Exacerbation of Minimal Change Disease Following mRNA COVID-19 Vaccination

Abstract

BACKGROUND Minimal change disease is a common cause of nephrotic syndrome in adults. There are few reported cases of vaccine-related podocytopathy with nephrotic-range proteinuria in the setting of a minimal change disease history. There have been rare reports of acute renal damage following vaccination to prevent COVID-19 and some cases of exacerbation of ongoing nephropathy. This report is a 33-year-old man with a 22-year history of nephrotic syndrome due to minimal change disease which exacerbated following a third dose of an mRNA SARS-CoV-2 vaccine for COVID-19. CASE REPORT We report a case of nephrotic syndrome after the third dose of the BNT162b2 mRNA COVID-19 vaccine. The patient presented with mild edema in the bilateral lower extremities and sacrum. Laboratory investigations confirmed nephrotic-range proteinuria and hypoalbuminemia. A kidney sonogram demonstrated mild renal parenchymal disease and a small non-obstructing right renal calculus. Renal biopsy revealed diffuse podocyte foot process effacement, punctuate IgG podocyte cytoplasmic staining, and minimal global glomerulosclerosis, consistent with a diagnosis of a diffuse podocytopathy with a minimal change disease phenotype. The patient was started on oral prednisone treatment, which led to remission of his symptoms and normalization of lab test results with normal BUN and Cr and resolution of proteinuria. Treatment was tapered off over the course of 28 weeks. CONCLUSIONS We presents a case of longstanding minimal change disease that showed exacerbation following a third dose of an mRNA vaccine for SARS-CoV-2. Although this may be a rare association, this case supports that patients with chronic glomerulonephritis need to be monitored.

Figure 1.

Kidney biopsy findings. (A) Light micrograph demonstrating unremarkable glomerulus (periodic acid Schiff stain; 400×). (B) Immunofluorescence stain for anti-human IgG demonstrating fine granular podocyte cytoplasmic “dusting” with IgG (arrows) (400×; contrast enhanced from original image for enhanced visualization of weak deposits). (C) Electron micrograph demonstrating a representative glomerular capillary loop with extensive podocyte foot process effacement (arrows). (D) Immunofluorescence stain for anti-human IgA demonstrating segmental weak granular mesangial IgA deposition (400×). (E) Electron micrograph of a mesangial region demonstrating a rare mesangial electron-dense deposit (arrow).

Figure 2.

Timeline and clinical course of the patient. UPC – urine protein creatinine.