Minimal change disease following influenza vaccination and acute renal failure: Just a coincidence?

Abstract

To the Editor, Since, 1966 different reports have associated minimal change disease (MCD) with different immunogens1 as well as the presence of acute renal failure (ARF) in the MCD,2 which pathogenic mechanisms are being debated up to the present. A 44-year old man was admitted to our hospital with edema in his face and legs and cervical lymphadenopathy which occurred 18 days after influenza vaccine (Agrippal®, Novartis). The laboratory showed: creatinine 44mg/l, urea 106mg/dl. In the urinalysis was evident: proteinuria 4g/24h and hyaline casts. Serological test (ANA, DNA, ANCAp, ANCAc, C3, C4, HBsAg, HCV and HIV) were negative. Renal biopsy was performed. Light microscopy showed evidence of severe acute tubular injury (Figure 1 A) and a moderate, diffuse interstitial inflammatory infiltrate consisting of mononuclear cells and severe edema. The immunofluorescence did not show deposits of IgG, IgA, IgM, C3 and C1q. Ultrastructural examination showed diffuse foot-process effacement, microvillous transformation and cytoplasmic vacuolization without basement-membrane remodeling (Figure 1 B). Minimal change disease, acute tubular injury, and moderate active interstitial nephritis were diagnosed. The patient started on oral prednisone (60mg/d), furosemide (80mg/d), enalapril (40mg/d), atorvastatin (20mg/d), Espironolactone-A (100mg/d), ranitidine 300 (mg/d) and low-sodium diet. The proteinuria (200mg/24h) and ARF (creatinine 1 mg/l), resolved rapidly.