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From the 1/7/2022 release of VAERS data:

This is VAERS ID 1333116

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Case Details

VAERS ID: 1333116 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-02-25
Onset:2021-03-25
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Acute kidney injury, Chest pain, Confusional state, Death
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-06
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Chronic kidney disease (Chronic renal insufficiency)
Preexisting Conditions: Medical History/Concurrent Conditions: Arterial hypertension; COVID-19; Dyslipidemia; End ileostomy (under palliative care); Gastritis chronic; Hysterectomy; Ileocecal resection; Microvascular angina; Sigmoid diverticulitis; Syncope; Type II diabetes mellitus
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITMODERNATX, INC.MOD20210

Write-up: Death; Aggravated chronic kidney disease; Thoracic pain; This regulatory authority case was reported by a physician and describes the occurrence of DEATH (Death), ACUTE KIDNEY INJURY (Aggravated chronic kidney disease), CONFUSIONAL STATE and CHEST PAIN (Thoracic pain) in an 87-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001442) for COVID-19 vaccination. The patient''s past medical history included Dyslipidemia, Arterial hypertension, Syncope, Type II diabetes mellitus, Microvascular angina, Gastritis chronic, COVID-19, Ileocecal resection, Sigmoid diverticulitis, End ileostomy (under palliative care) on 25-Mar-2021 and Hysterectomy. Concurrent medical conditions included Chronic kidney disease (Chronic renal insufficiency). On 25-Feb-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (unknown route) at an unspecified dose. On 25-Mar-2021, received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) dosage was changed to .5 ml in total. On 25-Mar-2021, the patient experienced ACUTE KIDNEY INJURY (Aggravated chronic kidney disease) (seriousness criterion medically significant), CONFUSIONAL STATE (seriousness criterion medically significant) and CHEST PAIN (Thoracic pain) (seriousness criterion medically significant). The patient died on 06-Apr-2021. The reported cause of death was Chronic renal insufficiency. It is unknown if an autopsy was performed. At the time of death, ACUTE KIDNEY INJURY (Aggravated chronic kidney disease) and CONFUSIONAL STATE outcome was unknown and CHEST PAIN (Thoracic pain) had not resolved. For mRNA-1273 (COVID 19 Vaccine Moderna) (Unknown), the reporter did not provide any causality assessments. No concomitant medications were reported. No treatment information was provided. Action taken with mRNA-1273 in response to the event was not applicable. It was reported that patient was already under palliative care due to kidney disease and having rejected dialysis. Per MR - End ileostomy removed from events and added to medical history. This is a case of death in a 87-year-old female subject with a medical history of ileostomy (under palliative care) and Chronic kidney disease, who died 12 days after receiving the second dose of vaccine. Very limited information has been provided at this time. No follow up is possible. Company Comment: This is a case of death in a 87-year-old female subject with a medical history of HTN, DM, CKD, Syncope, Angina, Gastritis, Sigmoid diverticulitis with resection, Covid-19 and Hysterectomy, who died 12 days after receiving the first dose of vaccine. Very limited information has been provided at this time. No follow up is possible. Most recent FOLLOW-UP information incorporated above includes: On 28-Apr-2021: Translated document received on 04 May 2021 has no new information. On 11-May-2021: Follow-up provide medical history and an additional event.; Reported Cause(s) of Death: Chronic renal insufficiency


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