The urgent need to vaccinate dialysis patients against severe acute respiratory syndrome coronavirus 2: a call to action

Impact of COVID-19 Vaccination on Mortality and Clinical Outcomes in Hemodialysis Patients

This study analyzed 550 hemodialysis patients, 469 unvaccinated and 81 vaccinated against COVID-19, to assess the impact on infection rates, mortality, and clinical/laboratory parameters. Gender distribution was similar (p = 0.209), but the vaccinated group's median age was significantly lower (p = 0.005). Hospitalization rates showed no significant difference (p = 0.987), while mortality was lower in the vaccinated group (p = 0.041). Only uric acid levels were significantly higher in the vaccinated group (p = 0.009); other parameters, including creatinine and B-type natriuretic peptide, showed no significant differences. Age was an independent predictor of mortality (HR = 1.07, p < 0.001). Peak mortality occurred in December 2022 and January 2023, predominantly among unvaccinated patients. Although vaccination lowered mortality, it did not significantly affect long-term survival rates (p = 0.308). Logistic regression identified age and dialysis duration as significant mortality factors. Monthly death counts indicated higher mortality among unvaccinated patients during peak pandemic months, suggesting that vaccination provides some protection, though no significant long-term survival benefit was found.

Chronic kidney disease and the global public health agenda: an international consensus

Early detection is a key strategy to prevent kidney disease, its progression and related complications, but numerous studies show that awareness of kidney disease at the population level is low. Therefore, increasing knowledge and implementing sustainable solutions for early detection of kidney disease are public health priorities. Economic and epidemiological data underscore why kidney disease should be placed on the global public health agenda - kidney disease prevalence is increasing globally and it is now the seventh leading risk factor for mortality worldwide. Moreover, demographic trends, the obesity epidemic and the sequelae of climate change are all likely to increase kidney disease prevalence further, with serious implications for survival, quality of life and health care spending worldwide. Importantly, the burden of kidney disease is highest among historically disadvantaged populations that often have limited access to optimal kidney disease therapies, which greatly contributes to current socioeconomic disparities in health outcomes. This joint statement from the International Society of Nephrology, European Renal Association and American Society of Nephrology, supported by three other regional nephrology societies, advocates for the inclusion of kidney disease in the current WHO statement on major non-communicable disease drivers of premature mortality.

PMMA dialyzers modulate both humoral and cell-mediate immune response to anti-COVID-19 vaccine (BNT162b2) in a cohort of chronic hemodialyzed patients

Patients on hemodialysis (HD) have a high risk of death from COVID-19. We evaluated the humoral and cell-mediated immune response to BNT162b2 (Pfizer-BioNTech) vaccine in HD patients, comparing HD with Poly-methyl-methacrylate (PMMA) and HD with Polysulphone (PS). Samples were collected before vaccination (T0) and 14-days after the 2ndvaccine (T2) in a TG (TG, n = 16-Foggia) and in a VG (CG, n = 36-Novara). Anti-SARS-CoV-2-Ig were titrated in the cohort 2-weeks after the 2nddose of vaccine. In the Testing-Group, serum neutralizing antibodies (NAb) were assayed and PBMCs isolated from patients were thawed, counted and stimulated with SARS-CoV-2 IGRA stimulation tube set. All patients had a positive ab-response, except in a case. PMMA-patients had higher levels of anti-SARS-CoV-2 IgG (p = 0.031); VG data confirmed these findings (p < 0.05). NAb evaluation: PMMA patients passed the positive cut-off value, while in PS group only only 1/8 patient did not respond. PMMA patients showed higher percentages of anti-SARS-CoV-2 S1/RBD-Ig after a complete vaccine schedule (p = 0.028). Interferon-gamma release: PMMA patients showed significantly higher release of IFNγ (p = 0.014). The full vaccination course provided sufficient protection against SARS-CoV-2 across the entire cohort, regardless of dialyzer type. After vaccination, PMMA patients show a better immune response, both humoral and cellular, at the end of the vaccination course than PS patients.

18-month longitudinal SARS COV-2 neutralizing antibody dynamics in haemodialysis patients receiving heterologous 3-dose vaccination (AZD-1222- AZD-1222- BNT162b2) in a lower middle income setting

BACKGROUND

Patients with chronic kidney disease on haemodialysis (HD) were given priority COVID-19 vaccination due to increased disease risk. The immune response to COVID-19 vaccination in patients on HD was diminished compared to healthy individuals in 2-dose studies. This study aimed to evaluate seroconversion rate, neutralizing antibody (nAB) levels and longitudinal antibody dynamics to 3-dose heterologous vaccination against COVID-19 in a cohort of HD patients compared to healthy controls and assess patient factors associated with antibody levels.

METHODS

This study was a case-control longitudinal evaluation of nAB dynamics in 74 HD patients compared to 37 healthy controls in a low/middle income setting. Corresponding samples were obtained from the two cohorts at time-points (TP) 1-1-month post 2nd dose of AZD1222 vaccine, TP2- 4 months post 2nd dose, TP4- 2 weeks post 3rd dose with BNT162b2 vaccine, TP5-5 months post 3rd dose and TP6-12 months post 3rd dose. Additional data is available at TP0- pre 2nd dose and TP3- 6 months post 2nd dose in HC and HD cohorts respectively. Anti-SARS-CoV-2 nAB were detected using Genscript cPassTM pseudoviral neutralization kit. Demographic and clinical details were obtained using an interviewer administered questionnaire.

RESULTS

Cohorts were gender matched while mean age of the HD cohort was 54.1yrs (vs HCs mean age, 42.6yrs, p < 0.05). Percentage seroconverted and mean/median antibody level (MAB) in the HD cohort vs HCs at each sampling point were, TP1-83.7% vs 100% (p < 0.05), MAB-450 IU/ml vs 1940 IU/ml (p < 0.0001); TP2-71.4% vs 100%, (p < 0.001), MAB- 235 IU/ml vs 453 IU/ml, (p < 0.05); TP4-95.2% vs 100% (p > 0.05), MAB-1029 IU/ml vs 1538 IU/ml (p < 0.0001); TP5-100% vs 100%, MAB-1542 IU/ml vs 1741IU/ml (p > 0.05); TP6-100% vs 100%, MAB-1961 IU/ml vs 2911 IU/ml (p > 0.05). At TP2, patients aged < 60 years (p < 0.001) were associated with maintaining seropositivity compared to patients > 60 years.

