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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2021  |  Volume : 32  |  Issue : 1  |  Page : 218-222
Coronavirus Disease-2019 in Children with Primary Kidney Disease: A Case series

1 Department of Rediatric Nephrology, Institute of Kidney Diseases and Research Center, Ahmedabad, Gujarat, India
2 Department of Nephrology, Institute of Kidney Diseases and Research Center, Ahmedabad, Gujarat, India

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Date of Web Publication16-Jun-2021


Underlying comorbid illness is a known risk factor for severe coronavirus disease-2019 (COVID-19). Clinical course of COVID-19 in children with primary kidney disease is not well understood. We present the clinical profile and management of COVID-19 in three children at a COVID hospital in India. These children had nephrotic syndrome, hemolytic uremic syndrome, and chronic kidney disease, respectively. The first two were immunosuppressed, mandating to stop their immunosuppressive medications temporarily. Both had mild course of illness. Third child presented with respiratory distress requiring oxygen support, falling into moderate disease. Renal functions were normal in all of them. They all responded well to oral azithromycin and supportive management. None of them received chloroquine, corticosteroids, or monoclonal antibodies. All three recovered without complications.

How to cite this article:
Meshram A, Vala KB, Saha A, Patel HV, Kute V, Gera D. Coronavirus Disease-2019 in Children with Primary Kidney Disease: A Case series. Saudi J Kidney Dis Transpl 2021;32:218-22

How to cite this URL:
Meshram A, Vala KB, Saha A, Patel HV, Kute V, Gera D. Coronavirus Disease-2019 in Children with Primary Kidney Disease: A Case series. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Sep 26];32:218-22. Available from: https://www.sjkdt.org/text.asp?2021/32/1/218/318527

   Introduction Top

Coronavirus (CoV) is a positive-sense single-stranded RNA virus with crown such as spikes on its outer surface. It is responsible for severe acute respiratory syndrome (SARS) in the host.[1] The first major SARS epidemic was seen in 2003 caused by SARS-CoV in Guangdong, China. A decade later in 2013, CoV caused MERS outbreak in Middle East another coronavirus named Middle East Respiratory Syndrome-Corona virus (MESR- countries.[2] In December 2019, SARS-CoV-2 emerged as a causative agent for novel CoV disease-19 (COVID-19) outbreak which turned into a global pandemic.[2]

COVID-19 primarily manifests as an acute respiratory illness, but it can affect multiple organs such as the kidney, heart, digestive tract, blood, and nervous system, pneumonia remaining the leading cause of death in children.[3] Majority of critically ill children with COVID-19 are found to have significant long-term underlying medical conditions.[4] Children with COVID-19 infection have good outcomes as compared to adults. Studies show renal diseases such as chronic kidney disease (CKD) are associated with enhanced risk of COVID-19 infection in adults.[5] However, clinical profile and outcome in children with primary renal disease with COVID-19 infection are unknown.[6]

We present three children with primary kidney disease who were diagnosed with COVID-19 and managed at a designated COVID hospital in Ahmedabad, Gujarat, India.

   Case Reports Top

Case 1

A 3-year-old girl having frequently relapsing nephrotic syndrome and being treated with levamisole presented with complaints of fever and vomiting for a week. On presentation, she was febrile, had stable vitals and oxygen saturation 99% on room air. No respiratory distress or adventitious sounds were noted on auscultation. The rest of the systems was normal on examination. Laboratory reports were showing remission state of nephrotic syndrome. Chest radiograph was normal [Figure 1]. As the child was staying in a containment zone, COVID-19 nucleic acid test (NAT) was done. Levamisole was stopped after the COVID-19 report came positive and stress dose steroids (prednisolone 0.5 mg/kg/day) were given for 10 days. Tablet azithromycin was given for five days as per hospital protocol for the management ment of COVID-19. Patient improved clinically, fever subsided, and no fresh complaints were observed during hospital stay. Tablet levamisole was restarted, and the patient was discharged. She is doing well on follow-up after two months.
Figure 1: Normal chest radiograph of first patient.

