Relapse of minimal change disease following the AstraZeneca COVID-19 vaccine
Authors: Clare Morlidge, Sally El-Kateb, Praveen Jeevaratnam, Barbara Thompson
Journal: Kidney International (2021)

Anecdotal reports linking minimal change disease (MCD) to vaccinations possibly due to immune dysregulation,1Clajus C. Spiegel J. Brocker V. et al.Minimal change nephrotic syndrome in an 82 year old patient following a tetanus-diphtheria-poliomyelitis-vaccination.BMC Nephrol. 2009; 10: 21Crossref PubMed Scopus (29) Google Scholar including influenza vaccine,2Kielstein J.T. Termuhlen L. Sohn J. Minimal change nephrotic syndrome in a 65-year-old patient following influenza vaccination.Clin Nephrol. 2000; 54: 246-248PubMed Google Scholar pneumococcal,3Kikuchi Y. Imakiire T. Hyodo T. et al.Minimal change nephrotic syndrome, lymphadenopathy and hyperimmunoglobulinemia after immunization with a pneumococcal vaccine.Clin Nephrol. 2002; 58: 68-72Crossref PubMed Google Scholar meningococcal C vaccines,4Abeyagunawardena A. Goldblatt D. Andrews N. Trompeter R. Risk of relapse after meningococcal C conjugate vaccine in nephrotic syndrome.Lancet. 2003; 362: 449-450Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar and BNT162b2 coronavirus disease 2019 (COVID-19) vaccine (Pfizer-BioNTech)5Lebedev L. Sapojnikov M. Wechsler A. et al.Minimal change disease following the Pfizer-BioNTech COVID-19 vaccine.Am J Kidney Dis. 2021; 78: 142-145Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar,6D'Agati V.D. Kudose S. Bomback A.S. et al.Minimal change disease and acute kidney injury following the Pfizer-BioNTech COVID-19 vaccine.Kidney Int. 2021; 100: 461-463Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar have been published. We report 2 cases of biopsy-proven MCD relapsing within 2 days of receiving an AstraZeneca COVID-19 vaccine. A 30-year-old man had received 1 g of rituximab in August 2020, having experienced annual relapses on tacrolimus. His prednisolone had been weaned to 1 mg/day by January and discontinued altogether by February 2021. Two days after his COVID-19 vaccine, he developed a headache and frothy urine. Urine protein-to-creatinine ratio 1 week later was 213 mg/mmol; albumin was preserved at 47 g/l; creatinine was stable at 82 μmol/l. At that time, lymphocyte subsets showed complete B-cell depletion; CD19 was 0.00. He did not seek medical attention until 2 months after receiving the vaccine when his urine protein-to-creatinine ratio was 142 mg/mmol. Repeat lymphocyte subsets then revealed B-cell return; CD19 was 0.06. Complete remission was achieved with 10 days of starting prednisolone 20 mg daily. A 40-year-old woman was maintained on prednisolone 5 mg daily and tacrolimus (Adoport); trough level was 4.6 μg/l before vaccination. One day after receiving her first COVID-19 vaccine, she developed a headache, frothy urine, and ankle swelling. After 1 week, her general practitioner recorded 3+ dipstick proteinuria. Unfortunately, no laboratory samples were sent. Prednisolone was increased to 30 mg daily, and complete remission was achieved within 2 weeks. Creatinine was unchanged at 105 μmol/l. The association with various vaccines has been described, occurring between 4 days to several weeks later.1Clajus C. Spiegel J. Brocker V. et al.Minimal change nephrotic syndrome in an 82 year old patient following a tetanus-diphtheria-poliomyelitis-vaccination.BMC Nephrol. 2009; 10: 21Crossref PubMed Scopus (29) Google Scholar,5Lebedev L. Sapojnikov M. Wechsler A. et al.Minimal change disease following the Pfizer-BioNTech COVID-19 vaccine.Am J Kidney Dis. 2021; 78: 142-145Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar,6D'Agati V.D. Kudose S. Bomback A.S. et al.Minimal change disease and acute kidney injury following the Pfizer-BioNTech COVID-19 vaccine.Kidney Int. 2021; 100: 461-463Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar,7Sette A. Crotty S. Adaptive immunity to SARS-CoV-2 and COVID-19.Cell. 2021; 184: 861-880Abstract Full Text Full Text PDF PubMed Scopus (1126) Google Scholar The timing of COVID-19 vaccination and the very early development of relapse of MCD in our cases raises questions as to the mechanisms involved. At 2 days after vaccination, one would assume the vaccine triggered a more generalized cytokine-mediated response.7Sette A. Crotty S. Adaptive immunity to SARS-CoV-2 and COVID-19.Cell. 2021; 184: 861-880Abstract Full Text Full Text PDF PubMed Scopus (1126) Google Scholar Others have postulated that symptoms after 4 days represent a rapid T cell–mediated response to viral mRNA.2Kielstein J.T. Termuhlen L. Sohn J. Minimal change nephrotic syndrome in a 65-year-old patient following influenza vaccination.Clin Nephrol. 2000; 54: 246-248PubMed Google Scholar,5Lebedev L. Sapojnikov M. Wechsler A. et al.Minimal change disease following the Pfizer-BioNTech COVID-19 vaccine.Am J Kidney Dis. 2021; 78: 142-145Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar,6D'Agati V.D. Kudose S. Bomback A.S. et al.Minimal change disease and acute kidney injury following the Pfizer-BioNTech COVID-19 vaccine.Kidney Int. 2021; 100: 461-463Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar We administered the second dose of a different COVID vaccine, and neither patient suffered an adverse effect. However, both patients were taking 15 mg prednisolone daily at the time. This may prove a useful strategy in similar cases. We await further reports to evaluate the true incidence. Minimal change disease and acute kidney injury following the Pfizer-BioNTech COVID-19 vaccineKidney InternationalVol. 100Issue 2PreviewAs mass vaccinations for coronavirus disease 2019 (COVID-19) are being administered worldwide, rare reports of adverse events are emerging. We report a case of minimal change disease presenting with nephrotic syndrome 1 week after a first injection of the COVID-19 vaccine (Pfizer-BioNTech). Full-Text PDF Granulomatous vasculitis after the AstraZeneca anti–SARS-CoV-2 vaccineKidney InternationalVol. 100Issue 3PreviewSeveral reports of newly diagnosed or relapses of immune-mediated renal diseases following vaccination with anti–severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA and AstraZeneca vaccines recently emerged in the litterature.1,2 Full-Text PDF COVID-19 vaccination followed by activation of glomerular diseases: does association equal causation?Kidney InternationalVol. 100Issue 5PreviewTo date, >4 billion doses of the various severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines have been administered worldwide in response to the coronavirus disease 2019 (COVID-19) pandemic. Even as widespread vaccination campaigns have contributed to declining case rates, adverse events are appearing beyond those originally reported in the clinical trials of vaccine efficacy and safety. Of particular relevance to the kidney is the increasing number of reports of de novo or reactivation of glomerular diseases (Table 11–25). Full-Text PDF