Clinical spectrum of gross haematuria following SARS-CoV-2 vaccination with mRNA vaccines

Alexander Ritter; Birgit Helmchen; Ariana Gaspert; Joerg Bleisch; Barbara Fritschi; Florian Buchkremer; Stephanie Damm; Nicolas Schmid; Thomas Schachtner; Harald Seeger

doi:10.1093/ckj/sfab284

Clinical spectrum of gross haematuria following SARS-CoV-2 vaccination with mRNA vaccines

Clin Kidney J. 2021 Dec 21;15(5):961-973. doi: 10.1093/ckj/sfab284. eCollection 2022 May.

Authors

Affiliations

¹ Division of Nephrology, University Hospital Zurich, Zurich, Switzerland.
² Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland.
³ Division of Nephrology, Spital Zollikerberg, Zollikerberg, Switzerland.
⁴ Nephrocare, Nieren- und Dialysezentrum Männedorf AG, Männedorf, Switzerland.
⁵ Division of Nephrology, Cantonal Hospital Aarau, Aarau, Switzerland.
⁶ Division of Nephrology, Cantonal Hospital Zug, Zug, Switzerland.
⁷ Division of Nephrology, City Hospital Zurich Waid, Zurich, Switzerland.

Abstract

Background: Novel messenger RNA (mRNA)-based vaccines play an important role in current vaccination campaigns against SARS-CoV-2. They are highly efficacious and generally well tolerated. Vaccination in patients with immune-mediated kidney diseases is recommended. A number of cases with de novo or relapsing glomerulonephritis shortly after vaccine application have been reported, some of which presented with gross haematuria.

Methods: We collected 10 cases of macrohaematuria following mRNA-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination at our tertiary care institution and referring centres. Additionally, we pooled all 25 published cases from the literature with ours to analyse their clinical characteristics.

Results: Most macrohaematuria episodes (72.2%) began within 2 days after vaccination, the majority after the second dose. In some individuals, repeated episodes occurred after subsequent doses of the same vaccine. A total of 65.7% of patients never had macrohaematuria before. A total of 45.7% were known to suffer from immunoglobulin A nephropathy (IgAN); the rest had no prior renal diagnosis. IgAN was the most frequent new diagnosis, but anti-neutrophil cytoplasmic antibody-associated vasculitis and anti-glomerular basement membrane disease were also identified. Acute kidney injury (AKI) occurred in 28.6% of patients, with an increase in serum creatinine not meeting Kidney Disease: Improving Global Outcomes AKI criteria in 28.6%. Treatment ranged from conservative management, renin-angiotensin-aldosterone system inhibitors, steroids and cyclophosphamide to plasmapheresis. While renal outcomes were mainly favourable in isolated IgAN, they were poor in patients with additional or isolated small vessel vasculitis.

Conclusion: Awareness of gross haematuria after SARS-CoV-2 vaccination is important. Close follow-up and additional work up, particularly in individuals without known underlying kidney disease or worsening renal function, is essential. For patients with vaccine-associated macrohaematuria, an alternative vaccine class might be considered for subsequent vaccinations.

Keywords: COVID-19; case series; glomerulonephritis; macrohaematuria; vasculitis.