CONCLUSION

Two dose vaccination of haemodialysis patients provided poor nAB levels which improved markedly following 3rd dose vaccination, the effect of which was long- lasting with high nAB levels in both patients and controls detectable at 1 year follow-up.

Monitoring strategy of COVID-19 vaccination in dialysis patients based on a multiplex immunodot method: The CovidDial study

INTRODUCTION

COVID-19 vaccine was demonstrated to be effective in dialysis patients, but boosters are mandatory due to a rapid waning of anti-spike antibodies. A vaccination strategy based on immunologic response might be useful to maintain a favorable risk-benefit balance in this vulnerable population.

METHODS

CoviDial is an observational prospective study enrolling 121 dialysis patients to receive a 3-dose mRNA-1273 vaccine according to a uniform schedule. At baseline, months 1, 3, 6, 9, and 12, anti-spike antibodies against four epitopes (S1, S2, ECD-S1 + S2, RBD) were monitored with a multiplex immunodot enzymatic assay. Potential correlation between initial serologic response and subsequent COVID-19 infection was then assessed.

RESULTS

Overall, 96.2% and 96.8% of patients had anti-RBD antibodies at 3 and 12 months, respectively. All antibodies titers significantly decreased at month 6 compared to month 3. Booster vaccine induced a robust serologic response at month 9, but with a waning 3 months later, particularly for anti-S2 (37.2 ± 3.3 vs. 61.3 ± 3.0, p < 0.0001) and anti-S1 + S2 antibodies (68.4 ± 3.3 vs. 88.4 ± 2.3, p = 0.0015). Fifteen patients were later tested positive for SARS-CoV-2. At month 3, mean titers of anti-RBD, anti-S1 + S2, and anti-S2 antibodies were lower in the subsequent SARS-CoV-2 infected cohort (71.57 ± 9.01 vs. 85.79 ± 2.61, p = 0.0131; 41.07 ± 7.96 vs. 61.68 ± 3.56, p = 0.0237; 13.79 ± 5.03 vs. 39.70 ± 3.86, p = 0.0096; respectively).

CONCLUSION

Three doses of mRNA-1273 vaccine induce a robust but time-limited immunologic response in dialysis patients. Lower anti-spike antibodies titers after initial vaccination are associated with a higher risk to subsequently contract SARS-CoV-2, even beyond 6 months.

Chronological Changes in Emotional Status and Vaccine Implementation Rate Among Patients on the Waiting List for Deceased-Donor Kidney Transplantation During the Prolonged COVID-19 Pandemic

BACKGROUND

To investigate the emotional attributes and vaccine implementation rate of patients waiting for kidney transplants during the prolonged COVID-19 pandemic.

METHODS

We included 145 patients who were on the waiting list at our institution. Clinical information was obtained from medical charts, and emotional changes were assessed using a telephone questionnaire comprising 13 questions, including vaccine implementation. We also investigated factors affecting the decision to accept or decline deceased-donor kidney transplantation during the COVID-19 pandemic.

RESULTS

Of the 145 patients, 121 (83.4%) provided informed consent and completed the questionnaire. The median age at registration on the waiting list for deceased-donor kidney transplantation and the median waiting period was 45.5 years and 103 months, respectively. This cohort comprised 84 males and 37 females. Twenty patients (16.5%) were diagnosed with COVID-19, and 15 (12.4%) were more curious about deceased-donor kidney transplantation. One hundred patients (82.6%) were vaccinated against COVID-19 more than thrice. Thirty patients (24.8%) declined, and 91 patients (75.2%) accepted an organ transplant offer during the COVID-19 pandemic. Multivariate analysis revealed that the long-term waiting period (P = .038) and anxiety about COVID-19, such as visiting the transplant facility (P < .0001) and prudence over time (P < .0001), were independent factors influencing the decline of a kidney transplant offer.

CONCLUSIONS

Our findings suggest that some patients hesitated to undergo deceased-donor kidney transplantation during the pandemic. There is a need to develop an appropriate system to ensure safe and secure kidney transplantation during prolonged pandemics.

Assessment of humoral immune response to different COVID-19 vaccines in patients undergoing maintenance hemodialysis

INTRODUCTION

The immune response to different Coronavirus Disease 2019 (COVID-19) vaccines is under-investigated in end-stage kidney disease (ESKD) patients, especially in the Middle East and North Africa. We carried out this research to estimate the effectiveness of COVID-19 immunization in ESKD patients on regular hemodialysis (HD).

METHODS

In this prospective observational study, we enrolled 60 ESKD patients on regular HD who had completed COVID-19 vaccination and 30 vaccinated healthy participants. Serum levels of severe acute respiratory syndrome coronavirus 2 immunoglobulin G (SARS-COV2 IgG) were quantified 1 month after completing the vaccination schedule, and all participants were followed up from October 2021 to March 2022. The vaccines used in the study were from Pfizer-BioNTech, AstraZeneca, and Sinopharm.

RESULTS

The median level of SARS-COV2 IgG was lower in HD patients than in healthy participants (p < 0.001). Regarding the type of COVID-19 vaccination, there was no statistical difference in SARS-COV2 IgG levels among HD patients. During the observation period, none of the HD patients had COVID-19.

CONCLUSION

COVID-19 vaccination appeared to be protective in HD patients for 6 months and the side effects of vaccines were tolerable.

Clinical characteristics and outcomes of COVID-19 patients with varying renal functions statuses during the Omicron pandemic in Shanghai

OBJECTIVE

This study aims to provide an academic summary of the clinical characteristics, outcomes and risk factors associated with prolonged hospital stays among the patients with varying renal function statuses during the Omicron pandemic in Shanghai.

METHODS

Clinical data was collected from COVID-19 patients admitted to Shanghai Jiaotong University School of Medicine Ruijin Hospital Northern District. Based on their baseline eGFR, the patients were divided into three groups: Group A (eGFR > = 90ml/min/1.73m2, n = 384), Group B (15ml/min/1.73m2 < = eGFR < 90ml/min/1.73m2, n = 220), and Group C (Hemodialysis-dependent patient, n = 92). Clinical characteristics and laboratory data were compared among the three groups. The cumulative hazards of ICU admission were compared using the Kaplan-Meier method. Univariate and multivariate linear regression analyses were conducted to identify the factors influencing the duration of positive nucleic acid test.

