Low Incidence of Rejection and De Novo Donor‐Specific Antibody Formation Following COVID ‐19 Vaccination or Infection Among Pediatric Kidney Transplant Recipients

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Abstract
Background: Studies in adults have demonstrated a risk for allograft rejection or development of donor‐specific antibodies (DSA) following SARS‐CoV‐2 vaccination. We examined the incidence of acute rejection and de novo DSA following COVID‐19 vaccination or infection among pediatric kidney transplant patients. Method: Retrospective analysis of 23 pediatric kidney transplant recipients without prior history of rejection, DSA, or COVID‐19 infection who received the SARS‐CoV‐2 mRNA vaccine. Risk for rejection was evaluated via monitoring of serum creatinine, DSA, and donor‐derived cell‐free DNA per center protocol. Results concerning for rejection prompted allograft biopsy, graded by the Banff classification system. Results: Eight of 23 (34.8%) received two doses of SARS‐CoV‐2 mRNA vaccine, 15 (65.3%) received three doses. Two (8.7%) had rejection; one with de novo DSA, another without. There was no difference in the number of doses of COVID‐19 vaccine received in those with rejection vs. no rejection ( p = 0.53). 13 (56.5%) developed SARS‐CoV‐2 infection, with no difference in the number of vaccines received between those infected with COVID‐19 vs. those who were not ( p = 0.69). No adjustments were made to the maintenance immunosuppression during SARS‐CoV‐2 infection, and there was no evidence of rejection or DSA formation after infection. Median follow‐up time was 29.9 months (IQR 25.0–33.4 months) after the first vaccine dose. Conclusion: In our small single‐center cohort, SARS‐CoV‐2 vaccination or infection is unlikely to increase the risk for rejection or de novo DSA in pediatric kidney transplant recipients. Larger prospective studies with a control group are needed to further understand the immune effects of the COVID‐19 vaccine and disease in this population.

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