Minimal Change Disease Relapse After SARS-CoV-2 Booster Vaccine

ABSTRACT

Immune dysregulation has been postulated as a pathogenetic mechanism for minimal change disease (MCD) and several vaccines have been reported to act as a trigger for relapse. While cases of both de-novo MCD and MCD relapse have been reported following severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) mRNA vaccinations, we report, to the best of our knowledge, the first case of MCD relapse following booster dose of Pfizer-BioNTech SARS-CoV-2 vaccine. 63-year-old Italian male, with history of nephrotic syndrome secondary to kidney biopsy proven MCD, who had achieved complete remission with steroid therapy, had follow up labs done that showed spot urine protein creatinine of 10.1 and albumin of 3.0g/dL. He had received the booster dose of Pfizer-BioNTech SARS-CoV-2 vaccine 2 weeks ago, and endorsed generalized weakness, puffiness over face, edema over upper extremities that appeared within a week after administration of the vaccine, and weight gain of 10 lbs over past week. Blood pressure was elevated (152/78 mmHg). He denied any recent infections, use of Nonsteroidal Anti-Inflammatory Drugs, or antibiotics. Other diagnostic work up revealed hypertriglyceridemia, normal serum creatinine. Serological work up for secondary causes of glomerular diseases was negative. He was initiated on oral prednisone therapy. Spot urine proteincreatinine decreased to 1.1, 2 weeks after initiation of steroids. Vaccination is a recognized trigger for relapse of nephrotic syndrome. mRNA vaccines are expected to produce a higher antibody response as well as increased production of cytokines and chemokines. This can lead to dysregulation in permeability factors that can result in relapsing glomerulonephritis. As data on adverse effects of SARS-CoV-2 vaccines continue to evolve, we suggest to closely monitor patients with history of nephrotic syndrome for relapse after receipt of the SARS-CoV-2 vaccine, including the booster dose. Further studies are needed to determine whether relapse of MCD is specific for SARS-CoV-2 mRNA vaccination and to decipher mechanisms for possible immune dysregulation in those patients. This may help in formulation of protocol for vaccination in patients with nephrotic syndrome and contribute to informed decision making.