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Yu B, Tamargo C, Brennan DC, Kant S. Measures to Increase Immunogenicity of SARS-CoV-2 Vaccines in Solid Organ Transplant Recipients: A Narrative Review. Vaccines (Basel) 2023; 11:1755. [PMID: 38140160 PMCID: PMC10748337 DOI: 10.3390/vaccines11121755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023] Open
Abstract
Purpose of review: To review the data on the immunogenicity of COVID-19 vaccines, administered by different strategies, in solid organ transplant recipients (SOTRs). Recent findings: COVID-19 booster vaccines were given to SOTRs as a widespread practice in many transplant centers, mostly as the third and/or fourth dose in an extended vaccine series, with a significantly improved humoral response compared with the initial two-dose scheme. However, one-third of SOTRs remained unresponsive, despite these boosters. Next steps: Vaccination with standard dosing remains the most feasible strategy for attaining protection against COVID-19. Additional booster doses and temporarily holding or reducing mycophenolate mofetil/mycophenolic acid may provide immunogenicity to vaccines, according to recent studies demonstrating some efficacy with these measures. Preexposure prophylaxis with monoclonal antibodies showed benefit in immunocompromised patients but is no longer recommended by the National Institutes of Health (NIH) due to diminished efficacy against Omicron and recent variants. Screening for the presence and titers of SARS-CoV-2-specific antibodies in SOTRs is not recommended in most clinical settings. T cell-based techniques are needed to evaluate vaccine efficacy and risk of infection. As SARS-CoV-2 continues to evolve, new vaccines based on conservative protein component/complexes of the COVID virus, in addition to its spike protein, are warranted to offer prolonged protection.
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Affiliation(s)
- Bo Yu
- Department of Medicine, University of Maryland Medical Center, Midtown Campus, Baltimore, MD 21201, USA;
| | - Christina Tamargo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
- Comprehensive Transplant Center, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Sam Kant
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
- Comprehensive Transplant Center, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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2
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Leung D, Chan EYH, Mu X, Rosa Duque JS, Cheng SM, Ho FTW, Tong PC, Lai WM, Lee MH, Chim S, Tam IY, Tsang LC, Kwan KK, Chung Y, Wong HH, Lee AM, Li WY, Sze ST, Lam JH, Lee DH, Chan SM, Tu W, Peiris M, Ma ALT, Lau YL. Humoral and Cellular Immunogenicity of 3 Doses of BNT162b2 in Children With Kidney Diseases. Kidney Int Rep 2023; 8:2356-2367. [PMID: 38025215 PMCID: PMC10658278 DOI: 10.1016/j.ekir.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Patients with severe kidney diseases are at risk of complications from COVID-19; however, little is known about the effectiveness of COVID-19 vaccines in children and adolescents with kidney diseases. Methods We investigated the immunogenicity and safety of an accelerated 3-dose primary series of COVID-19 vaccination among 59 pediatric patients with chronic kidney disease (CKD) (mean age 12.9 years; 30 male) with or without immunosuppression, dialysis, or kidney transplant. Dosage was 0.1 ml BNT162b2 to those aged 5 to 11 years, and 0.3 ml BNT162b2 to those aged 11 to 18 years. Results Three doses of either vaccine type elicited significant antibody responses that included spike receptor-binding domain (S-RBD) IgG (90.5%-93.8% seropositive) and surrogate virus neutralization (geometric mean sVNT% level, 78.6%-79.3%). There were notable T cell responses. Weaker neutralization responses were observed among those on immunosuppression, especially those receiving higher number of immunosuppressants or on mycophenolate mofetil. Neutralization was reduced against Omicron BA.1 compared to wild type (WT, i.e., ancestral) (post-dose 3 sVNT% level; 82.7% vs. 27.4%; P < 0.0001). However, the T cell response against Omicron BA.1 was preserved, which likely confers protection against severe COVID-19. Infected patients exhibited hybrid immunity after vaccination, as evidenced by the higher Omicron BA.1 neutralization response among these infected patients who received 2 doses compared with those who were uninfected. Generally mild or moderate adverse reactions following vaccines were reported. Conclusion An accelerated 3-dose primary series with BNT162b2 is immunogenic and safe in young children and adolescents with kidney diseases.
