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International Registry of Covid Infection in Glomerulonephritis (I-RocGN)

Returning?

A A A

Thank you for agreeing to contribute to the I-RocGN. Please complete as much of the survey as possible. Even if you cannot answer some questions or complete the survey, any entries will be informative.

This survey is to be completed by a health care professional caring for a patient with Glomerular disease and confirmed or highly suspicious coronavirus (COVID-19) infection.

Please submit reports a minimum of 7 days after confirmation of COVID-19 diagnosis and after sufficient time has passed to observe the disease course through resolution of acute illness or death.

If you have any questions, please reach out to: niddkcovidgn@niddk.nih.gov

Thank you!

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Name of Reporter

Email address of Reporter

Reporter : ______
Subject ID : ______

Name of Institution or Practice providing care

Country of patient

If in the US, please provide state

Date of COVID diagnosis

D-M-Y

Is the patient less than 90 years of age

Yes

No

Age

Gender

Race

Ethnicity

Patient weight (kg)

Patient Height (cm)

BMI

View equation

Does the patient have glomerular disease?

* must provide value

Yes

No

Did the patient have PRE-EXISTING glomerular disease before COVID or develop GN at the time of COVID diagnosis

Is this COVID-19 associated nephropathy in the native kidney or renal transplant?

Is this a "control" patient with COVID infection?

* must provide value

Yes

No

Glomerular disease diagnosis

Glomerular Disease other

Histology associated with COVID-19 associated nephropathy

other glomerular disease

Were any of these features present on the biopsy of this patient with COVID associated nephropathy?

collapsing features

crescents

vascular thrombosis

tubular reticular inclusions (TRI)

acute tubular necrosis, tubular injury

interstitial nephritis/inflammatory infiltrate

"Virally infected cells"/viral inclusions

microangiopathic changes

subepithelial humps

What serologies or other testing were relevant/positive for this patient with COVID associated GN?
(check all that apply)

ANA

dsDNA

ENA

SSA

SSB

p-ANCA

c-ANCA

anti MPO

anti PR3

anti-GBM (glomerular Basement membrane)

C3 (low)

C4 (low)

Anti -PLA2R

Anti-THSDA

C3 nephritic factor

C5b-9

APOL1-genotyping

other testing

none are relevant for this glomerular disease

What is the ANA value?

What is the dsDNA value?

What is the ENA value?

What is the SSA value?

What is the SSB value?

What is the anti-MPO value?

What is the anti-PR3 value ?

What is the anti-GBM value ?

What is the C3 value?

What is the C4 value?

What is the Anti -PLA2R value?

What is the Anti-THSDA value?

other testing

APOL1 genotyping results

Was this presence of a glomerular disease found incidentally during evaluation for COVID related symptoms?

Yes

No

What prompted the patient with COVID-associated GN to seek medical attention?
(Please select all that apply)

symptoms concerning for COVID

swelling, edema

gross hematuria

rash

foamy urine

fatigue, malaise, lethargy

hemoptosis

epistaxis

abdominal pain

vomiting

diarrhea

headache

anorexia

sore throat

urinary tract infection

flank pain

other

other symptom prompting evaluation for GN

When was the diagnosis of new onset GN made relative to the COVID-19 diagnosis?

Approximate duration of kidney disease prior to COVID diagnosis

Was the patient taking Immunosuppressive medication at time of COVID- diagnosis

Yes

No

Immunosuppressive medications
(select all that apply)

Corticosteriods (include IV if given within 1 mos of infection)

ACTHAR

Mycophenolate mofetil or Myfortic

imuran/azathioprine

Calcineurin inhibitor

MTor inhibitor / Sirolimus

Cyclophosphamide (include IV if given within 1 mos of infection )

Rituximab (include if given within 6 mos of infection)

Other anti CD20 therapies (include if given within 6 mos of infection )

Proteasome inhibitor (ie. Bortezomib)

Anti CD38 Antibodies

Eculizumab or other anti-complement therapy

Belimumab

Janus kinase inhibitors (ie. tofacitinib)

Hydroxychloroquine (Plaquenil)

Other immunosuppression

Oral predisone dose(if applicable)

Intravenous methylprednisolone dose (if applicable)

IV corticosteroid given prior to COVID diagnosis

When was IV corticosteroids last administered?