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Case 2

A 10-year-male child was diagnosed in February 2020, as recurrent antifactor H antibody-associated atypical hemolytic uremic syndrome (aHUS) with underlying complement factor H-related protein mutation. He was referred with fever and for the management of relapsing course of aHUS. Patient tested positive for COVID-19 by NAT. On examination SpO2 was 98%–99% without oxygen support. Chest radiograph showed no abnormal findings [Figure 2]. The patient was on oral prednisolone 1 mg/kg/day and MMF 800 mg/m2/day since March 2020. He had also received two doses of injection rituximab in March–April 2020. In view of COVID-19, steroid was changed to stress dose and MMF was stopped. Injection intravenous immunoglobulin (IVIG) was given in 2 g/kg dose in divided doses over two days. Hypertension was controlled within target limits with oral antihypertensives. He improved clinically during the course with five days of oral azithromycin. After recovery, the patient gradually progressed to CKD requiring dialysis. For immunosuppression, only steroids were continued at 1 mg/kg/day. Patient was discharged after stabilization on maintenance hemodialysis.
Figure 2: Normal chest radiograph of second patient.

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Case 3

A 12-year-old female child, case of CKD secondary to steroid-resistant nephrotic syndrome (SRNS) was admitted with fever and respiratory distress. Chest radiograph was showing bilateral tiny areas of air space opacities with few linear opacities, consistent with viral pneumonia [Figure 3]. She tested positive for COVID-19 NAT. She was shifted to COVID ward where she was treated as per COVID management protocol. She required oxygen support by simple mask at 6 L/min for 48 h. She responded well and improved clinically. Oxygen support was removed as respiratory distress abated. Repeat COVID-19 NAT after seven days was negative. Conservative management was started for CKD. She was hemodynamically stable when discharged from the hospital.
Figure 3: Chest radiograph of third patient showing tiny areas of air space opacities with few linear opacities seen in both lung fields predominantly in the peripheral and lower zone.

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The authors obtained all appropriate consent forms from the patients’ guardians and relatives for the publication of the case reports.

   Discussion Top

During the COVID-19 outbreak, 916 patients have been admitted to our hospital. Out of the 364 who tested positive for COVID-19 NAT, only three (0.8%) were pediatric patients.

COVID-19 is a disease caused by SARS-CoV-2 infection, which has resulted in an outbreak around the globe, leading to a pandemic.[7] In children, CoV is known to cause mainly respiratory symptoms such as fever, rhinitis, otitis, pharyngitis, laryngitis, and headache but also bronchitis, bronchiolitis, wheezing, pneumonia, and gastrointestinal symptoms (which are more common in children than adults).[8],[9] Clinical types of COVID-19 in pediatric patients are classified as mild, moderate, and severe disease and critical illness.[6]

In a case series of 34 children from Shenzhen, China, in February 2020, 9% were asymptomatic, 65% had common respiratory symptoms and 26% had mild disease, which signifies that children have milder clinical involvement as compared to adults.[10] This observation is consistent with our series where only one out of three cases required oxygen support, rest had only mild symptoms. Furthermore, most common symptoms observed were fever and cough in above study, similarly all our patients had fever at presentation [Table 1]. In another case series of 20 children, presentation was with low to moderate or no fever, rhinitis, cough, fatigue, headache, and diarrhea. However, they reported some cases with dyspnea, cyanosis, and poor feeding apart from milder symptoms.[11]
Table 1: Demographics, immunosuppression, management and outcome of cases.

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Two children in our series were on immunesuppressive medication when diagnosed with COVID-19. They maintained a milder course throughout the illness. The first case with nephrotic syndrome did not show relapse. Nevertheless, immunosuppressive medications were stopped lest symptoms might worsen. In a study published in Lancet, all 18 children had a mild clinical course of COVID-19 in spite of having underlying kidney disease and on immunosuppression therapy.[5]

Laboratory profile in our patients showed no worsening in baseline renal functions due to COVID-19. Mildly raised liver enzymes and positive C-reactive protein (CRP) were seen in only third patient having CKD. Coagulation profile were normal for all three cases. Chest radiograph was abnormal in one out of three cases [Table 2]. Aforementioned case series of 34 children had documented no significant laboratory derangements except leukopenia in 83% cases and elevated CRP in single case. But majority had abnormal chest radiograph.[10]
Table 2: Laboratory profile of cases.

