Ritter Alexander, Helmchen Birgit, Gaspert Ariana, Bleisch Joerg, Fritschi Barbara, Buchkremer Florian, Damm Stephanie, Schmid Nicolas, Schachtner Thomas, Seeger Harald
Division of Nephrology, University Hospital Zurich, Zurich, Switzerland.
Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland.
Clin Kidney J. 2021 Dec 21;15(5):961-973. doi: 10.1093/ckj/sfab284. eCollection 2022 May.
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 or relapsing glomerulonephritis shortly after vaccine application have been reported, some of which presented with gross haematuria.
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.
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.
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.
新型信使核糖核酸（mRNA）疫苗在当前针对严重急性呼吸综合征冠状病毒2（SARS-CoV-2）的疫苗接种运动中发挥着重要作用。它们高效且总体耐受性良好。建议对免疫介导性肾脏病患者进行疫苗接种。已有多例在接种疫苗后不久出现新发或复发性肾小球肾炎的病例报告，其中一些出现肉眼血尿。
我们在我们的三级医疗机构和转诊中心收集了10例基于mRNA的SARS-CoV-2疫苗接种后出现肉眼血尿的病例。此外，我们将文献中所有已发表的25例病例与我们的病例汇总，以分析其临床特征。
大多数肉眼血尿发作（72.2%）在接种疫苗后2天内开始，大多数在第二剂之后。在一些个体中，后续接种同一疫苗后出现反复发作。共有65.7%的患者以前从未有过肉眼血尿。共有45.7%的患者已知患有免疫球蛋白A肾病（IgAN）；其余患者既往无肾脏诊断。IgAN是最常见的新诊断，但也发现了抗中性粒细胞胞浆抗体相关性血管炎和抗肾小球基底膜病。28.6%的患者发生急性肾损伤（AKI），28.6%的患者血清肌酐升高但未达到改善全球肾脏病预后组织（KDIGO）的AKI标准。治疗方法包括保守治疗、肾素-血管紧张素-醛固酮系统抑制剂、类固醇和环磷酰胺，直至血浆置换。虽然孤立性IgAN患者的肾脏预后主要良好，但合并或孤立性小血管血管炎患者的预后较差。
认识到SARS-CoV-2疫苗接种后出现肉眼血尿很重要。密切随访和进一步检查至关重要，尤其是在无已知潜在肾脏疾病或肾功能恶化的个体中。对于与疫苗相关的肉眼血尿患者，后续接种疫苗时可考虑使用其他类型的疫苗。
