Minimal change disease following the Moderna mRNA-1273 SARS-CoV-2 vaccine

To the editor:

The immunologic response following several varieties of vaccination has been described as a potential trigger for the development of both de novo as well as recurrent minimal change disease (MCD).¹ There have been emerging cases, including that described by D’Agati et al., of MCD shortly after vaccination with the BNT162b2 vaccine (Pfizer-BioNTech).^{2 , 3} We report, to the best of the authors’ knowledge, the first case of MCD presenting as nephrotic syndrome following the Moderna mRNA-1273 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine.

The patient, a 63-year-old woman, had a medical history that was significant only for hypertension and tobacco dependence. She had no prior history of renal disease. In April 2021, she presented to our hospital with a 4-week history of progressive anasarca, fatigue, periorbital edema, and dyspnea. The patient relayed that the edema and development of foamy urine appeared abruptly and occurred less than a week after having received the first (and only) dose of the Moderna mRNA-1273 SARS-CoV-2 vaccine (lot 006B21A). Vaccination was confirmed by cross-referencing her outpatient pharmacy, which administered the dose. Unfortunately, anti-S protein antibody titer is not available to report.

Clinical and diagnostic evaluation also revealed newly uncontrolled hypertension (181/82 mm Hg) as well as mild acute kidney injury (serum creatinine 1.48 mg/dl; baseline was 0.7 mg/dl). Hypoalbuminemia (0.7 g/dl), urinalysis with 3+ proteinuria (without microscopic hematuria), and hyperlipidemia (triglycerides, 221 mg/dl; total cholesterol, 450 mg/dl) were noted. Nephrotic syndrome was confirmed as the 24-hour urine collection revealed 13.4 g proteinuria. Renal biopsy was promptly performed. Pathology confirmed MCD, with mild acute tubular injury, although a focal acute interstitial nephritis was also present. Four of 69 sampled glomeruli were globally sclerosed. There was 10% tubulointerstitial fibrosis. The sampled glomeruli were found to have 100% foot process effacement (Figure 1 ).

Figure 1.

Electron micrograph featuring glomerular capillary loop with diffuse podocyte effacement. Bar = 2 μm. Original magnification ×3500. To optimize viewing of this image, please see the online version of this article at www.kidney-international.org.

Treatment with conservative measures, including valsartan, 80 mg orally twice a day, for renin-angiotensin-aldosterone system inhibition was initiated along with a loop diuretic. She was also given pulse methyl-prednisolone, 500 mg i.v. for 3 days, followed by 1 mg/kg prednisone orally. On the basis of other case reports and our experience with MCD, we anticipate a prompt response to these measures.⁴ We have recommended the patient forgo the second scheduled dose of the Moderna mRNA-1273 SARS-CoV-2 vaccine. In addition, the authors believe further rechallenges or boosters of this particular vaccine in this patient would be unwise until this potential relationship is more clear.