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As per our hospital protocol, patients were treated with oral azithromycin and supportive treatment such as fluid management, calorie intake. All three patients improved and did not require advanced drugs or corticosteroids for the treatment of COVID-19. One patient responded well after 48 h of oxygen support by mask. The patient with HUS was given injection IVIG after stopping immunosuppression for ongoing hemolysis. None of the three cases developed any complications due to COVID-19.

There was no definitive treatment available for children in the face of the COVID-19 pandemic until Zhejiang University School of Medicine recommended Interferon a2b nebulization and lopinavir/ritonavir with corticosteroids for children with COVID-19, but efficacy and safety were remained to be determined.[11]In a previously mentioned case series of 34 children, 59% were treated with Lopinavir/ Ritonavir but no one received corticosteroids or monoclonal antibodies.[10] The current options include antimalarial agent chloroquine, monoclonal antibodies against spike glycoprotein S of coronavirus, protease inhibitors such aslopinavir/ritonavir.[7]

   Conclusion Top

Children appear to contract milder form of COVID-19 even when there are underlying chronic diseases such as CKD. Immunosuppressive medication for any indication does not seem to affect the severity of symptoms in COVID-19. However, further studies and clinical trials with large cohort, are needed to confirm above observations and to establish natural course of COVID-19 in children with primary kidney diseases.

Conflict of interest: None declared.

   References Top

Shereen MA, Khan S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91-8.  Back to cited text no. 1
Wang N, Shi X, Jiang L, et al. Structure of MERS-CoV spike receptor-binding domain complexed with human receptor DPP4. Cell Res 2013;23:986-93.  Back to cited text no. 2
Henry BM, Lippi G. Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID-19) infection. Int Urol Nephrol 2020;52:1193-4.  Back to cited text no. 3
Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) Infection admitted to US and Canadian pediatric intensive care units. JAMA Pediatr 2020;174: 868-73.  Back to cited text no. 4
Marlais M, Wlodkowski T, Vivarelli M, et al. The severity of COVID-19 in children on immunosuppressive medication. Lancet Child Adolesc Health 2020;4:e17-8.  Back to cited text no. 5
Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: An observational cohort study. Lancet Infect Dis 2020;20:689-96.  Back to cited text no. 6
Zimmermann P, Curtis N. Coronavirus infections in children including COVID-19: An overview of the epidemiology, clinical features, diagnosis, treatment and prevention options in children. Pediatr Infect Dis J 2020;39:355-68.  Back to cited text no. 7
Vabret A, Mourez T, Gouarin S, Petitjean J, Freymuth F. An outbreak of coronavirus OC43 respiratory infection in Normandy, France. Clin Infect Dis 2003;36:985-9.  Back to cited text no. 8
Chiu SS, Chan KH, Chu KW, et al. Human coronavirus NL63 infection and other coronavirus infections in children hospitalized with acute respiratory disease in Hong Kong, China. Clin Infect Dis 2005;40:1721-9.  Back to cited text no. 9
Wang XF, Yuan J, Zheng YJ, et al. Retracted: Clinical and epidemiological characteristics of 34 children with 2019 novel coronavirus infection in Shenzhen. Zhonghua ErKeZaZhi 2020;58:E008.  Back to cited text no. 10
Chen ZM, Fu JF, Shu Q, et al. Diagnosis and treatment recommendations for pediatric respiratory infection caused by the 2019 novel coronavirus. World J Pediatr 2020;16:240-6.  Back to cited text no. 11

Correspondence Address:
Anshuman Saha
Department of Pediatric Nephrology, Institute of Kidney Diseases and Research Center, Ahmedabad, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.318527

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]

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