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Kidney Week

Abstract: PO1486

Minimal Change Disease Following the mRNA-1237 Vaccine in a Kidney Transplant Recipient

Session Information

Category: Glomerular Diseases

  • 1202 Glomerular Diseases: Immunology and Inflammation

Authors

  • Rodriguez, Juanly N., University of Miami School of Medicine, Miami, Florida, United States
  • Sivan, Shobana, University of Miami School of Medicine, Miami, Florida, United States
  • Goggins, Mariella Ortigosa, University of Miami School of Medicine, Miami, Florida, United States
Introduction

Kidney transplant recipients (KTR) are susceptible to post-transplant glomerulopathies. Minimal change disease (MCD) seen rarely. Few cases have been reported post-immunization, recently with the Pfizer-BioNTech vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report a case of de novo MCD after mRNA-1273 vaccine in a deceased donor KTR, with sudden onset nephrotic syndrome (NS) and acute kidney injury (AKI) a week after the first dose.

Case Description

45-yo woman with history of ESKD from lupus nephritis, underwent DDKT on 09/2019 from a 20-yo Caucasian male, kidney donor profile index 16%, calculated panel reactive antibody 0%. Complicated by delayed graft function. On day 27 post-transplantation serum creatinine (Scr) improved to 0.8 mg/dl. Maintenance immunosuppression tacrolimus and mycophenolic acid. 11 months post-KT contracted COVID-19 pneumonia, managed conservatively. 6 months later developed anasarca 4 days post-mRNA-1273 vaccine. Initial Scr 2.10 mg/dl, urine analysis 4 + protein / 2 RBCs, urine protein to creatinine ratio (UPCR) 9.6 g/g, albumin 2.1 g/dl consistent with NS. SARS-CoV-2 PCR negative. Positive IgG antibody, titer 3.87 s/co (0-0.99), tacrolimus 4.7 ng/ml. Normal C3/C4 levels, anti-DNA antibody 5 IU/m. Allograft biopsy showed mild tubulitis and interstitial nephritis on light microscopy (LM), immunofluorescence negative for C4d, electron microscopy with moderate foot process effacement and no electron dense deposits, suspicious for MCD. Prednisone 1mg/kg/day was started. 4 weeks later UPCR 1.12 g/g, Scr 0.8 mg/dl and albumin 3.3 g/dl.

Discussion

This is a seropositive SARS-CoV-2 KTR from previous COVID-19 pneumonia who developed NS and AKI following the mRNA-1273 vaccine. Biopsy consisted with MCD. Immunogenicity to mRNA vaccines in transplant recipients is blunted after the first dose but higher in seropositive patients. Timing from vaccine exposure to development of MCD ranges from days to months, our patient mounted an immune response in 4 days. The acute tubular injury seen in LM is atypical, unclear if this is a cell mediated process from allograft rejection or part of the pathogenesis post-immunization. In cases of AKI with NS, days to weeks following either class of mRNA vaccine a prompt initiation of steroids and further investigation with kidney biopsy is warranted.