COVID-19-Related Collapsing Focal Segmental Glomerulosclerosis and Apolipoprotein L1: A Report of Two Cases

Introduction: Acute kidney injury has been seen in approximately 15% of the patient with COVID-19 infection Acute tubular injury was presumed to be the most common cause of AKI, but it did not explain significant proteinuria and hematuria We present the case report of 2 patients with collapsing focal segmental glomerulopathy with COVID-19 Case Description: Case 1, a 28 years old African American female and Case 2, a 58 years old African American male with baseline CKD III, admiited with COVID-19 infection and had acute kidney injury with significant proteinuria with hypoalbuminemia Patients had kidney biopsies Please see table for all the details Discussion: Possible etiologies of acute kidney injury in COVID 19 are tubular injury due to cytokine storm, direct cytopathic effect and immune mediated glomerulonephritis Both the patients had collapsing FSGS in addition to tubular injury suggesting injury to the podocytes Viral particles were not seen on both the biopsies, and hence direct cytopathic effect was not considered to be the mechanism of renal injury, although viral level below the detection threshold could not be excluded Collapsing FSGS has been seen with other viral infections including Parvo-virus infection, Cytomegalovirus infection and HIV Variant of apolipoprotein L1 (APOL1) gene in African Americans have been shown to be associated with FSGS These two patients had genetic susceptibility due to APOL1 and COVID infection caused interferon surge leading to a second hit Teaching Points: Renal biopsy should be consedered in patients with COVID-19 and Nephrotic range proteinuria APOL1 testing should be done in patients with African American descent