D-M-Y

Time since administration of IV corticosteroids

View equation

Specify Calcineurin Inhibitor

Oral Cyclophosphamide dose

(If applicable, choose dosing regimen)

Intravenous Cyclophosphamide

(if applicable, specify number of days given prior to COVID diagnosis)

Date of last IV cytoxan dose

D-M-Y

Time since last cytoxan dose

View equation

Rituximab dosage

Specify number of months that Rituximab was given prior to COVID diagnosis

What was the date of the last Rituximab dose?

D-M-Y

Time since last rituximab dose

View equation

Other CD20 Therapy (name)

Specify number of days that other anti-CD20 therapy was given prior to COVID diagnosis

Name of other immunosuppressive medication

Was the patient on a ACE inhibitor at time of COVID diagnosis

Yes

No

Was the patient on an angiotensin receptor blocker (ARB) at time of COVID diagnosis

Yes

No

Was the patient taking both ACEI AND ARB?

Yes

No

Serum creatinine prior to COVID infection

Specify serum creatinine (sCr) units
(used for subsequent entries in survey)

For this serum creatinine, approximately how long prior to the diagnosis of COVID diagnosis was this collected?

When was this serum creatinine last checked ?

D-M-Y

Amount of time elapsed from Serum creatinine (PRE_COVID ) to COVID infection

View equation

HIDDEN - ORIG QUESTION - Estimated GFR prior to COVID infection

HIDDEN Serum Creatinine normalized to mg/dl, convert from umol/mL

View equation

Estimated GFR prior to COVID infection

View equation

Proteinuria (quantified) prior to COVID infection

(if only dipstick results are available, select value in next question)

Proteinuria ( specify units of measurement )
- g/24 hr

- mg/mmol or g/g or mg/mg (UPCR)
- dipstick

-NA if not available

Serum albumin prior to infection

Specify serum albumin units
(to be used for subsequent entries in survey )

Hematuria on dipstick

No/negative

+1

+2

>=+3

Not checked/NA

How would you characterize the renal disease activity before COVID diagnosis

Do you routinely monitor any particular serologies, markers or antibodies to assess disease activity in this patient?
(ie ANA, anti-PLA2R, anti-PR3)

Yes

No

When was the last time you checked relevant serologies prior to infection?

D-M-Y

Elapsed time from Pre-COVID serologies to COVID diagnosis

View equation

Please choose the markers used to follow disease activity in this patient with pre-existing glomerular disease
(choose all that apply)

ANA

dsDNA

ENA

SSA

SSB

p-ANCA

c-ANCA

anti MPO

anti PR3

anti-GBM (glomerular Basement membrane)

C3

C4

Anti -PLA2R

Anti-THSDA

C3 nephritic factor

C5b-9

other testing

What was the most recent value of ANA prior to COVID ?

What was the most recent value of dsDNA prior to COVID?

What was the most recent value of ENA prior to COVID?

What was the most recent value of SSA prior to COVID?

What was the most recent value of SSB prior to COVID?

What was the most recent value of anti MPO prior to COVID?

What was the most recent value of anti -PR3 prior to COVID?

What was the most recent value of C3 prior to COVID?

What was the most recent value of C4 prior to COVID?

What was the most recent value of anti PLA2R prior to COVID?

What was the most recent value of anti -THSDA prior to COVID?

What was the most recent value of anti GBM prior to COVID?

