 8.3 21 368 ESR 41 mm/h, CRP 229 mg/L, ferritin 2542 ng/ml 5 Dialysis dependent, repeat COVID-19 negative 6 Normal 2.2 N 21 <1.5 3–5 13.9 8.5 408 LDH 590 U/L, CRP 33.4 mg/L, ferritin 374 ng/ml 27 Azithromycin, hydroxychloroquine, steroids sCr 0.8 mg/dl, UPCR 4.3 g/g, decreased CRP 7 3.5 (at adm) 6.7 Y 1+ on UA 21–50 11.4 14 250 None 8 2 (at adm) 9 Y 100 mg/dl on UA 2.6 0 10.6 13.1 (with lymphopenia) 320 LDH 3075 U/L, CRP 4.7 mg/L, ferritin >7500 ng/ml, CK 3309 U/L <30 Tocilizumab, hydroxychloroquine, ceftriaxone, azithromycin sCr 1.2 mg/dl 9 5.7 Y 300 mg/dl on UA 2.7 >5 12.8 9.2 (with lymphopenia) 454 LDH 309 U/L, CRP 13 mg/L, ESR>100 mm/h, ferritin 924 ng/ml, CK 128 U/L 30 Tocilizumab, hydroxychloroquine, ceftriaxone, azithromycin Dialysis dependent 10 1.5–1.8 4.8 N 0.5 4.2 3 11.5 3.2 107 LDH 524 U/L, CRP 50.8 mg/L, ESR 33 mm/h, ferritin 2282 ng/ml, IL-6 21.4 pg/ml, +ANA 1 Hydroxychloroquine sCr 2.5 mg/dl, urine prot 100 mg/dl on UA, repeat COVID-19 positive 11 Normal 0.8 N 8.8 1.7 6–15 12.3 14.8 283 LDH 300 U/L, CRP 153 mg/L, ferritin 397 ng/ml 18 Tacrolimus sCr 1.3 mg/dl, repeat COVID-19 positive 12 2.9 N 6.8 3.0 Present 9 6.1 183 LDH 1019 U/L, ESR 127 mm/h, ferritin 635 ng/ml, +ANA, +anti-dsDNA Ab 35 None sCr 2.4 mg/dl, UPCR 5–6 g/g, improved edema 13 0.9 2.5 N 9.2 2.0 20–50 8 6.8 182 IL-6 79 pg/ml 6 Steroids Died from multiorgan failure secondary to COVID-19 14 0.9 20 Y >300 mg/dl on UA 3.1 >182, with RBC casts 9.5 9.1 167 CRP 143 mg/L, CK 1460 U/L, +anti-GBM Ab 16 PLEX, steroids, cyclophosphamide Dialysis dependent with sCr 6.7 mg/dl, repeat COVID-19 negative 15 1.7 2.6 N 0.2 4.5 60 8.1 3.9 211 IL-6 6.6 pg/ml 55 Tocilizumab, IVIG, steroids, thymoglobulin sCr 2 mg/dl, UPCR 0.1 g/g, repeat COVID-19 negative 16 Dialysis dependent 9.4 Y 3.4 4.4 6.1 202 LDH 333 U/L, ESR 79 mm/h, CRP 195.6 mg/L, ferritin 1630 ng/ml 4 Tocilizumab, hydroxychloroquine, piperacillin-tazobactam, azithromycin Dialysis dependent with sCr 6.7 mg/dl 17 2.5 2.9 N 0.2 4.4 3 10.1 3.3 286 CRP 0.49 ng/ml, ferritin 1677 ng/ml (previously) 7 None sCr 2.2 mg/dl Pt, patient; sCr, serum creatinine (milligrams per deciliter); urine prot, urine protein-creatinine ratio or 24-h urine protein; sAlb, serum albumin (grams per deciliter); RBC, red blood cell (per high-power field); Hgb, hemoglobin (grams per deciliter); WBC, white blood cell count (103 per microliter); Plt, platelet (103 per microliter); Y, yes; LDH, lactate dehydrogenase; ESR, erythrocyte sedimentation rate; hsCRP, high-sensitivity C-reactive protein; IL-2R, IL-2 receptor; UPCR, urine protein-creatinine ratio; repeat COVID-19, repeat PCR testing for severe acute respiratory syndrome coronavirus 2; N, no; UACR, urine microalbumin-creatinine ratio; CRP, C-reactive protein; CK, creatine kinase; +, positive; HCV Ab, Ab for hepatitis C virus; adm, admission; UA, urinalysis; ANA, antinuclear antibody; dsDNA, double-stranded DNA; PLEX, plasmapheresis; IVIG, intravenous Ig.
Pt Diagnosis Light Microscopy Electron Microscopy Diagnosis Other Findings No. Glom No. GS No. Collapse No. Noncollapsed FSGS Hypercellularity Microcysts II IFTA VS FPE TRI Viral Particles 1 Collapsing FSGS ATI 20 0 14 0 N Y Focal Mild Mild NAa NAa N 2 Collapsing FSGS ATI 8 3 2 0 N Y Focal Moderate Moderate to severe 100 Y N 3 Collapsing FSGS ATI 18 4 4 1 N Y None Moderate Moderate 30 N N 4 Collapsing FSGS ATI 10 1 5 0 N N Focal Severe Mild NA NA NA 5 Collapsing FSGS ATI 11 3 7 0 N Y Focal Severe Moderate to severe 90 N N 6 MCD ATI 17 0 0 0 N Y None None None 100 Y N 7 ATI 15 0 0 0 N N Focal None Mild 15 Y N 8 ATI Pigment casts 22 0 0 0 N N None None Mild 10 Y N 9 ATI 2 1 0 0 N N None Mild Moderate NAa NAa N 10 ATI 8 0 0 0 N N None None Moderate 5 N N 11 MGN PLA2R stain positiveb 15 3 0 4 N N Focal Mild Mild to moderate 100 N N 12 MGN PLA2R stain negativeb 3 2 0 0 N Y Focal Moderate Moderate to severe 30 Y N 13 LN class 4+5 35 9 0 0 Mes, Endo, Crescents N Diffuse Mild Mild 90 Y N 14 Anti-GBM GN ATI, RBC casts 32 1 0 0 Crescents Y Diffuse Mild Moderate NAa NAa N 15 TCMR grade 2A 11 1 0 0 N N Focal None Mild NA NA NA 16 Infarctionc NA NA NA NA NA N Focal Severe NA NA NA NA 17 ATI 20 1 0 0 N N None None Mild NA NA NA Pt, patient; glom, No., number; glomerulus or glomeruli; GS, global sclerosis; II, interstitial inflammation; IFTA, tubular atrophy and interstitial fibrosis; VS, vascular sclerosis; FPE, foot process effacement (percentage); N, no; Y, yes; NA, not available; MCD, minimal change disease; LN, lupus nephritis; Mes, mesangial hypercellularity; Endo, endocapillary hypercellularity; RBC, red blood cell; TCMR, T cell–mediated rejection.
↵a All glomeruli were involved by crescents in the patient with anti-GBM GN, and no glomeruli were available for ultrastructural examination in two patients with native kidney biopsies.
↵b Performed by tissue staining.
↵c Nephrectomy specimen.
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