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Affiliation(s)
- Daniel Leung
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Eugene Yu-hin Chan
- Pediatric Nephrology Centre, Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| | - Xiaofeng Mu
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Jaime S. Rosa Duque
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Samuel M.S. Cheng
- School of Public Health, The University of Hong Kong, Hong Kong, China
| | - Fanny Tsz-wai Ho
- Pediatric Nephrology Centre, Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| | - Pak-chiu Tong
- Pediatric Nephrology Centre, Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| | - Wai-ming Lai
- Pediatric Nephrology Centre, Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| | - Matthew H.L. Lee
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong, China
| | - Stella Chim
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong, China
| | - Issan Y.S. Tam
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Leo C.H. Tsang
- School of Public Health, The University of Hong Kong, Hong Kong, China
| | - Kelvin K.H. Kwan
- School of Public Health, The University of Hong Kong, Hong Kong, China
| | - Yuet Chung
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Howard H.W. Wong
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Amos M.T. Lee
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Wing Yan Li
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Summer T.K. Sze
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Jennifer H.Y. Lam
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Derek H.L. Lee
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Sau Man Chan
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Wenwei Tu
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Malik Peiris
- School of Public Health, The University of Hong Kong, Hong Kong, China
- Centre for Immunology & Infection C2i, Hong Kong, China
| | - Alison Lap-tak Ma
- Pediatric Nephrology Centre, Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| | - Yu Lung Lau
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
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Sintusek P, Buranapraditkun S, Khunsri S, Thongmee T, Vichaiwattana P, Polsawat W, Poovorawan Y. Safety and Efficacy of a Third Dose of the BNT162b2 Vaccine in Liver-Transplanted and Healthy Adolescents. JPGN REPORTS 2023; 4:e373. [PMID: 38034438 PMCID: PMC10684171 DOI: 10.1097/pg9.0000000000000373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/09/2023] [Indexed: 12/02/2023]
Abstract
Objectives According to our previous study, the 2-dose-BNT162b2 vaccination is less effective against the Omicron variant. This study aimed to assess the safety and efficacy of a 3-dose-BNT162b2 vaccination in liver-transplanted (LT) and healthy adolescents. Methods LT and healthy adolescents who met the inclusion criteria received a third dose of the BNT162b2 vaccine (30 µg). Antireceptor-binding domain immunoglobulin and T-cell-specific responses to severe acute respiratory syndrome coronavirus 2 spike peptides were assessed 3 months before the third dose (Visit -1) and 0 (Visit 0), 1 (Visit 1), and 2 months (Visit 2) after the third dose. Antinucleocapsid immunoglobulin and neutralizing antibodies were assessed at Visits 0 and 1. Adverse events (AEs) were monitored. Results Eleven LT and 14 healthy adolescents aged 14.64 (13.2, 15.7) years (44.2% male) had antireceptor-binding domain immunoglobulin geometric mean titers of 1412.47 (95% confidence interval [CI], 948.18-2041.11) and 1235.79 (95% CI, 901.07-1705.73) U/mL at Visit -1 but increased to 38 587.76 (95% CI, 24 628.03-60 460.18) and 29 222.38 (95% CI, 16 291.72-52 401.03) U/mL (P < 0.05) at Visit 1, respectively. This was consistent with neutralizing antibodies (42.29% and 95.37% vs 44.65% and 91.68%, P < 0.001) and interferon-γ-secreting cells in LT and healthy adolescents at Visit 0 versus Visit 1, respectively. For serious AEs, an LT girl with autoimmune overlap syndrome died 5 months postvaccination from acute liver failure. Conclusions In both LT and healthy adolescents, humoral and cellular immune responses were high after the 3-dose-BNT162b2 vaccination. However, serious AEs were suspected in LT adolescents with autoimmune diseases.