RESULTS

Between March 25, 2022, and May 31, 2022, a total of 696 COVID-19 patients were included in the study. Among the dialysis patients, 92% (85) of dialysis patients had not received any COVID-19 vaccination, and 14.1%(13) of hemodialysis (HD) patients eventually progressed to severe or critical cases. A total of 13 (2.15%) patients were admitted to the ICU, with 8 (61.5%) were HD patients. The duration of nucleic acid positivity showed a negative correlation with eGFR (B: -0.048, 95%CI: -0.059~-0.037, P = 0.000), platelet counts (B: -0.011, 95%CI: -0.017~-0.005, P = 0.001) or lymphocyte counts (B: -0.658, 95%CI: -1.229~-0.086, P = 0.024).

CONCLUSIONS

The majority of Omicron patients have a favorable prognosis, while HD patients experience relatively poorer outcomes and higher rates of ICU admission. Decreased eGFR and low lymphocyte/platelet counts are the important risk factors associated with prolonged Omicron infection.

Immunogenicity and safety of COVID-19 BNT162b2 booster vaccine in end-stage kidney disease patients receiving haemodialysis in Yogyakarta, Indonesia: a cohort prospective study

BACKGROUND

A significant decrease in antibody titres several months after COVID-19 primary vaccination in end-stage kidney disease (ESKD) patients receiving maintenance haemodialysis has recently been reported. The waning in antibody titres has led to the recommendations for a booster dose to increase the antibody titres after vaccination. Consequently, it is crucial to analyse the long-term humoral immune responses after COVID-19 primary vaccination and assess the immunogenicity and safety of booster doses in haemodialysis (HD) patients.

METHODS

Patients on maintenance haemodialysis who received the primary vaccine of CoronaVac (Sinovac) vaccine were administered with BNT162b2 (Pfizer-BioNTech) as the booster dose. The immunogenicity was assessed before (V1), one month (V2) and eight months (V3) after the primary vaccination, as well as one month after the booster dose (V4). Patients were followed up one month after the booster dose to assess the adverse events (AEs).

RESULTS

The geometric mean titre (GMT) of anti-SARS-CoV-2 S-RBD IgG antibody at 8 months after the primary vaccination increased significantly to 5,296.63 (95%CI: 2,930.89-9,571.94) U/mL (p =  < 0.0001) compared to before the primary vaccination. The GMT also increased significantly to 19,142.56 (95% CI: 13,489.63-27,227.01) U/mL (p < 0.0001) 1 month after the booster vaccine. Meanwhile, the median inhibition rate of neutralizing antibodies (NAbs) at 8 months after the primary vaccine and 1 month after the booster dose were not significantly different (p > 0.9999). The most common AEs after the booster dose included mild pain at the injection site (55.26%), mild fatigue (10.53%), and swelling at the injection site (10.53%). No serious AEs were reported.

CONCLUSIONS

The majority of ESKD patients on haemodialysis mounted a good antibody response to the BNT162b2 booster vaccination with tolerable adverse events.

Blunted humoral immune response to the fourth dose of BNT162b2 COVID-19 vaccine in patients undergoing hemodialysis

BACKGROUND

We aimed to investigate the impact of a fourth dose of BNT162b2 vaccine (Comirnaty®, Pfizer-BioNTech) on anti-SARS-CoV-2 (anti-S IgG) antibody titers in patients receiving hemodialysis (HD) and healthcare workers (HCWs).

METHODS

A multi-institutional retrospective study at five dialysis clinics in Japan was conducted using 238 HD patients and 58 HCW controls who received four doses of the BNT162b2 mRNA vaccine. Anti-S IgG titers were measured at 1, 3, and 6 months after the second dose, at 1 and 5/6 months after the third dose, and at 1 month after the fourth dose of vaccine.

RESULTS

The log anti-S IgG titers of the HD patients after the second vaccination were significantly lower than those of the control group, but equalized 1 month after the third vaccination: 9.94 (95% CI 9.82-10.10) vs. 9.81 (95% CI 9.66-9.96), (P = 0.32). In both groups, the fold-increase in anti-S IgG titers was significantly lower after the fourth dose than after the third dose of vaccine. In addition, there was a strong negative correlation between antibody titers 1 month after the fourth vaccination and antibody titers immediately before the vaccination. In both groups, the waning rate of anti-S IgG titers from the post-vaccination peak level after the third vaccine dose was significantly slower than that after the second dose.

CONCLUSIONS

These findings suggest that the humoral immune response was blunted after the fourth dose of the conventional BNT162b2 vaccine. However, multiple vaccinations could extend the window of humoral immune protection.

Trajectory of Humoral Responses to Two Doses of ChAdOx1 nCoV-19 Vaccination in Patients Receiving Maintenance Hemodialysis

The ChAdOx1 nCoV-19 (AZD1222) vaccine is one of the most commonly delivered SARS-CoV-2 vaccines worldwide; however, few clinical studies have investigated its immunogenicity in dialysis patients. We prospectively enrolled 123 patients on maintenance hemodialysis at a medical center in Taiwan. All patients were infection-naive, had received two doses of the AZD1222 vaccine, and were monitored for 7 months. The primary outcomes were anti-SARS-CoV-2 receptor-binding domain (RBD) antibody concentrations before and after each dose and 5 months after the second dose and neutralization capacity against ancestral SARS-CoV-2, delta, and omicron variants. The anti-SARS-CoV-2 RBD antibody titers significantly increased with time following vaccination, with a peak at 1 month after the second dose (median titer, 498.8 U/mL; interquartile range, 162.5 to 1,050 U/mL), and a 4.7-fold decrease at 5 months. At 1 month after the second dose, 84.6, 83.7, and 1.6% of the participants had neutralizing antibodies against the ancestral virus, delta variant, and omicron variant, respectively, measured by a commercial surrogate neutralization assay. The geometric mean 50% pseudovirus neutralization titers for the ancestral virus, delta variant, and omicron variant were 639.1, 264.2, and 24.7, respectively. The anti-RBD antibody titers correlated well with neutralization capacity against the ancestral virus and delta variant. Transferrin saturation and C-reactive protein were associated with neutralization against the ancestral virus and delta variant. Although two doses of the AZD1222 vaccine initially elicited high anti-RBD antibody titers and neutralization against the ancestral virus and delta variant in hemodialysis patients, neutralizing antibodies against omicron variant were rarely detected, and the anti-RBD and neutralization antibodies waned over time. Additional/booster vaccinations are warranted in this population. IMPORTANCE Patients with kidney failure have worse immune response following vaccination compared to general population, but few clinical studies have investigated immunogenicity of ChAdOx1 nCoV-19 (AZD1222) vaccination in hemodialysis patients. Here, we showed two doses of AZD1222 vaccines lead to high seroconversion rate of anti-SARS-CoV-2 receptor-binding domain (RBD) antibodies, and more than 80% patients acquired neutralizing antibodies against ancestral virus and delta variant. However, seldom did they obtain neutralizing antibodies against the omicron variant. The geometric mean 50% pseudovirus neutralization titer against the ancestral virus was 25.9-fold higher than that against the omicron variant. Also, there was a substantial decay in anti-RBD titers with time. Our findings provided evidence supporting that more protective measures, including additional/booster vaccinations, is warranted in these patients during the current COVID-19 pandemic.