What was best description of the serologic activity relevant to the patient's glomerular disease before COVID diagnosis (if relevant)

(i.e. ANA, dsDNA, anti-PLA2R, anti-THSDA, ANCA, PR3, MPO, complement)

Not relevant to this patient's glomerular disease

Normal, negative, inactive

Minimal activity ( mildly elevated titers or mild decrease in complement levels )

Moderate activity

Severe activity (high titers)

not available, not assessed

Did the patient have any of these comorbid conditions ?

Hypertension

Diabetes

Chronic kidney disease

End stage kidney disease, on dialysis

Cardiovascular Disease

Asthma

COPD

Other chronic lung disease

Cancer

Transplant (bone marrow or solid organ excluding renal transplant)

Renal transplant

HIV / AIDS

Obesity

Lupus

Rheumatoid arthritis

Chronic liver disease (NAFLD, cirrhosis)

History of stroke

Current Smoker

Use of tobacco products other than cigarettes

Other relevant comorbidity not listed above

Was COVID diagnosis confirmed by testing

Yes

No

How was COVID-19 infection confirmed ?

nucleic acid amplification or SARS-CoV-2 RNA including RT-PCR

antigen test

serology antibody detection (IgM)

serology antibody detection (IgG)

Does the patient have one of the newer strains/variants (ie. SARS-CoV-2 VOC 202012/01)

Which variant?

Did the patient have symptoms of COVID infection

Specify approximate number of days of symptoms related to COVID infection (if known)

Symptoms of COVID 19 infection

Fever

chills, rigors

Cough

Dypsnea, shortness of breath

Anosmia, loss of smell

Myalgia

GI symptoms (nausea, vomiting, diarrhea)

Pink Eye / conjunctivitis

Nasal congestion

Fatigue

Anorexia / loss of appetite

Sore throat

Neurologic symptoms, stroke

Rash

Other

Other, please describe

Was the patient hospitalized

When was the patient hospitalized?

D-M-Y

Was the patient admitted to the Intensive Care unit?

Yes

No

Was the patient Intubated

Yes

No

Duration of time on ventilator

Was the patient placed on ECMO

Yes

No

Did the patient require Pressors

Yes

No

What is the best description of the patient's course?

mild illness, uncomplicated

pneumonia, but no need for supplemental oxygen

severe pneumonia with signs of respiratory distress and need for supplemental oxygen

Acute respiratory distress syndrome (bilateral opacities) requiring non invasive ventilation or CPAP

ARDS requiring mechanical ventilation

septic shock (requiring pressors)

Please provide description of the chest imaging (CXR and/or CT scan)
(choose all that apply to best describe findings)

No acute findings

Ground-glass opacities

Consolidation

Pleural effusions

Pulmonary Fibrosis

Pneumothorax

Date of initial set of labs after diagnosis of COVID

D-M-Y

WBC

Hemoglobin

Platelet

Lymphocyte count (absolute)

Absolute neutrophil count

CD4 count

CD8 count

D-dimer

D-dimer units

what is the normal range for D-Dimer in your lab?

Was the D-Dimer ABOVE the upper limit of quantification in your lab?

Yes

No

C-Reactive Protein

What is the normal range for CRP in your lab?

What are the units for CRP?

Was the CRP ABOVE the upper limit of quantification in your lab?

Yes

No

ESR

Was the ESR ABOVE the upper limit of quantification in your lab?

Yes

No

IL-6

What is the normal range for this IL6 value in your particular lab?

Fibrinogen

Ferritin

lactate dehydrogenase (LDH)

what are the units for LDH in your lab?

What is the normal range for LDH in your lab?

