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Table of Contents
Year : 2022  |  Volume : 16  |  Issue : 4  |  Page : 465-466

Acute rejection following COVID-19 vaccine (AstraZeneca)

Department of Nephrology, Primus Hospital, New Delhi, India

Date of Submission30-Mar-2022
Date of Acceptance17-Oct-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Prof. Vivek B Kute
Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr. H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_36_22

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How to cite this article:
Varma PP, Kute VB, Kumar P. Acute rejection following COVID-19 vaccine (AstraZeneca). Indian J Transplant 2022;16:465-6

How to cite this URL:
Varma PP, Kute VB, Kumar P. Acute rejection following COVID-19 vaccine (AstraZeneca). Indian J Transplant [serial online] 2022 [cited 2023 Feb 8];16:465-6. Available from: https://www.ijtonline.in/text.asp?2022/16/4/465/364620

Dear Editor,

A 27-year male, a case of hypertensive kidney disease, received renal allograft from his father in July 2020. Induction was with rabbit thymoglobulin and he was on triple-drug immunosuppression with tacrolimus (TAC), mycophenolate mofetil, and steroids. Posttransplant course was smooth and his creatinine settled to 1 mg/dl. Ten months after transplantation, in May 2021, he developed a fever and tested COVID-19 reverse transcription polymerase chain reaction positive. His creatinine remained between 1 and 1.1 mg/dl and TAC level between 4 and 6 ng/ml and he made an uneventful recovery. As per our center protocol, we maintain TAC level between 3 and 5 ng/ml after a year of transplantation (symphony trial 3–7 ng/ml). Four months later, in September 2021, he received the first dose of AstraZeneca (Covishield) vaccine. There was local pain at the injection site for 1–2 days. A week later on routine testing, his serum creatinine was 1.35 mg/dl and TAC level 4.5 ng/ml. On repeat testing, creatinine values were 1.42 and 1.5 mg/dl. A kidney biopsy [Figure 1] was done, which showed acute cellular rejection [Figure 1]a and [Figure 1]b. C4d stain was negative. COVID-19 anti-spike antibody level was 10,043 IU/ml. The patient was treated with three pulses of methylprednisolone 500 mg a day. A fortnight later, creatinine returned to 1.1 mg/dl. Five months later, the patient is doing fine and has a creatinine of 1.07 mg/dl.
Figure 1: A kidney biopsy showing acute cellular rejection (a). C4d stain was negative (b). Blue arrows show areas of plasma cell rich interstitial infiltrates, Yellow arrow shows area of tubulitis

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Immunocompromised transplant population is vulnerable to develop COVID-19 infection with 5–20 times higher mortality.[1] They are taken as a priority group for COVID-19 vaccination but the seroconversion rate in this group is poor (10%–54%), and hence boosters are recommended.[1],[2] Vaccination is not reported to be associated with any major serious adverse reaction except for local site pain, redness, and mild systemic features such as fever and body ache.[3] Three cases of vaccination-related acute rejections have been reported in renal transplant recipients – two with Pfizer and one with Moderna vaccine [Table 1]. All three cases had biopsy-proven acute cellular rejection and occurred after the second dose of vaccine. Donor-specific antibody (DSA) was mildly positive in one and negative in two cases. Two of these cases had complete reversal of rejection with methylprednisolone pulse therapy and third case required antithymocyte globulin and plasmapheresis too, with incomplete recovery. Although exact pathogenesis of rejection is not clear but the absence of DSA and the histologic picture of acute cellular rejection highlights the predominant role of cellular immune response.[4],[5],[6] Comparative data of these cases and our patient are presented in [Table 1]. Our patient developed acute cellular rejection after the first dose of COVID-19 vaccine but had suffered from COVID-19 infection four months back. Like three reported cases, our case shows a strong association of rejection episode following COVID vaccination. Limitation is that association and causation differences cannot be made in this case report. Though it is not possible to prove the relationship between vaccine and rejection but like in other reported cases circumstantial evidence suggests vaccine to be the culprit. Our case had suffered from COVID-19 infection 4 months back and would have developed antibodies. Vaccination most likely resulted in increase in antibodies levels which we feel caused the rejection. Case highlights that acute rejection although a rare complication of COVID-19 vaccination, should be kept in mind in patients showing an acute rise in creatinine following vaccination.
Table 1: Comparative data of three other patients

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his 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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Caillard S, Thaunat O. COVID-19 vaccination in kidney transplant recipients. Nat Rev Nephrol 2021;17:785-7.  Back to cited text no. 1
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. 2
Bau JT, Churchill L, Pandher M, Benediktsson H, Tibbles LA, Gill S. Acute kidney allograft rejection following coronavirus mRNA vaccination: A case report. Transplant Direct 2022;8:e1274.  Back to cited text no. 3
Boyarsky BJ, Werbel WA, Avery RK, Tobian AA, Massie AB, Segev DL, et al. Antibody response to 2-dose SARS-CoV-2 mRNA vaccine series in solid organ transplant recipients. JAMA 2021;325:2204-6.  Back to cited text no. 4
Ou MT, Boyarsky BJ, Motter JD, Greenberg RS, Teles AT, Ruddy JA, et al. Safety and reactogenicity of 2 doses of SARS-CoV-2 vaccination in solid organ transplant recipients. Transplantation 2021;105:2170-4.  Back to cited text no. 5
Jang HW, Bae S, Ko Y, Lim SJ, Kwon HE, Jung JH, et al. Acute T cell-mediated rejection after administration of the BNT162b2 mRNA COVID-19 vaccine in a kidney transplant recipient: A case report. Korean J Transplant 2021;35:253-6.  Back to cited text no. 6


  [Figure 1]

  [Table 1]


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