Outcomes of vaccinations against respiratory diseases in patients with end-stage renal disease undergoing hemodialysis: A systematic review and meta-analysis

Due to the nature of the disease, end-stage renal disease (ESRD) patients suffer from dysfunction of the adaptive immune system, which leads to a poorer response to vaccination. Accordingly, it is crucial to evaluate the efficacy and safety of management strategies, including vaccinations, which could potentially reduce the risk of respiratory diseases, such as pneumonia, influenza, or COVID-19, and its associated outcomes. We searched PubMed, CENTRAL, ScienceDirect, Scopus, ProQuest, and Google Scholar databases using designated MeSH keywords. The risk of bias was assessed using ROBINS-I. The quality of evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Relative risk (RR) and 95% confidence interval (CI) were calculated. Heterogeneity was investigated using forest plots and I2 statistics. This systematic review included a total of 48 studies, with 13 studies of influenza (H1N1 and H3N2) vaccination and 35 studies of COVID-19 vaccination. H1N1 vaccination in ESRD patients undergoing hemodialysis induced lower seroconversion rates (RR 0.62, 95% CI: 0.56-0.68, p <0.00001) and lower seroprotection rates (RR 0.76, 95% CI: 0.70-0.83, p <0.00001) compared to controls. H3N2 vaccination in ESRD patients undergoing hemodialysis yielded lower seroconversion rates (RR 0.76, 95% CI: 0.68-0.85, p <0.00001) and lower seroprotection rates (RR 0.84, 95% CI: 0.77-0.90, p <0.00001) compared to controls. Twenty-nine studies demonstrate significantly lower antibody levels in ESRD patients undergoing hemodialysis compared to the controls following COVID-19 vaccination. This review presents evidence of lower seroconversion and seroprotection rates after vaccination against viral respiratory diseases in patients with ESRD undergoing hemodialysis. Since hemodialysis patients are more susceptible to infection and severe disease progression, a weakened yet substantial serological response can be considered adequate to recommend vaccination against respiratory diseases in this population. Vaccination dose, schedule, or strategy adjustments should be considered in stable ESRD patients on maintenance hemodialysis. Trial registration: Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255983, identifier: CRD42021255983.

Cellular and Humoral Responses in Dialysis Patients after Vaccination with the BNT162b2 or mRNA-1273 Vaccines

The outbreak of SARS-CoV-2 has raised considerable concern about the detrimental effects it can induce in public health, with the interest of the scientific community being focused on the development of preventive and therapeutic approaches. Patients with end-stage renal disease (ESRD) are amongst vulnerable populations for critical illness owing to the presence of other comorbidities, their defective immune system, and their inability of self-isolation. To date, vaccination constitutes the most promising method to manage viral dispersion. Therefore, it is particularly important to investigate the effectiveness of available vaccines against SARS-CoV-2 in this risk group. Here, we summarize initial experience regarding the humoral and cellular immune responses elicited in dialysis patients after completion of the recommended vaccination regimen, as well as after booster dose administration, with one of the two mRNA vaccines, namely, BNT162b2 and mRNA-1273. In conclusion, a significantly diminished and delayed immune pattern was observed in ESRD patients compared to healthy population, with a peak in antibody titers occurring 3-5 weeks after the second dose. A booster dose significantly augmented the immune response in dialysis patients with either mRNA-based vaccine. Variables adversely correlating with the weak immunogenicity observed in dialysis patients include immunosuppressive therapy, older age, comorbidities, longer time in hemodialysis treatment, and higher body mass index. On the contrary, previous COVID-19 infection and administration of the mRNA-1273 vaccine are deemed to induce a more favorable immune response. Further investigation is needed to thoroughly understand the efficacy of mRNA-based vaccines in hemodialysis patients and define predictive factors that can influence it.

Waning Humoral Response 6 Month after Double Vaccination with the mRNA-BNT162b2 Vaccine in Hemodialysis Patients

Introduction

Although most hemodialysis patients (HDP) exhibit an initial seroresponse to vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), studies have shown this response to be lower compared to healthy subjects. This fact raised concerns regarding the durability of the immune response and effective protection against severe Coronavirus disease 2019 (COVID-19) in this vulnerable population. The aim of our study was to evaluate the change in antibody levels over time in HDP population.

Materials and Methods

We performed a prospective multicenter study, evaluating antibody response among HDP at 2 and at 6 months after complete two-dose vaccination course with the mRNA-BNT162b2 (Pfizer-BioNTech) vaccine. The study was performed in 14 hemodialysis units of a private dialysis provider in Lithuania. The serum samples of 189 HDP were tested for SARS-CoV-2 IgG against the Spike glycoprotein.

Results

189 HDP participated in the study. Patients were 64.3±15.7 years of age, 116 (61.4%) were males and 73 (38.6%) were females. Among them, 183 (96.8%) were seropositive for anti-S IgG at 2 months after the second immunization dose. Six months after the second dose only 145 (76.7%) of study participants had positive anti-S IgG titers. The median level of anti-S IgG titers after 2 months was 383.1 BAU/mL (166.2-995.6) and after 6 months this level significantly decreased to 51.4 BAU/mL (22.0-104.0) (p<0.001). Seroresponses at both time points inversely correlated with increasing patient's age. Risk factor for absent response after 2 months included oncologic disease. Systemic autoimmune disease and a history of myocardial infarction increased risk to be seronegative 6 months after the second vaccine dose.

Conclusions

The majority of hemodialysis patients seroresponded after BNT162b2/Pfizer vaccination, but vaccine-induced humoral immunity wanes over time.

Frailty and Humoral Immune Responses Following COVID-19 Vaccination among Patients Undergoing Hemodialysis

BACKGROUND

Patients with end-stage kidney disease who are undergoing dialysis have reduced immune responses to COVID-19 vaccination. Frailty is extremely common among dialysis patients and may contribute to the impaired immunogenicity. This study aimed to determine the association between frailty and humoral immune responses following COVID-19 vaccination in hemodialysis patients.