CPK

lactate

lactate units of measurement

Therapies used for infection (check all that apply)

chloroquine

hydroxychloroqine

azithromycin

remdisivir

lopinavir

other antiviral

anti-cytokine IL6, (i.e. tocilizumab , sarilumab, Siltuximab)

Anakinra or other IL-1 blockade

convalescent sera therapy/hyperimmune plasma

IVIG

corticosteroids

darunavir

ritonavir

Janus kinase inhibitor (ie. Ruxolitinib,Baricitinib)

Vitamin C

favipiravir

RAAS Antagonism

cobicstat

inhalation solutions

complement inhibition

leronlimab

duvelisib

decitabine

infliximab

Silmitasertib

inhaled nitric oxide

Anti-Spike SARS-CoV-2 Monoclonal Antibodies

colchicine

natural killer cell infusion

fostamatinib

other

Which steroid was used as therapy for COVID?

Expand

Which steroid was used as therapy for COVID?

Betamethasone

Cortisone

Dexamethasone

Hydrocortisone

Methylprednisolone

Prednisolone

Prednisone

Triamcinolone

What route were steroids administered?

Intravenous (IV)

oral (PO)

IV and PO

What was TOTAL/CUMULATIVE dosage of steroids given over the entire course of treatment of COVID?

(Please add total dosages used. For example

- prednisone: 60 mg x 5 days, total dosage = 300 mg

-dexamethasone: 6 mg x 10 day; total dosage = 60 mg

Equivalent dose in prednisone

View equation

Other, therapy

Were any of the therapies for COVID infection given under a clinical trial

Yes

No

Was it a randomized trial

Yes

No

If enrolled in a randomized trial, please provide names of therapies compared (example: plaquenil vs placebo)

Was anticoagulation/thromboprophylaxis given to prevent thrombosis?

Yes

No

If Yes, choose all that apply

unfractionated Heparin

low molecular weight heparin (LMWH)

fondaparinux

DOAC

Antiplatelet Drugs

other

Other anticoagulation therapy

What formulation of LMWH was used ?

enoxaparin/lovenox

dalteparin

tinazparin

nadroparin

Was anticoagulation given in standard prophylaxis dosages or medium dose or high dose?

Did patient develop a thrombotic event despite being on prophylactic anticoagulation?

Yes

No

Steroids

Calcineurin inhibitor

Mycophenolate mofetil or myfortic

Azathioprine

mTor inhibitor / sirolimus

Cyclophosphamide (oral)

plaquenil

Other immunosuppressive medication

What medications or treatments were given to specifically manage the New Onset Glomerular disease that occurred in setting of COVID-19?

steroids

cyclophosphamide

rituximab

other anti -CD20 monoclonal antibody (ie ocrelizumab, veltuzumab,obinutuzumab, ofatumumab)

tacrolimus

cyclosporine

mycophenolate mofetil or myfortic

azathioprine

plasma exchange

mTOR inhibitor (ie sirolimus)

complement inhibition

JaK inhibitor

other

no specific therapy was given during the acute infection

Regimen of steroids use (dose, duration, taper if relevant)

What is the other medication used?

If on ACEI or ARB at time of diagnosis of COVID, was it discontinued during management of infection

If yes please choose reason: (all that apply)

Concerns with increasing viral infectivity

Acute kidney injury/renal failure

Hypotension

Electrolyte abnormalities (ie. hyperkalemia)

Cardiac

Yes

No

Cardiac arrest

Yes

No

Myocardial infarction

Yes

No

Arrhythmia

Yes

No

Was onset of this arrhythmia temporally related to treatment with hydroxychloroquine as therapy for COVID?

Yes

No

Was onset of this arrhythmia temporally related to treatment with azithromycin as therapy for COVID?

