key: cord-0720864-ckxuogfl
authors: D’Agati, Vivette D.; Kudose, Satoru; Bomback, Andrew S.; Adamidis, Ananea; Tartini, Albert
title: Minimal Change Disease and AKI following the Pfizer-BioNTech COVID-19 Vaccine
date: 2021-05-15
journal: Kidney Int
DOI: 10.1016/j.kint.2021.04.035
sha: 1b82fd972ef1b4b67b8d4ea51357c1aa3b5547c7
doc_id: 720864
cord_uid: ckxuogfl

nan

To the Editor: As mass vaccinations for 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 one week after a first injection of the COVID-19 vaccine (Pfizer-BioNTech).

A 77 year-old white male with 15-year history of type 2 diabetes mellitus without retinopathy received a first dose of the Pfizer-BioNTech vaccine on March 17, 2021. Past medical history included obesity, prior smoking and coronary artery disease. Baseline serum creatinine ranged 1.0 to 1.3 mg/dL with no proteinuria over the previous year. Outpatient medications included atorvastatin, aspirin, dulaglutide, empagliflozin, glipizide, losartan, metformin, and metoprolol. There was no history of NSAID use. Seven days after vaccination, he presented to his local physician complaining of abrupt onset of lower extremity edema. Laboratory testing revealed 4+ proteinuria by dipstick and serum albumin 2.5 g/dL. Nephrology consultation 12 days after vaccination found anasarca with 13.6 kg weight gain due to edema, elevated BP (152/81), and 4+ proteinuria on urinalysis with inactive urine sediment, prompting hospital admission. Laboratory evaluation by 14 days after vaccination showed 24-hour urine protein 23.2 g/day, serum creatinine 2.33 mg/dL and serum albumin 3.0 g/dL. Complete blood count was normal and HgbA1c was 7.5%. Serologies included elevated C3 and C4 and negative hepatitis B surface antigen and hepatitis C antibody.

A kidney biopsy was performed 16 days after vaccination (figure 1). Among 7 glomeruli sampled for light microscopy, 4 were globally sclerotic and 3 were histologically unremarkable. There was 25% tubular atrophy and interstitial fibrosis with moderate arteriosclerosis. Cortical tubules displayed diffuse acute epithelial injury. No immune deposits were identified by immunofluorescence (2 glomeruli) or electron microscopy (2 glomeruli). Electron microscopy revealed 100% podocyte foot process effacement, leading to a diagnosis of minimal change disease with acute tubular injury. The ultrastructural findings of minimal segmental mesangial sclerosis and glomerular basement membrane thickening (mean 460 nm) suggested underlying mild diabetic changes.

Empiric pulse solumedrol 1 g daily for 3 days was initiated upon hospital admission followed by oral prednisone 60 mg daily post biopsy. In the hospital, he required intravenous furosemide drip 10 mg/hr, transitioned to bumetanide 0.25 mg/hr, for 5 days for fluid overload. Creatinine peaked during the hospitalization at 3.17 mg/dL at 19 days post vaccination. The patient was discharged 3 days later with 19.8 g/g proteinuria by spot ratio, serum albumin 2.9 g/dL, and serum creatinine 2.54 mg/dL. At most recent follow-up, approximately 3 weeks after initiation of corticosteroids, creatinine remains elevated at 3.74 mg/dl with 24-hour urine protein 18.8 g/day (figure 2). This is the second report of minimal change disease occurring within a week of initial dose of the Pfizer-BioNTech vaccine. The first report was of a 50 year-old healthy man who developed lower extremity edema 4 days after injection, followed rapidly by anasarca and AKI, with serum creatinine 2.3 mg/dL and urine protein 6.9 g/day on admission. 1 He responded to steroid therapy with complete remission. 1 The strong temporal association with vaccination in both cases suggests rapid T-cell mediated immune response to viral mRNA as a possible trigger for podocytopathy. Acute onset of minimal change disease has also been reported in a 65 year-old woman and a 44 year-old man at 4 days and 18 days, respectively, following the influenza vaccine. 2, 3 While definitive causality is difficult to establish, greater awareness of this potential side effect of vaccination is needed to determine its frequency. With

Minimal Change Disease Following the Pfizer-BioNTech COVID-19 Vaccine

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Light microscopy shows a histologically unremarkable glomerulus (Hematoxylin & eosin, 400X). (B) A low power view shows diffuse cortical acute tubular injury with focal shedding of degenerating epithelial cells into the lumen. (H&E, 200X). (C) Electron microscopy demonstrates complete podocyte foot process effacement (8000X)