DESIGN, SETTING, PARTICIPANTS

Adult hemodialysis patients without prior SARS-CoV-2 infection who received a priming dose of ChAdOx1 nCoV-19, an adenovirus-vectored vaccine, were assessed for eligibility. Participants were categorized as robust, pre-frail, or frail using the Fried frailty criteria. Humoral responses were assessed 28 days after vaccination by measuring titers of anti-spike IgG antibodies. The primary outcome was anti-spike antibody seroconversion, defined as antibody levels ≥50 AU/mL. Multivariable-adjusted logistic regression models were used to assess the association between frailty status and the primary outcome.

RESULTS

A total of 206 participants (mean age 67 ± 13 years, 50% women) were included in the study, of whom 50 (24%) were characterized as frail, 86 (42%) were characterized as pre-frail, and 70 (34%) were characterized as robust. Anti-spike antibody levels were progressively lower with more advanced stages of frailty (P <0.001). Compared with robust patients, a significantly smaller proportion of pre-frail and frail patients developed anti-spike antibody seroconversion (87%, 66%, and 40%, respectively; P <0.001). Frailty was associated with the absence of humoral responses after adjustment for age, sex, body mass index, diabetes, coronary artery disease, serum albumin, and lymphocyte count (OR=0.25; 95% CI, 0.08-0.80).

CONCLUSIONS

Frailty is independently associated with impaired humoral responses following COVID-19 vaccination among hemodialysis patients. Strategies aimed at preventing or attenuating frailty in the dialysis population are warranted.

COVID-19 Vaccination Trends and Side Effects among Egyptian Hemodialysis Patients: A Multicenter Survey Study

(1) Background: Vaccination may be a key intervention to prevent infection in chronic hemodialysis (CHD) patients. This study aimed to determine the COVID-19 vaccination status in Egyptian CHD patients and to analyze the safety and detailed side effect profile of the COVID-19 vaccine among these patients. (2) Methods: This survey-based study was conducted on 670 end-stage renal disease (ESRD) patients on CHD from 3 December 2021 to 5 February 2022. Subjects were asked about sociodemographic characteristics, clinical and therapeutic data, in addition to their COVID-19 vaccination status. If the subject had been vaccinated, we inquired about the type of vaccine and the side effects that occurred within a few days after administration of the first and second dose of the COVID-19 vaccine. Additionally, subjects were asked about the onset of side effects (days from vaccination), timing of maximum symptoms, intensity of symptoms and their effect on activity and need for medical attention. (3) Results: The study included 670 CHD patients with a mean age of 50.79 years; 58.1% were females. The vast majority (614; 91.6%) of the studied patients received two doses of the vaccine. Side effects were more commonly reported after the first dose than the second dose. The main side effects reported were generalized weakness/fatigue (56%), headache (43.8%) and fever (40.4%), and sore arm/pain was also reported (29.3%). Adverse events mostly occurred within one day after vaccination and the maximum symptoms usually happened on the second day. The median duration of symptoms was 3 days with a maximum duration up to 5 days. The univariate logistic regression analysis showed that male gender (OR 1.848; (95% CI, 1.242−2.749), p = 0.002), age (OR 0.981; (95% CI, 0.969−0.993), p = 0.003), smoking (OR 6.067; (95% CI, 3.514−10.475), p < 0.001), duration since starting HD (OR 0.998; (95% CI, 0.998−0.999), p < 0.001), associated comorbidities (OR 2.202; (95% CI, 1.478−3.281), p < 0.001) and prior COVID-19 infection (OR 3.318; (95% CI, 1.952−5.642), p < 0.001) were the main determinants of adverse events related to COVID-19 vaccination. (4) Conclusions: our preliminary findings support the favorable short-term safety profile of the COVID-19 vaccine among CHD patients, and hence can reassure both clinicians and patients, as well as further promote COVID-19 vaccine administration among these patients.

SARS-CoV-2 in dialysis patients and the impact of vaccination

Background

In centre haemodialysis (ICHD) patients have been identified as high risk of contracting Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection due to frequent healthcare contact and poor innate and adaptive immunity. Our ICHD patients were offered immunisation from January 2021. We aimed to assess outcomes following SARS-CoV-2 infection and report on the effect of vaccination in our ICHD patients.

Methods

Demographics, SARS-CoV-2 status, hospitalisation, mortality and vaccination status were analysed. From 11^th March 2020 to 31^st March 2021, 662 ICHD patients were included in the study and these patients were then followed up until 31^st August 2021.

Results

SARS-CoV-2 infection occurred in 28.4% with 51.1% of them requiring hospitalisation in contrast to community infection rates of 13.9% and hospitalisation of 9.0%. 28-day mortality was 19.2% in comparison to 1.9% of the community. Mortality increased to 34.0% over the study period. Mortality over the study period was 1.8 times in infected patients (HR 1.81 (1.32–2.49) P < 0.001) despite adjustment for age, gender and ethnicity. 91.3% of ICHD patients have now received both doses of SARS-CoV-2 vaccinations.

Conclusions

ICHD patients are at increased risk of acquiring SARS-CoV-2, with increased rates of hospitalisation and mortality. The increased mortality extends well beyond the 28 days post-infection and persists in those who have recovered. Peaks and troughs in infection rates mirrored community trends. Preliminary data indicates that the SARS-CoV-2 vaccination provides protection to ICHD patients, with ICHD case rates now comparable to that of the local population.

Antibody Response and Adverse Events of AZD1222 COVID-19 Vaccination in Patients Undergoing Dialysis: A Prospective Cohort Study

This study observed the antibody response and adverse events of AZD1222 (Oxford/AstraZeneca) vaccination in dialysis patients. A prospective cohort study was conducted in E-Da Healthcare Group hospitals between 1 July and 30 November 2021. Patients receiving hemodialysis (HD, n = 204) or peritoneal dialysis (PD, n = 116) were enrolled alongside healthy subjects (control, n = 34). Anti-SARS-CoV-2 S1 RBD IgG antibodies were measured before the first vaccination (T0), four to six weeks afterwards (T1), one week before the second dose (T2), and four to six weeks afterwards (T3). Adverse events were recorded one week after each dose. The positive IgG rates in the HD (T1: 72%; T2: 62%) and PD (T1: 69%; T2: 70%) groups were lower than the control group (T1: 97%; T2: 91%), with lower median antibody titers. At T3, the positive antibody response rates (HD: 94%; PD: 93%; control: 100%) and titers were similar. Titers were higher after the second dose in all groups. Adverse events were more severe after the first dose and less common with HD than PD or controls. Dialysis patients exhibited lower antibody responses than controls after the first dose of the AZD1222 vaccine but achieved similar responses after consecutive vaccination. Age, health status, two vaccine doses, and alcohol consumption may influence antibody levels.

