Email address of reporter
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Name of Institution or Practice Providing Care
AF:Afghanistan AX:Åland Islands AL:Albania DZ:Algeria AS:American Samoa AD:Andorra AO:Angola AI:Anguilla AQ:Antarctica AG:Antigua and Barbuda AR:Argentina AM:Armenia AW:Aruba AU:Australia AT:Austria AZ:Azerbaijan BS:Bahamas BH:Bahrain BD:Bangladesh BB:Barbados BY:Belarus BE:Belgium BZ:Belize BJ:Benin BM:Bermuda BT:Bhutan BO:Bolivia BA:Bosnia and Herzegovina BW:Botswana BV:Bouvet Island BR:Brazil IO:British Indian Ocean Territory BN:Brunei Darussalam BG:Bulgaria BF:Burkina Faso BI:Burundi KH:Cambodia CM:Cameroon CA:Canada CV:Cape Verde KY:Cayman Islands CF:Central African Republic TD:Chad CL:Chile CN:China CX:Christmas Island CC:Cocos (Keeling) Islands CO:Colombia KM:Comoros CG:Congo CD:Congo, The Democratic Republic of The CK:Cook Islands CR:Costa Rica CI:Cote D'ivoire HR:Croatia CU:Cuba CY:Cyprus CZ:Czechia DK:Denmark DJ:Djibouti DM:Dominica DO:Dominican Republic EC:Ecuador EG:Egypt SV:El Salvador GQ:Equatorial Guinea ER:Eritrea EE:Estonia ET:Ethiopia FK:Falkland Islands (Malvinas) FO:Faroe Islands FJ:Fiji FI:Finland FR:France GF:French Guiana PF:French Polynesia TF:French Southern Territories GA:Gabon GM:Gambia GE:Georgia DE:Germany GH:Ghana GI:Gibraltar GR:Greece GL:Greenland GD:Grenada GP:Guadeloupe GU:Guam GT:Guatemala GG:Guernsey GN:Guinea GW:Guinea-bissau GY:Guyana HT:Haiti HM:Heard Island and Mcdonald Islands VA:Holy See (Vatican City State) HN:Honduras HK:Hong Kong HU:Hungary IS:Iceland IN:India ID:Indonesia IR:Iran, Islamic Republic of IQ:Iraq IE:Ireland IM:Isle of Man IL:Israel IT:Italy JM:Jamaica JP:Japan JE:Jersey JO:Jordan KZ:Kazakhstan KE:Kenya KI:Kiribati KP:Korea, Democratic People's Republic of KR:Korea, Republic of KW:Kuwait KG:Kyrgyzstan LA:Lao People's Democratic Republic LV:Latvia LB:Lebanon LS:Lesotho LR:Liberia LY:Libyan Arab Jamahiriya LI:Liechtenstein LT:Lithuania LU:Luxembourg MO:Macao MK:Macedonia, The Former Yugoslav Republic of MG:Madagascar MW:Malawi MY:Malaysia MV:Maldives ML:Mali MT:Malta MH:Marshall Islands MQ:Martinique MR:Mauritania MU:Mauritius YT:Mayotte MX:Mexico FM:Micronesia, Federated States of MD:Moldova, Republic of MC:Monaco MN:Mongolia ME:Montenegro MS:Montserrat MA:Morocco MZ:Mozambique MM:Myanmar NA:Namibia NR:Nauru NP:Nepal NL:Netherlands AN:Netherlands Antilles NC:New Caledonia NZ:New Zealand NI:Nicaragua NE:Niger NG:Nigeria NU:Niue NF:Norfolk Island MP:Northern Mariana Islands NO:Norway OM:Oman PK:Pakistan PW:Palau PS:Palestinian Territory, Occupied PA:Panama PG:Papua New Guinea PY:Paraguay PE:Peru PH:Philippines PN:Pitcairn PL:Poland PT:Portugal PR:Puerto Rico QA:Qatar RE:Reunion RO:Romania RU:Russian Federation RW:Rwanda SH:Saint Helena KN:Saint Kitts and Nevis LC:Saint Lucia PM:Saint Pierre and Miquelon VC:Saint Vincent and The Grenadines WS:Samoa SM:San Marino ST:Sao Tome and Principe SA:Saudi Arabia SN:Senegal RS:Serbia SC:Seychelles SL:Sierra Leone SG:Singapore SK:Slovakia SI:Slovenia SB:Solomon Islands SO:Somalia ZA:South Africa GS:South Georgia and The South Sandwich Islands ES:Spain LK:Sri Lanka SD:Sudan SR:Suriname SJ:Svalbard and Jan Mayen SZ:Swaziland SE:Sweden CH:Switzerland SY:Syrian Arab Republic TW:Taiwan, Province of China TJ:Tajikistan TZ:Tanzania, United Republic of TH:Thailand TL:Timor-leste TG:Togo TK:Tokelau TO:Tonga TT:Trinidad and Tobago TN:Tunisia TR:Turkey TM:Turkmenistan TC:Turks and Caicos Islands TV:Tuvalu UG:Uganda UA:Ukraine AE:United Arab Emirates GB:United Kingdom US:United States UM:United States Minor Outlying Islands UY:Uruguay UZ:Uzbekistan VU:Vanuatu VE:Venezuela VN:Viet Nam VG:Virgin Islands, British VI:Virgin Islands, U.S. WF:Wallis and Futuna EH:Western Sahara YE:Yemen ZM:Zambia ZW:Zimbabwe
(years)
Male female
American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other Unknown
Hispanic/latino Not Hispanic/Latino Unknown, chose not to answer
Did this patient develop new onset glomerulonephritis after receiving SARs-Cov2 vaccination?