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Affiliation(s)
- Palittiya Sintusek
- From the Thai Pediatric Gastroenterology, Hepatology and Immunology (TPGHAI) Research Unit, Division of Gastroenterology, Department of Pediatrics
| | - Supranee Buranapraditkun
- Division of Allergy and Clinical Immunology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence in Vaccine Research and Development (Chula Vaccine Research Center-Chula VRC), Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Siriporn Khunsri
- From the Thai Pediatric Gastroenterology, Hepatology and Immunology (TPGHAI) Research Unit, Division of Gastroenterology, Department of Pediatrics
| | - Thanunrat Thongmee
- Center of Excellence in Clinical Virology, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, The Thai Red Cross Society, Bangkok, Thailand
| | - Preeyaporn Vichaiwattana
- Center of Excellence in Clinical Virology, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, The Thai Red Cross Society, Bangkok, Thailand
| | - Warunee Polsawat
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Yong Poovorawan
- Center of Excellence in Clinical Virology, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, The Thai Red Cross Society, Bangkok, Thailand
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Emmanouilidou-Fotoulaki E, Karava V, Dotis J, Kondou A, Printza N. Immunologic Response to SARS-CoV-2 Vaccination in Pediatric Kidney Transplant Recipients: A Systematic Review and Meta-Analysis. Vaccines (Basel) 2023; 11:1080. [PMID: 37376469 DOI: 10.3390/vaccines11061080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
The pediatric population is at a lower risk of severe SARS-CoV-2 infection compared to adults. Nevertheless, immunosuppression in pediatric and adolescent kidney transplant recipients (KTRs) increases their hazard compared to the general population. This systematic review evaluates the efficacy of SARS-CoV-2 vaccines and determines the risk factors of no seroconversion in this population. PubMed-MEDLINE databases were searched for cohort studies. A meta-analysis was performed using fixed and random effect models. In total, seven studies including 254 patients were further analyzed. The random effect model demonstrated a 63% seroconversion rate (95% CI 0.5, 0.76) following a two-dose schedule, which increased to 85% (95% CI 0.76, 0.93) after the third dose administration. Seropositivity was lower in patients under mycophenolate mofetil compared to azathioprine (OR 0.09, 95% CI 0.02, 0.43). Rituximab administration decreased the seroconversion rate (OR 0.12, 95% CI 0.03, 0.43). The glomerular filtration rate (GFR) was 9.25 mL/min/1.73 m2 lower (95% CI 16.37, 2.13) in patients with no seroconversion. The seroconversion rate was lower in vaccinated compared to infected patients (OR 0.13, 95% CI 0.02, 0.72). In conclusion, vaccination against SARS-CoV-2 in pediatric and adolescent KTRs elicits a humoral response, and a third dose is advised. Previous rituximab administration, antimetabolite therapy with mycophenolate mofetil and lower GFR reduce the likelihood for seroconversion.
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Affiliation(s)
- Elpida Emmanouilidou-Fotoulaki
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Vasiliki Karava
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - John Dotis
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Antonia Kondou
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Nikoleta Printza
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
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Taheri S. Efficacy and safety of booster vaccination against SARS-CoV-2 in dialysis and renal transplant patients: systematic review and meta-analysis. Int Urol Nephrol 2023; 55:791-802. [PMID: 36723829 PMCID: PMC9890430 DOI: 10.1007/s11255-023-03471-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/16/2023] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients under renal replacement therapy are at an increased risk of severe infection with SARS-CoV-2, and have been known to have impaired response to standard vaccination. This systematic review and meta-analysis aims at evaluating the efficacy of booster dose vaccination in this population. METHODS A systematic review has been conducted to find trials on the booster dose vaccination in kidney transplant recipients (KTRs) or patients under dialysis. Data of seroconversion rates at different timepoints, especially 1 month prior and post-booster dose vaccination have been collected and analyzed. Effects of different factors including type of renal replacement therapy (RRT), vaccine type and brands, magnitude of response to the standard vaccination, and immunosuppression drugs on the response rates have been investigated. Meta-analyses were performed using software Stata v.17. RESULTS Overall 58 studies were included. Both RRT patient subgroups represented significant seroconversion, post- (versus pre-) booster dose vaccination, but only in KTRs the booster dose seroconversion surpassed that of the standard protocol. T-cell response was also significantly augmented after booster vaccination, with no difference between the RRT subgroups. mRNA and vector vaccine types had comparable immunogenicity when employed as boosters, both significantly higher than the inactivated virus vaccine, with no significant disparity regarding the vaccine brands. Patients with poor response to standard vaccination had a significant response to booster dose, with dialysis patients having stronger response. The differential effects of vaccine types and brands in the poor responders was similar to that of the overall RRT population. No rejection episodes or graft failure post-booster vaccination was reported. CONCLUSION In patients under RRT, booster dose vaccination against SARS-CoV-2 is safe and efficacious determined by significant seroconversion, and therefore, it should be considered to be implemented in all these patients. Since in the KTR patients, the third dose vaccination significantly increased the seroconversion rates even beyond that of the standard protocol, three dose vaccine doses is recommended to be recognized as the standard vaccination protocol in this population. The same recommendation could be considered for dialysis patients, due to their augmented risk of breakthrough infection.