Yes

No

Other Cardiac complication

Gastrointestinal and Hepatobiliary

Yes

No

Liver injury (increased AST/ALT>= 2x upper limit of normal)

Yes

No

Other GI complication

Central nervous system

Yes

No

Stroke

Yes

No

Seizure

Yes

No

Other CNS

Hematologic including thrombotic events

Yes

No

Disseminated intravascular coagulation (DIC)

Yes

No

Pulmonary embolism (PE)

Yes

No

Venous thromboembolism (besides PE)

Yes

No

please specify site/location of DVT

Microangiopathy

Yes

No

Other hematological complication

Superimposed Infection

Yes

No

Please specify type of infection

Other complication not specified above

Did the patient develop Acute kidney Injury
(definitions of AKI are provided in next question)

Yes

No

If patient developed AKI, please indicate stage based on KDIGO criteria

●Stage 1 - Increase in Scr to 1.5 to 1.9 x baseline, or increase in Scr by ≥0.3 mg/dL (≥26.5 micromol/L),

●Stage 2 - Increase in Scr to 2.0 to 2.9 x baseline,

●Stage 3 - Increase in Scr to 3.0 x baseline, or increase in Scr to ≥4.0 mg/dL (≥353.6 micromol/L), or initiation of RRT

If patient was not dialysis dependent prior to COVID infection, did the patient require initiation of renal replacement therapy (RRT) during COVID infection

Yes

No

If RRT was initiated, please indicate form(s) used (check all that apply)

Continuous renal replacement (CRRT)

Prolonged Intermittent Kidney Replacement Therapy (PIKRT)

Sustained, low-efficiency dialysis (SLED)

Intermittent HD

Slow Continuous Ultrafiltration (SCUF)

Peritoneal dialysis

Duration of RRT

Serum creatinine
-On admission if hospitalized.
-If outpatient, please provide lab value at or around time of diagnosis, if available

Peak serum creatinine during COVID infection

What is the date of this peak serum creatinine?

D-M-Y

Time between COVID diagnosis and peak Serum creatinine

View equation

Number of days to peak serum creatinine

Serum albumin during COVID infection

What was the lowest value (nadir) of serum albumin during COVID ?

Peak Proteinuria (quantified) during COVID Infection

(if only dipstick results available please select from next question below

if proteinuria not checked, choose NA in next question below )

Proteinuria (specify units of measurement)

Hematuria
(urinalysis dipstick)

No/negative

+1

+2

>=+3

Not checked/NA

Did the patient Recover from the infection

Yes

No

Did the patient die

Yes

No

If death, days since diagnosis

Date of death

D-M-Y

Time elapsed from COVID diagnosis to death

View equation

If hospitalized, length of hospital stay

Did the patient have confirmatory negative testing after infection

Yes

No

Days since COVID diagnosis

Date of follow up close to hospital discharge or resolution of symptoms

D-M-Y

Time since COVID diagnosis

View equation

If patient required initiation of RRT during hospitalization, do they need dialysis at time of discharge

Serum creatinine after COVID infection

Date of serum creatinine lab after covid infection

D-M-Y

HIDDEN - ORIG QUESTION - NOW CALC estimated GFR after COVID infection

Time elapsed from covid diagnosis to follow up Serum creatinine labs

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HIDDEN - normalized serum creatinine to mg/dl, convert from umol/mL

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estimated GFR after COVID infection

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Proteinuria (quantified) after COVID infection

if only dipstick results available, select from below

if not applicable or not checked, choose NA in next question below

Proteinuria (specify units)

Serum albumin after COVID infection

Hematuria
(urinalysis dipstick)

No/negative

+1

+2

>=+3

Not checked/NA

What is the best characterization of the activity or status of the patient's underlying kidney disease compared to pre-infection

unchanged

worse, active

improved

relapse

remission

unable to assess

Compared to before the COVID diagnosis, how would you describe the patient's serologic activity relevant to the patient's glomerular disease after the infection

(i.e. ANA, dsDNA, ANCA, anti- PLA2R, anti- THSDA, complement)

same

worse (ie. antibody titers increased or complement levels decreased)

better (ie. antibody titers improved)

unable to assess , not evaluated, not applicable

Are there any lessons or other important aspects that you would like to share about his case.

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Subject ID

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Would you be willing to provide follow up of renal function and glomerular disease activity (if relevant) in a follow up survey ?

Yes

No

Thank you, We will send a follow up survey in the near future

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