Yes
No
Did the patient experience RELAPSE of their known glomerulonephritis after COVID vaccination
Yes
No
Did GN occur in native kidney or transplanted kidney?
native kidney transplant kidney
Did GN occur after the Primary Vaccination series or after Booster?
Primary vaccination
booster
What was date of Renal biopsy ?
Today M-D-Y
Which COVID-19 vaccine(s) did the patient receive?
Did the patient receive one dose of a vaccine or two doses?
one
two
Please enter the date of Vaccine Dose 1
Today M-D-Y
Please enter the date of Vaccine Dose 2
Today M-D-Y
Did the patient receive Booster doses after the primary Vaccine series?
Yes
No
Please enter the date of the Booster dose #1
Today M-D-Y
Please enter the date of Booster dose #2
(leave blank if not received)
Today M-D-Y
Did GN diagnosis occur after the 1st dose or 2nd dose (of 2 dose series) or after the boosters?
after 1st dose
after 2nd dose
after Booster 1
after Booster 2
Elapsed Time from Vaccine dose #1 to Date of Renal biopsy
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Elapsed time from Vaccine dose #2 to Date of Renal biopsy
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Elapsed Time from Booster dose #1 to Date of Renal biopsy
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Elapsed Time from Booster dose #2 to Date of Renal biopsy
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Elapsed time from last shot to renal biopsy
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Was the 2nd dose of vaccine or another vaccine adminstered if the patient had new onset GN after 1st dose of vaccine?
What histology was seen on the Renal Biopsy?
For this MN case, please specify positive Tissue staining/ expression of antigens on renal biopsies
Please select features present on Renal biopsy
(choose all that apply)
Was genotyping for APOL1 risk alleles performed?
Yes
No
What were results of APOL1 genotyping?
0 APOL1 risk allele
1 APOL1 risk allele
2 APOL1 risk alleles (high risk)
Please select relevant positive serologies that were related to new onset GN
(choose all that apply)
Was the patient checked for the presence of Antibodies to SARC-CoV2 spike protein after vaccination?
Yes
No
Was the spike protein present?
Yes
No
Did the patient develop any of the following signs or symptoms of renal disease after COVID-19 vaccination ?
(choose all that apply)
Approximately how long after COVID vaccine administration did renal-related symptoms appear?
within hours
with 1-2 days
within 3-4 days
within 5-7 days
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 weeks
8 weeks
3 months
NOT SURE
Did the patient develop other (non-renal) symptoms or problems after COVID vaccine?
(choose all that apply)
Check any underlying conditions that the patient had prior to Vaccine
(choose all that apply)
What other systemic autoimmune condition did the patient have?
What other medical condition did the patient have before vaccination ?
Did the patient have known history of COVID-19 infection prior to getting the COVID vaccine?
Yes
No
If known, please enter the date of diagnosis of previous COVID-19 infection
Today M-D-Y
Elapsed time from COVID infection to Vaccination
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Did the patient have a prior history of reactions to OTHER vaccines (besides COVID vaccine)?
Yes
No
What reactions did the patient have to previous vaccines?
What was serum creatinine prior to vaccination?
(if available baseline data)
mg/dl
What is the date of previous (baseline) serum creatinine prior to vaccination?
Today M-D-Y
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grams/gram
Baseline labs BEFORE vaccination Please enter the data below for this patient's baseline (prior to vaccination) labs.
