key: cord-0697824-vr6ugfq4 authors: Mayet, Valentin; Mousseaux, Cyril; Petit-Hoang, Camille; Ouali, Nacera; Rafat, Cedric; Mesnard, Laurent; Luque, Yosu; Rondeau, Eric; Buob, David; François, Hélène title: COVID-19-associated acute kidney injury: after the tubule and the glomerulus, now the vessel? date: 2020-11-28 journal: Clin Kidney J DOI: 10.1093/ckj/sfaa210 sha: 31f7785b5b01ccde19958ce6b70277b3d110590b doc_id: 697824 cord_uid: vr6ugfq4 nan Coronavirus disease 2019 (COVID-19)-associated acute kidney injury (AKI) is being increasingly recognized and goes beyond the usual pattern of acute tubular necrosis often seen in intensive care patients with respiratory distress and shock. Recent renal histopathology studies in COVID-19 patients have shown various patterns: acute tubular necrosis with some degree of proximal tubular dysfunction and collapsing focal and segmental glomerulosclerosis, but also dysimmune glomerulopathies including pauci-immune crescentic glomerulonephritis, antiglomerular basement nephritis and membranous nephropathy [1] [2] [3] . The physiopathology of AKI in this context may correspond to a direct viral effect through angiotensin-converting enzyme 2 binding on renal tubules and/or podocytes, but most likely may be a consequence of inflammation (or 'cytokine storm'). So far, apart from some cases of thrombotic microangiopathy [2] and renal artery thrombosis [4] that may be due to COVID-19 coagulopathy, no specific lesions have been described in renal small arteries. A 67-year-old man of African ancestry with a medical history of untreated chronic lymphocytic leukaemia (CLL) was admitted for fever and dyspnoea related to COVID-19 pneumonia [confirmed both by thoracic computed tomography (CT) and nasopharyngeal polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]. At admission, he presented with AKI with a serum creatinine of 291 mmoL/L. Abdominal CT scan showed normal-sized kidneys without any urinary tract obstruction. Proteinuria was 0.8 g/g on spot urine protein:creatinine ratio collection associated with haematuria (150 000 red blood cells/mL on urine cytobacteriology). The patient quickly became anuric and developed acute respiratory distress requiring mechanical ventilation; intermittent haemodialysis was started at Day 4 following admission. At Day 30, mechanical ventilation was weaned and a kidney biopsy was performed due to persistent renal failure with proteinuria (0.27 g/g without haematuria, serum creatinine 564 mmol/L). The biopsy revealed segmental fibrinoid necrosis of one arteriole accompanied by interstitial lymphocytic infiltration and severe acute tubular necrosis ( Figure 1A) . We found no collapsing glomerulopathy out of 10 normal glomeruli ( Figure 1B) . The interstitium infiltrate was composed of CD5 þ CD20 þ lymphocytes related to CLL. No specific immune staining was detected by immunofluorescence. Serologic tests for human immunodeficiency virus and hepatitis B and C virus were negative, but cytoplasmic anti-neutrophil cytoplasmic antibodies were positive (1/320) on immunofluorescence with no specificity detected by enzyme-linked immunoabsorbent assay. Renal function and proteinuria improved spontaneously while the patient received no specific COVID-19 treatment. At Day 120, serum creatinine was 152 mmol/L and proteinuria 0.04 g/g. To our knowledge, this is the first report of a COVID-19associated necrotizing vasculitis affecting the kidneys with Received: 16.9.2020; Editorial decision: 28.9.2020 V C The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com AKI and collapsing glomerulopathy associated with COVID-19 and APOL 1 high-risk genotype COVID-19-associated kidney injury: a case series of kidney biopsy findings Kidney biopsy findings in patients with COVID-19 Renal artery thrombosis induced by COVID-19 Black arrow: fibrinoid necrosis; black asterisk: vascular lumen; white asterisk: perivascular inflammatory infiltrate. Haematoxylin and eosin stain, original magnification Â400. (B) Acute tubular necrosis associated with ischaemic glomeruli. Black asterisk: ischaemic glomerulus. Masson's trichome stain spontaneous remission. We believe that this case illustrates the arteriolar tropism of cytokine storm associated with SARS-CoV-2 infection. None declared. All data are incorporated into the article.