Multicenter Clinicopathologic Correlation of Kidney Biopsies Performed in COVID-19 Patients Presenting With Acute Kidney Injury or Proteinuria

Abstract

Rationale & objective: Kidney biopsy data inform us about pathologic processes associated with infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We conducted a multicenter evaluation of kidney biopsy findings in living patients to identify various kidney disease pathology findings in patients with coronavirus disease 2019 (COVID-19) and their association with SARS-CoV-2 infection.

Study design: Case series.

Setting & participants: We identified 14 native and 3 transplant kidney biopsies performed for cause in patients with documented recent or concurrent SARS-CoV-2 infection treated at 7 large hospital systems in the United States.

Observations: Men and women were equally represented in this case series, with a higher proportion of Black (n=8) and Hispanic (n=5) patients. All 17 patients had SARS-CoV-2 infection confirmed by reverse transcriptase-polymerase chain reaction, but only 3 presented with severe COVID-19 symptoms. Acute kidney injury (n=15) and proteinuria (n=11) were the most common indications for biopsy and these symptoms developed concurrently or within 1 week of COVID-19 symptoms in all patients. Acute tubular injury (n=14), collapsing glomerulopathy (n=7), and endothelial injury/thrombotic microangiopathy (n=6) were the most common histologic findings. 2 of the 3 transplant recipients developed active antibody-mediated rejection weeks after COVID-19. 8 patients required dialysis, but others improved with conservative management.

Limitations: Small study size and short clinical follow-up.

Conclusions: Cases of even symptomatically mild COVID-19 were accompanied by acute kidney injury and/or heavy proteinuria that prompted a diagnostic kidney biopsy. Although acute tubular injury was seen among most of them, uncommon pathology such as collapsing glomerulopathy and acute endothelial injury were detected, and most of these patients progressed to irreversible kidney injury and dialysis.

Keywords: Coronavirus disease 2019 (COVID-19); acute kidney injury (AKI); allograft biopsy; antibody-mediated rejection (AMR); case series; collapsing glomerulopathy; kidney biopsy; renal complications of COVID-19; renal pathology; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); thrombotic microangiopathy.

Graphical abstract

Figure 1

Kidney biopsy findings from representative cases. (A) Case 7, acute tubular necrosis; (B) case 7, collapsing glomerulonephritis (GN); (C) case 6, collapsing GN; (D) case 9, collapsing GN and thrombotic microangiopathy (TMA); (E) case 8, TMA (A-E: Jones methenamine silver; original magnification, ×400); (F) case 8, TMA (electron microscopy; original magnification, ×20,900).