Chronic kidney disease linked to SARS-CoV-2 infection: a case report

Abstract

Background: The recent COVID-19 pandemic has raised concerns about patient diagnosis and follow-up of chronically ill patients. Patients suffering from chronic illnesses, concomitantly infected by SARS-CoV-2, globally tend to have a worse prognosis and poor outcomes. Renal tropism and acute kidney injury following SARS-CoV-2 infection has recently been described in the literature, with elevated mortality rates. Furthermore, patients with pre-existing chronic kidney disease, infected by SARS-CoV-2, should be monitored carefully. Here, we report the case of a 69-year-old patient with splenic marginal zone lymphoma, suffering from longstanding chronic kidney disease following SARS-CoV-2 infection.

Case presentation: A 69-year-old male patient previously diagnosed with pulmonary embolism and splenic marginal zone lymphoma (Splenomegaly, Matutes 2/5, CD5 negative and CD23 positive), was admitted to the hospital with shortness of breath, fever and asthenia. A nasopharyngeal swab test was performed in addition to a CT-scan, which confirmed SARS-CoV-2 infection. Blood creatinine increased following SARS-CoV-2 infection at 130 μmol/l, with usual values at 95 μmol/l. The patient was discharged at home with rest and symptomatic medical treatment (paracetamol and hydration), then readmitted to the hospital in August 2020. A kidney biopsy was therefore conducted as blood creatinine levels were abnormally elevated. Immunodetection performed in a renal biopsy specimen confirmed co-localization of SARS-CoV2 nucleocapsid and protease 3C proteins with ACE2, Lewis x and sialyl-Lewis x antigens in proximal convoluted tubules and podocytes. Co-localization of structural and non-structural viral proteins clearly demonstrated viral replication in proximal convoluted tubules in this chronically ill patient. Additionally, we observed the co-localization of sialyl-Lewis x and ACE2 receptors in the same proximal convoluted tubules. Reverse Transcriptase-Polymerase Chain Reaction test performed on the kidney biopsy was negative, with very low Ct levels (above 40). The patient was finally readmitted to the haematology department for initiation of chemotherapy, including CHOP protocol and Rituximab.

Conclusions: Our case emphasizes on the importance of monitoring kidney function in immunosuppressed patients and patients suffering from cancer following SARS-CoV-2 infection, through histological screening. Further studies will be required to decipher the mechanisms underlying chronic kidney disease and the putative role of sialyl-Lewis x and HBGA during SARS-CoV-2 infection.

Keywords: COVID-19; Case report; Chronic kidney disease; Chronic viral replication; Coronavirus; HBGA; Immunocompromised; Lewis antigens; SARS-CoV-2.

Fig. 1

Histopathology and immunodetection assays in formalin-fixed paraffin embedded kidney biopsy from a 69-year-old patient suffering from chronic COVID-19 infection. A (HES, × 200) and B (PAS, × 200): grade I interstitial fibrosis associated with grade I tubular atrophy without glomerular damage; focal desquamation of the brush border of epithelial cells of proximal convoluted tubules (arrow), associated with focal sloughing of epithelial cells of proximal convoluted tubules with intra-tubular cell casts (arrowheads); C, D, E and I (× 600): co-detection of SARS-CoV-2 nucleoprotein (green fluorescence) and protease-3C (red fluorescence) in epithelial cells of proximal convoluted tubules (arrows) using anti-NP and anti-Prot3C mAb; F, G, H and J (× 600): co-detection of SARS-CoV-2 nucleoprotein (green fluorescence) and protease3C (red fluorescence) in the glomerular apparatus (arrows) using anti-NP and anti-Prot3C mAb; K (× 200): ACE2 detection on the brush border of epithelial cells of proximal convoluted tubules (arrowhead) using anti-ACE2 mAb. Positive detection is shown by brown staining; L (× 200): A antigen expression in glomerular capillary walls (arrowhead) and distal convoluted tubules (arrow) using anti-A mAb. Positive detection is shown by brown staining; M (× 200): Le^x antigen expression in proximal convoluted tubules (arrowhead) and podocytes (arrow) using anti-Le^x mAb. Positive detection is shown by brown staining; N (× 200): sialyl-Le^x antigen expression in proximal convoluted tubules (arrowhead) and podocytes (arrow). Positive detection is shown by brown staining

Fig. 2

Trends of renal function in a patient suffering from Chronic Kidney Disease following SARS-CoV-2 infection. eGFR: estimated Glomerular Filtration Rate