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Table of Contents
LETTER TO EDITOR
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 240-241

Acute rejection post-ChAdOx1 nCoV-19 vaccine in a kidney-transplant recipient


1 Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Immunopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission23-Oct-2021
Date of Acceptance05-Apr-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Raja Ramachandran
Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_107_21

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How to cite this article:
Manoharan K, Sekar A, Nada R, Minz R, Singh S, Sharma A, Rathi M, Kohli HS, Ramachandran R. Acute rejection post-ChAdOx1 nCoV-19 vaccine in a kidney-transplant recipient. Indian J Transplant 2022;16:240-1

How to cite this URL:
Manoharan K, Sekar A, Nada R, Minz R, Singh S, Sharma A, Rathi M, Kohli HS, Ramachandran R. Acute rejection post-ChAdOx1 nCoV-19 vaccine in a kidney-transplant recipient. Indian J Transplant [serial online] 2022 [cited 2022 Sep 25];16:240-1. Available from: https://www.ijtonline.in/text.asp?2022/16/2/240/349371



Sir,

Kidney-transplant recipients (KTRs) on immunosuppressive therapy are at a heightened risk for severe COVID-19.[1],[2] The American Society of Transplantation recommends all solid organ recipients to get vaccinated against COVID-19.[3] In the current report, we highlight a 27-year-old KTR who developed acute rejection after the first dose of ChAdOx1 nCoV-19 Vaccine (COVISHIELD manufactured by Serum Institute of India Pvt. Ltd).

The patient underwent a kidney transplant in 2019 for end-stage kidney disease due to focal segmental glomerulosclerosis with her mother as the donor (HLA-haplomatch). Her pretransplant flow cross-match and donor-specific antibodies (DSAs) by single antigen bead (SAB) were negative. Her maintenance immunosuppressive regimen consisted of tacrolimus (last trough level 4.6 ng/ml), mycophenolate mofetil, and prednisolone with good compliance. On June 29, 2021, she received her first dose of COVISHIELD vaccine, following which her serum creatinine increased from a baseline of 1.4 mg/dl to 3.2 mg/dl [Supplemental Figure 1]. Her allograft biopsy revealed both T cell-mediated rejection (t3, i2) and active antibody-mediated rejection (g2, ptc3 with c4d positivity) [Figure 1]a, [Figure 1]b, [Figure 1]c. Her SAB-DSA was positive with a peak mean fluorescence intensity of 20,813 (antibody against A*03-686, A*33-2965, B*52-1024, B*58-949, DRB1*13-20813, DRB1*15-2626). She was worked up for underlying infection, but her cultures were sterile. Chest X-ray and ultrasonogram of the abdomen did not reveal any source for subclinical infection. Her anti-rejection therapy consisted of pulse methylprednisolone followed by rabbit antithymocyte globulin, five sessions of plasmapheresis, and intravenous immunoglobulins. Despite therapy, her serum creatinine did not exhibit a declining trend, and we repeated an allograft biopsy. It showed g1ptc3 with interstitial inflammation composed of lymphocytes and plasma cells [Figure 1]d, for which she subsequently received bortezomib therapy. Her creatinine posttherapy was 2.7 mg/dl.

Figure 1: (a) First renal allograft biopsy showing fibrin thrombi in one of the glomerulus and arteriole. Peritubular capillaries are dilated with significant margination of leukocytes (hematoxylin and eosin, ×200). (b) Many tubules depicting infiltration by more than 10 lymphomononuclear cells indicating severe tubulitis (t3). Surrounding interstitium showing marked edema and inflammatory cells (periodic acid–Schiff, ×200). (c) Immunofluorescence showing 2+ intense linear positivity for C4d in the wall of peritubular capillaries (fluorescein isothiocyanate, ×200). (d) Renal allograft biopsy after therapy showing glomerulitis and peritubular capillary dilatation with margination of leukocytes (hematoxylin and eosin, ×200)

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The current report highlights a rare complication of acute rejection following vaccination in a KTR. In the past, increased rejection was noted following administration of the influenza vaccine.[4] The adjuvant in the vaccine, causing immune system activation, was proposed as the underlying cause. Furthermore, the chronology of events and lack of chronicity on the allograft biopsy suggest initiation of rejection cascade post-ChAdOx1 nCoV-19 Vaccination. Previously, Del Bello et al. reported acute rejection after the second dose of mRNA COVID-19 Vaccine (Pfizer-BioNTech).[5] To conclude, we emphasize a word of caution concerning acute rejection and careful monitoring of serum creatinine in KTRs postvaccination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Caillard S, Chavarot N, Francois H, Matignon M, Greze C, Kamar N, et al. Is COVID-19 infection more severe in kidney transplant recipients? Am J Transplant 2021;21:1295-303.  Back to cited text no. 1
    
2.
Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). People with Certain Medical Conditions. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html. [Last updated on 2021 Aug 20].  Back to cited text no. 2
    
3.
COVID-19: Vaccine FAQ Sheet. American Society of Transplantation. Available from: https://www.myast.org/covid-19-vaccine-faq-sheet. [Last updated on 2021 Aug 13].  Back to cited text no. 3
    
4.
Fischer AS, Møller BK, Krag S, Jespersen B. Influenza virus vaccination and kidney graft rejection: Causality or coincidence. Clin Kidney J 2015;8:325-8.  Back to cited text no. 4
    
5.
Del Bello A, Marion O, Delas A, Congy-Jolivet N, Colombat M, Kamar N. Acute rejection after anti-SARS-CoV-2 mRNA vaccination in a patient who underwent a kidney transplant. Kidney Int 2021;100:238-9.  Back to cited text no. 5
    


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