Efficacy and Safety of COVID-19 Vaccine in Patients on Renal Replacement Therapy

Patients with CKD on RRT are at high risk for severe disease and mortality in COVID-19 disease. We decided to conduct an observational prospective study to evaluate antibody response after vaccination for COVID-19 in a cohort of 210 adult patients on RRT (148 on HD; 20 on PD; and 42 kidney transplant recipients). Blood samples were taken before and 4 weeks after vaccination. Antibody levels were evaluated with CLIA immunoassay testing for IgG anti-trimeric spike protein of SARS-CoV-2. A positive antibody titer was present in 89.9% of HD patients, 90% of PD patients, and 52.4% of kidney transplant recipients. Non-responders were more frequent among patients on immunosuppressive therapy. Mycophenolate use in kidney transplant patients was associated with lower antibody response. The median antibody titer was 626 (228–1480) BAU/mL; higher in younger patients and those previously exposed to the virus and lower in HD patients with neoplasms and/or on immunosuppressive therapy. Only two patients developed COVID-19 in the observation period: they both had mild disease and antibody titers lower than 1000 BAU/mL. Our data show a valid response to COVID-19 mRNA vaccination in HD and PD patients and a reduced response in kidney transplant recipients. Mycophenolate was the most relevant factor associated with low response.

How Are Albertans "Adjusting to and Coping With" Dialysis? A Cross-Sectional Survey

Background

Depression and anxiety are commonly reported (40% and 11%-52%) among adults receiving dialysis, compared with ~10% among all Canadians. Mental health in dialysis care is underrecognized and undertreated.

Objective

(1) To describe preferences for mental health support reported by Albertans receiving dialysis; (2) to compare depression, anxiety, and quality-of-life (QOL) domains for people who would or would not engage in support for mental health; and (3) to explore sociodemographic, mental health, and QOL domains that explain whether people would or would not engage in support for mental health.

Design

A cross-sectional survey.

Setting

Alberta, Canada.

Patients

Adults receiving all modalities of dialysis (N = 2972).

Measurements

An online survey with questions about preferences for mental health support and patient-reported outcome measures (Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7 [GAD-7], and Kidney Disease QOL Instrument-36 [KDQOL-36]).

Methods

To address objectives 1 and 2, we conducted chi-square tests (for discrete variables) and t tests (for continuous variables) to compare the distributions of the above measures for two groups: Albertans receiving dialysis who would engage or would not engage in support for mental health. We subsequently conducted a series of binary logistic regressions guided by the purposeful variable selection approach to identify a subset of the most relevant explanatory variables for determining whether or not people are more likely to engage in support for mental health (objective 3). To further explain differences between the two groups, we analyzed open-text comments following a summative content analysis approach.

Results

Among 384 respondents, 72 did not provide a dialysis modality or answer the PHQ-9. The final data set included responses from 312 participants. Of these, 59.6% would consider engaging in support, including discussing medication with a family doctor (72.1%) or nephrologist (62.9%), peer support groups (64.9%), and talk therapy (60%). Phone was slightly favored (73%) over in person at dialysis (67.6%), outpatient (67.2%), or video (59.4%). Moderate to severe depressive symptoms (PHQ-9 score ≥10) was reported by 33.4%, and most respondents (63.9%) reported minimal anxiety symptoms; 36.1% reported mild to severe anxiety symptoms (GAD-7 score ≥5). The mean (SD) PHQ-9 score was 8.9 (6.4) for those who would engage in support, and lower at 5.8 (4.8) for those who would not. The mean (SD) GAD-7 score was 5.2 (5.6) for those who would engage in support and 2.8 (4.1) for those who would not. In the final logistic regression model, people who were unable to work had 2 times the odds of engaging in support than people who are able to work. People were also more likely to engage in support if they had been on dialysis for fewer years and had lower (worse) mental health scores (odds ratios = 1.06 and 1.38, respectively). The final model explained 15.5% (Nagelkerke R2) of the variance and with 66.6% correct classification. We analyzed 146 comments in response to the question, "Is there anything else you like to tell us." The top 2 categories for both groups were QOL and impact of dialysis environment. The third category differed: those who would engage wrote about support, whereas those who would not engage wrote about "dialysis is the least of my worries."

Limitations

A low response rate of 12.9% limits representativeness; people who chose not to participate may have different experiences of mental health.

Conclusions

Incorporating patients' preferences and willingness to engage in support for mental health will inform future visioning for person-centered mental health care in dialysis.

Vaccination against SARS-CoV-2 in Haemodialysis Patients: Spike's Ab Response and the Influence of BMI and Age

Patients with chronic kidney disease (CKD-5D) in dialysis have been associated with higher rates of SARS-CoV-2 infection. Objective: To identify the CKD-5D patients’ immune system behavior regarding the Pfizer-BioNTech (BNT162b2 mRNA) vaccine (Comirnaty©). This was a multicenter study carried out in 38 dialysis units in NephroCare Portugal. Eligible patients from two cohorts—one composed of completely vaccinated patients with Comirnaty© (vaccinated group) against a second cohort of patients who recovered from SARS-CoV-2 infection (control group)—were selected through representative sampling for each cohort. Humoral response was assessed at 3 (t0) and 6 months (t1) after complete vaccination and, in the control group, 6 months after COVID-19 recovery. In the vaccinated group, at t0, the median anti-Spike IgG level was 1120 AU/mL and, at t1, all participants’ antibody level decreased to a median of 455 AU/mL. In the control group, the median serum SARS-CoV-2 antibodies level was 1836 AU/mL. In the vaccinated group, at t0, patients < 70 years presented a significantly (p = 0.002) higher level of anti-Spike IgG titres. In contrast, older patients from the control group presented a significantly (p = 0.038) higher IgG. No correlation was found between age and anti-Spike IgG antibodies level in any of the studied groups. Patients with a higher body mass index showed a greater immune response in both the vaccinated and control group, although without significance. We concluded that, in the vaccinated group, elderly patients developed a lower immune response than younger patients and the levels of anti-Spike IgG antibodies declined faster between t0 and t1, while in the control group, the oldest and overweight patients developed the best humoral response.