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Affiliation(s)
- Saeed Taheri
- New Lahijan Scientific Foundation, Lahijan, Iran.
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Stich M, Di Cristanziano V, Tönshoff B, Weber LT, Dötsch J, Rammer MT, Rieger S, Heger E, Garbade SF, Burgmaier K, Benning L, Speer C, Habbig S, Haumann S. Humoral immune response and live-virus neutralization of the SARS-CoV-2 omicron (BA.1) variant after COVID-19 mRNA vaccination in children and young adults with chronic kidney disease. Pediatr Nephrol 2022; 38:1935-1948. [PMID: 36409368 PMCID: PMC9684918 DOI: 10.1007/s00467-022-05806-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/28/2022] [Accepted: 10/28/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Data on humoral immune response to standard COVID-19 vaccination are scarce in adolescent patients and lacking for children below 12 years of age with chronic kidney disease including kidney transplant recipients. METHODS We therefore investigated in this retrospective two-center study (DRKS00024668; registered 23.03.2021) the humoral immune response to a standard two-dose mRNA vaccine regimen in 123 CKD patients aged 5-30 years. A live-virus assay was used to assess the serum neutralizing activity against the SARS-CoV-2 omicron (BA.1) variant. RESULTS Children aged 5-11 years had a comparable rate and degree of immune response to adolescents despite lower vaccine doses (10 µg vs. 30 µg BNT162b2). Treatment with two (odds ratio 9.24) or three or more (odds ratio 17.07) immunosuppressants was an independent risk factor for nonresponse. The immune response differed significantly among three patient cohorts: 48 of 77 (62.3%) kidney transplant recipients, 21 of 26 (80.8%) patients on immunosuppressive therapy, and 19 of 20 (95.0%) patients with chronic kidney disease without immunosuppressive therapy responded. In the kidney transplant recipients, immunosuppressive regimens comprising mycophenolate mofetil, an eGFR of < 60 mL/min/1.73 m2, and female sex were independent risk factors for nonresponse. Two of 18 (11.1%) and 8 of 16 (50.0%) patients with an anti-S1-RBD IgG of 100-1411 and > 1411 BAU/mL, respectively, showed a neutralization activity against the omicron variant. CONCLUSION A standard mRNA vaccine regimen in immunosuppressed children and adolescents with kidney disease elicits an attenuated humoral immune response with effective live virus neutralization against the omicron variant in approximately 10% of the patients, underlying the need for omicron-adapted vaccination. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Maximilian Stich
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Veronica Di Cristanziano
- Institute of Virology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Lutz Thorsten Weber
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Jörg Dötsch
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Marian Theodor Rammer
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Susanne Rieger
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Eva Heger
- Institute of Virology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Sven F Garbade
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Kathrin Burgmaier
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Louise Benning
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Sandra Habbig
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany.
| | - Sophie Haumann
- Department of Pediatrics, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
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Crane C, Loop L, Anterasian C, Geng B, Ingulli E. Balancing B cell responses to the allograft: implications for vaccination. Front Immunol 2022; 13:948379. [PMID: 35967363 PMCID: PMC9363634 DOI: 10.3389/fimmu.2022.948379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
Balancing enough immunosuppression to prevent allograft rejection and yet maintaining an intact immune system to respond to vaccinations, eliminate invading pathogens or cancer cells is an ongoing challenge to transplant physicians. Antibody mediated allograft rejection remains problematic in kidney transplantation and is the most common cause of graft loss despite current immunosuppressive therapies. The goal of immunosuppressive therapies is to prevent graft rejection; however, they prevent optimal vaccine responses as well. At the center of acute and chronic antibody mediated rejection and vaccine responses is the B lymphocyte. This review will highlight the role of B cells in alloimmune responses including the dependency on T cells for antibody production. We will discuss the need to improve vaccination rates in transplant recipients and present data on B cell populations and SARS-CoV-2 vaccine response rates in pediatric kidney transplant recipients.
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Affiliation(s)
- Clarkson Crane
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
| | - Lauren Loop
- Department of Pediatrics, Division of Allergy and Immunology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
| | - Christine Anterasian
- Department of Pediatrics, Division of Allergy and Immunology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington and Seattle Children's Hospital, Seattle, WA, United States
| | - Bob Geng
- Department of Pediatrics, Division of Allergy and Immunology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
| | - Elizabeth Ingulli
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children’s Hospital, San Diego, CA, United States
- *Correspondence: Elizabeth Ingulli,
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