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Lab Date Serum Creatinine (mg/dl) eGFR Proteinuria (g/g) Serum Albumin (g/dl)
serum Creatinine at time of biopsy
Lab Date 1 (at/near the time of Renal biopsy)
Today M-D-Y
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Labs AFTER Vaccination at (around) time of GN diagnosis/Renal Biopsy Please enter the labs data available after vaccination at (or around) time of Renal biopsy
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Lab Date Serum Creatinine (mg/dl) eGFR Proteinuria (g/g) Serum Albumin (g/dl)
Today M-D-Y
time elapsed from renal biopsy to follow up 1
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Serum Creatinine follow up 1
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Serum albumin follow up 1
Today M-D-Y
time elapsed from renal biopsy to follow up 2
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Serum Creatinine follow up 2
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Serum albumin follow up 2
Today M-D-Y
time elapsed from renal biopsy to follow up 3
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Serum Creatinine follow up 3
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Serum albumin follow up 3
Today M-D-Y
time elapsed from renal biopsy to follow up 4
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Serum Creatinine follow up 4
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Serum albumin follow up 4
Today M-D-Y
time elapsed from renal biopsy to follow up 5
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Serum Creatinine follow up 5
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Serum albumin follow up 5
Today M-D-Y
time elapsed from renal biopsy to follow up 6
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Serum Creatinine follow up 6
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Serum albumin follow up 6
Today M-D-Y
time elapsed from renal biopsy to follow up 7
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Serum Creatinine follow up 7
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Serum albumin follow up 7
Today M-D-Y
time elapsed from renal biopsy to follow up 8
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Serum Creatinine follow up 8
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Serum albumin follow up 8
Today M-D-Y
time elapsed from renal biopsy to follow up 9
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Serum Creatinine follow up 9
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Serum albumin follow up 9
Today M-D-Y
time elapsed from renal biopsy to follow up 10
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Serum Creatinine follow up 10
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Serum albumin follow up 10
Today M-D-Y
time elapsed from renal biopsy to follow up 11
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Serum Creatinine follow up 11
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Serum albumin follow up 11
Today M-D-Y
time elapsed from renal biopsy to follow up 12
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Serum Creatinine follow up 12
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Serum albumin follow up 12
Today M-D-Y
time elapsed from renal biopsy to follow up 13
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Serum Creatinine follow up 13
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Serum albumin follow up 13
Today M-D-Y
time elapsed from renal biopsy to follow up 14
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Serum Creatinine follow up 14
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Serum albumin follow up 14
Today M-D-Y
time elapsed from renal biopsy to follow up 15
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Serum Creatinine follow up 15
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Serum albumin follow up 15
Today M-D-Y
time elapsed from renal biopsy to follow up 16
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Serum Creatinine follow up 16
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Serum albumin follow up 16
Follow up labs AFTER GN diagnosis Please enter follow up lab data after GN diagnosis
Enter directly into table
Lab Date Time Elasped from renal biopsy to labs Serum Creatinine (mg/dl) eGFR Proteinuria (g/g)
Serum Albumin (g/dl) Lab Date Time Elasped from renal biopsy to labs Serum Creatinine (mg/dl) eGFR Proteinuria (g/g)
Serum Albumin (g/dl)
How was GN managed?
(choose all that apply)
If conservative management, did the GN improve spontaneously?
Yes
No
Please select immunosuppressive treatments provided for new onset GN after Vaccine
(check all that apply)
Please provide more details on the regimen of steroids used such as:
-corticosteroid preparation(s)
-oral and/or IV
-dosage/day -duration of steroids -Taper
Please provide details of the dosage and duration including
-preparation (CellCept vs Myfortic)
-dosage
-duration
Please provide any details of the dosage of Tacrolimus used including
-dose
-duration
Please provide more details on regimen of rituximab used including
-dose (ie 375 mg/m2, 500 mg, 1 gram)
-frequency (ie weekly x4, 2 doses on Day 1, 15, single dose)
-number of cycles given
-timing between cycles (ie 6 months)
What other immunosuppression was provided?
Date of most recent follow up
Today M-D-Y
Time elapsed from Renal Biopsy to most recent follow up
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At most recent follow up, please selection option that best describes status of kidney disease
How would you best characterize timing of the patient relapse?
choose all that apply
AT most recent follow up, what is best characterization of the relevant serologies related to the GN?
What is the value for the ANA at the time of renal biopsy?
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Serologies relevant to the glomerulenephritis
Please enter Serial Labs, if availiable durectly into table
ANA
dsDNA ENA SS-A(Ro) SS-B(La) C3 C4 P-ANCA C-ANCA Anti PR3 Anti MPO Anti GBM Anti PLA2R Anti THSD7a
Did the patient receive any other vaccines within 3 months (before or after) of the COVID vaccine?
Yes
No
Which vaccine(s) did the patient receive ?
(choose all that apply)
What was the date of administration of other vaccine(s) that was closest in timing to the COVID vaccine?
Today M-D-Y
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