Acute rejection after anti–SARS-CoV-2 mRNA vaccination in a patient who underwent a kidney transplant
Authors: Arnaud Del Bello, Olivier Marion, Audrey Delas, Nicolas Congy-Jolivet, Magali Colombat, Nassim Kamar
Journal: Kidney International (2021)

Anti–severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination is recommended in patients who underwent a transplant because of an increased risk of developing severe coronavirus disease 2019 (COVID-19), and mortality.1Caillard S. Anglicheau D. Matignon M. et al.An initial report from the French SOT COVID Registry suggests high mortality due to COVID-19 in recipients of kidney transplants.Kidney Int. 2020; 98: 1549-1558Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar Because of a weak immunogenicity of mRNA 2-dose vaccines in transplant patients, the French Health Authority recommended to offer a third dose to immunosuppressed patients to boost the immune response.2Boyarsky B.J. Werbel W.A. Avery R.K. et al.Immunogenicity of a single dose of SARS-CoV-2 messenger RNA vaccine in solid organ transplant recipients.JAMA. 2021; 325: 1784-1786Crossref PubMed Scopus (419) Google Scholar,3https://www.mesvaccins.net/textes/dgs_urgent_n43_vaccination_modalites_d_administration_des_rappels.pdfGoogle Scholar However, no biological monitoring before and after vaccination is recommended. We report on the case of a 23-year-old non–human leukocyte antigen–sensitized patients who underwent a kidney transplant who presented an acute rejection after the second dose of the BNT162b2 mRNA COVID-19 Vaccine (Pfizer-BioNTech). She had undergone a deceased donor kidney transplantation for nephronophthisis 18 months earlier. The post-transplant period was uneventful. Her maintenance therapy was based on tacrolimus (target trough level, 5 ng/ml and 7 ng/ml), mycophenolic acid, and low-dose steroid. Fifteen days before the first dose, her serum creatinine level was at 80 μmol/L and anti–SARS-CoV-2 serology was negative. Eight days after the second dose, systematic blood tests revealed impaired kidney function at 130 μmol/L, which then raised to 360 μmol/L (Figure 1). A kidney biopsy revealed a cellular acute rejection. Donor-specific anti–human leukocyte antigen antibodies became detectable with a weak intensity, targeting donor human leukocyte antigen class II antigens. Anti–SARS-CoV-2 spike protein antibodies became positive. Tacrolimus trough level was unchanged at 5 ng/ml. At 10 days, after steroid pulses (500 mg/d for 3 days), the patient's serum creatinine level had decreased to 230 μmol/L. Another kidney biopsy is planned to discuss the use of polyclonal antibodies. Hence, this report suggests that kidney function should be carefully monitored in kidney transplantation undergoing anti–SARS-CoV-2 vaccination, especially if a third boost dose is performed. An initial report from the French SOT COVID Registry suggests high mortality due to COVID-19 in recipients of kidney transplantsKidney InternationalVol. 98Issue 6PreviewNotwithstanding the ongoing coronavirus disease-2019 (Covid-19) pandemic, information on its clinical presentation and prognosis in recipients of a kidney transplant remain scanty. The aim of this registry-based observational study was to explore characteristics and clinical outcomes of recipients of kidney transplants included in the French nationwide Registry of Solid Organ Transplant Recipients with Covid-19. Covid-19 was diagnosed in symptomatic patients who had a positive PCR assay for SARS-CoV-2 or having typical lung lesions on imaging. Full-Text PDF