Benefit-risk evaluation of COVID-19 vaccination in special population groups of interest

Several population groups display an increased risk of severe disease and mortality following SARS-CoV-2 infection. These include those who are immunocompromised (IC), have a cancer diagnosis, human immunodeficiency virus (HIV) infection or chronic inflammatory disease including autoimmune disease, primary immunodeficiencies, and those with kidney or liver disease. As such, improved understanding of the course of COVID-19 disease, as well as the efficacy, safety, and benefit-risk profiles of COVID-19 vaccines in these vulnerable groups is paramount in order to inform health policy makers and identify evidence-based vaccination strategies. In this review, we seek to summarize current data, including recommendations by national health authorities, on the impact and benefit-risk profiles of COVID-19 vaccination in these populations. Moving forward, although significant efforts have been made to elucidate and characterize COVID-19 disease course and vaccine responses in these groups, further larger-scale and longer-term evaluation will be instrumental to help further guide management and vaccination strategies, particularly given concerns about waning of vaccine-induced immunity and the recent surge of transmission with SARS-CoV-2 variants of concern.

Presence of specific SARS-COV2 antibodies in hemodialysis patients and their caregivers after the first wave of COVID-19

Hemodialysis (HD) patients are at risk for severe COVID-19 and cannot comply with social distancing. SARS-COV2 seroprevalence in French patients and caregivers after the first wave of COVID-19 is unknown. SeroCOVIDial is a prospective study conducted between June and December 2020. SARS-COV2 seroprevalence was evaluated by a rapid serological test (BIOSYNEX) in HD patients and caregivers, and the presence or not of anti-SARS-COV2 neutralizing or non-neutralizing antibodies in patients was also determined by ELISA and seroneutralization. In June 2020, 451 HD patients and 238 caregivers were included. Overall SARS-COV2 seroprevalence was 8.4% (patients) and 6.7% (caregivers), and was 87.1% (patients) and 90.0% (caregivers) in participants with a previously documented SARS-COV2 infection. Overall seroprevalence reached 13.8% (patients) and 12.6% (caregivers) following the second epidemic wave. During the follow-up, 38 (8.4%) patients died (9 of COVID-19). Among the 44 (10.6%) patients who became infected, only two were seropositive at M0. The levels of anti-SARS-COV2 antibodies decreased over time in patients and caregivers. The BIOSYNEX test showed 82.9% sensitivity and 97.7% specificity. Prevalence of anti-SARS-COV2 antibodies was low in HD patients and caregivers after the first epidemic wave but rose after the second wave. A rapid serological test showed good performances and could be useful for future monitoring of anti-SARS-COV2 antibodies.

Impact of the COVID-19 pandemic on patients with chronic kidney disease: A narrative review

ABSTRACT

Severe acute respiratory disease coronavirus 2 is currently causing the coronavirus disease 2019 (COVID-19) pandemic, placing extreme strain on the global health system. Vaccination is the main measure for preventing the COVID-19 epidemic, especially for high-risk groups including patients with chronic kidney disease (CKD). However, CKD patients receiving dialysis or kidney transplant may be characterized by decreased renal function and immune disorders, which may have uncertainties in their health. This overview aims to introduce the possible impact of the COVID-19 vaccine on kidney disease and its application in patients with CKD to provide evidence for the COVID-19 vaccine in patients with CKD. The data for this study were collected from PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and the China Knowledge Resource Integrated Database (CNKI). The following keywords were used: "COVID-19", "COVID-19 vaccine," and "CKD". The publication time of the papers was set from the establishment of the databases to September 2021. A total of 47 studies were included, and patients with CKD are a high-risk group for COVID-19 infection and severe illness. Vaccination is a powerful tool for preventing CKD patients from COVID-19. Because of possible side effects, the recurrence or deterioration of kidney disease may occur in CKD patients after vaccination. Although vaccination for patients with CKD remains a problem, with the advantages outweighing the disadvantages, stable CKD patients should complete a vaccination plan, and doctors should be aware of the recurrence or deterioration of kidney disease and close monitoring.

DATA ACCESS STATEMENT

Research data supporting this publication are available from the electronic databases of PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and the China Knowledge Resource Integrated Database (CNKI).

Response to three doses of the Pfizer/BioNTech BNT162b2 COVID-19 vaccine: a retrospective study of a cohort of haemodialysis patients in France

BACKGROUND

The mortality rate associated with coronavirus disease 2019 (COVID-19) is high among haemodialyzed patients. We sought to describe the serological status of haemodialysis patients having received up to three doses of BNT162b2 mRNA vaccine, and to identify factors associated with a poor humoral response.

METHODS

We performed a retrospective, observational study of patients attending a dialysis centre in Antibes, France. One or two of each patient's monthly venous blood samples were assayed for anti-spike (S1) immunoglobulin G (IgG).

RESULTS

We included 142 patients, of whom 124 remained COVID-19-negative throughout the study. Among these COVID-19-negative patients, the humoral immune response rate (defined as an anti-S1 IgG titre ≥1.2 U/ml) was 82.9% after two injections and 95.8% after three injections, and the median [interquartile range] titre increased significantly from 7.09 [2.21; 19.94] U/ml with two injections to 93.26 [34.25; 176.06] U/ml with three. Among patients with two injections, the mean body mass index and serum albumin levels were significantly higher in responders than in non-responders (26.5 kg/m2 vs. 23.2 kg/m2, p = 0.0392; and 41.9 g/l vs. 39.0 g/l, p = 0.0042, respectively). For the study population as a whole at the end of the study, a history of COVID-19, at least two vaccine doses, and being on the French national waiting list for kidney transplantation were the only factors independently associated with the anti-S1 IgG titre.

CONCLUSIONS

Dialysis patients vaccinated with two doses of BNT162b2 might not be sufficiently protected against SARS-CoV-2 and so should receive a third (booster) dose.

TRIAL REGISTRATION

The present retrospective study of clinical practice was not interventional and so was not registered.

SARS-CoV-2 Antibody and T Cell Response after a Third Vaccine Dose in Hemodialysis Patients Compared with Healthy Controls

Hemodialysis (HD) patients have an increased risk of severe SARS-CoV-2 infection. In this study, we assess the impact of a third vaccine dose (3D) on antibody levels and T cell response in HD patients and a healthy control group in a prospective cohort study consisting of 60 HD patients and 65 healthy controls. Each participant received two doses of the BNT-162b2 mRNA vaccine and an mRNA vaccine 3D. The SARS-CoV-2 antibody response was measured 6 months after the second vaccine dose and 6 to 8 weeks after the 3D. We assessed INF-γ secretion 6–8 weeks post 3D in 24 healthy controls, 17 HD patients with a normal response, and 20 low responder HD patients. The groups were compared using univariate quantile regressions and multiple analyses. After the 3D, the SARS-CoV-2-specific antibody and INF-γ titers of most HD patients were comparable to those of healthy controls. A subgroup of HD patients who had shown a diminished antibody response after the first two vaccine doses developed a significantly lower antibody and INF-γ response compared to responder HD patients and controls even after the 3D. A new strategy is needed to protect low/non-responder HD patients from severe SARS-CoV-2 infection.

Humoral antibody response to the first dose of the ChAdOx1 nCoV-19 vaccine in Asian patients undergoing hemodialysis

Background and objectives

The immunogenicity of vaccines is known to be attenuated in patients with end‐stage kidney disease due to uremia. Patients on dialysis were excluded from coronavirus disease 2019 (COVID‐19) vaccine trials; thus, the effectiveness of vaccines for this population is unclear. The aim of this study was to explore whether Asian dialysis patients can effectively produce an immune response after being vaccinated with the first dose of the ChAdOx1 nCoV‐19 vaccine.

Design setting, participants, and measurements

In this prospective cohort study, we included Asian hemodialysis patients who received the ChAdOx1 nCoV‐19 vaccine. At 3 weeks after the first dose of vaccination, we assessed the humoral immune response by measuring anti‐SARS‐CoV‐2 S antibody titers. The primary outcome was the seropositive rate following vaccination, defined as an antibody titer greater than or equal to 0.8 U/ml. Factors associated with seropositivity were explored in multivariate logistic regression analyses.

Results

In total, 434 participants were included. The mean age was 64 years, the mean dialysis vintage was 6 years, and 61% of the participants were men. At a mean time of 22 days from vaccination, 56% of the participants were seropositive. The vast majority (88%) had low antibody titers (< 15 U/ml). The multivariate logistic regression analyses showed that older age (every increase of 10 years, odds ratio [OR] 0.80, 95% CI 0.65–0.98, p = 0.03) was negatively associated with seropositivity and that higher Kt/V (every increase of 0.1, OR 1.14, 95% CI 1.01–1.28, p = 0.03) and higher serum albumin level (every increase of 0.1 g/dl, OR 1.09, 95% CI 1.02–1.18, p = 0.02) were positively associated with seropositivity.

Conclusions

In Asian hemodialysis patients, the seropositive rate was low, and most had low antibody titers after the first dose of the ChAdOx1 nCoV‐19 vaccine. Younger age, better dialysis adequacy, and higher albumin levels were associated with seropositivity.

Predictors of humoral response to SARS-CoV-2 mRNA vaccine BNT162b2 in patients receiving maintenance dialysis

Objective

Patients on dialysis are at high risk for severe COVID-19 and associated morbidity and mortality. We examined the humoral response to SARS-CoV-2 mRNA vaccine BNT162b2 in a maintenance dialysis population.

Design

Single-center cohort study.

Setting and participants

Adult maintenance dialysis patients at 3 outpatient dialysis units of a large academic center.

Methods

Participants were vaccinated with 2 doses of BNT162b2, 3 weeks apart. We assessed anti-SARS-CoV-2 spike antibodies (anti-S) ∼4-7 weeks after the second dose and evaluated risk factors associated with insufficient response. Definitions of antibody response are as follows: nonresponse (anti-S level, <50 AU/mL), low response (anti-S level, 50-839 AU/mL), and sufficient response (anti-S level, ≥840 AU/mL).

Results

Among the 173 participants who received 2 vaccine doses, the median age was 60 years (range, 28-88), 53.2% were men, 85% were of Black race, 86% were on in-center hemodialysis and 14% were on peritoneal dialysis. Also, 7 participants (4%) had no response, 27 (15.6%) had a low response, and 139 (80.3%) had a sufficient antibody response. In multivariable analysis, factors significantly associated with insufficient antibody response included end-stage renal disease comorbidity index score ≥5 and absence of prior hepatitis B vaccination response.

Conclusions

Although most of our study participants seroconverted after 2 doses of BNT162b2, 20% of our cohort did not achieve sufficient humoral response. Our findings demonstrate the urgent need for a more effective vaccine strategy in this high-risk patient population and highlight the importance of ongoing preventative measures until protective immunity is achieved.

SARS-CoV-2 mRNA Vaccine-Induced Cellular and Humoral Immunity in Hemodialysis Patients

Background/Aims: Chronic kidney disease CKD patients on intermittent hemodialysis IHD are exposed to SARS-CoV-2 infection and carry a risk of developing severe symptoms. The aim of this study was to evaluate the humoral and cellular immunity induced by two doses of mRNA vaccines, the Pfizer-BioNTech (Comirnaty) COVID-19 Vaccine and the Moderna (mRNA-1273) COVID-19 vaccine. Patients and methods: The study included 281 patients from five dialysis centers in northern Poland. Within 2 weeks prior to the first dose of the vaccine, a blood sample was collected for an evaluation of SARS-CoV-2 antibodies. Thirty to forty-five days after the second dose of the vaccine, a blood sample was taken to evaluate humoral and cellular response. Results: Patients with stage 5 CKD on IHD were characterized by a considerable SARS-CoV-2 vaccine-induced seroconversion rate. The strongest factors influencing the antibodies AB level after vaccination were a pre-vaccination history of SARS-CoV-2 infection, age, the neutrophil-to-lymphocyte ratio NLR, neutrophil absolute count, and the hemoglobin level. Cellular immunity was higher in patients with a pre-vaccination history of SARS-CoV-2 infection. Cellular immunity depended on the albumin level. Positive cellular response to vaccination was a positive factor reducing all-cause mortality, except for COVID-19 mortality (no such deaths were reported during our follow-up). Cellular immunity and humoral immunity were positively mutually dependent. High levels of albumin and hemoglobin, low neutrophil count, and a reduced NLR, translated into better response to vaccination. Conclusions: Patients with stage 5 CKD on IHD were characterized by a considerable SARS-CoV-2 vaccine-induced seroconversion rate and a good rate of cellular immunity. The factors that change with exacerbating inflammation and malnutrition (albumin, hemoglobin, neutrophil count, the NLR) affected the efficacy of the vaccination.

The Humoral Immune Response of the ChAdOx1 nCoV-19 Vaccine in Maintenance Dialysis Patients without Prior COVID-19 Infection

BACKGROUND

Chronic kidney disease (CKD) patients tend to have a reduced immune response to infection and vaccination. The efficacy of current available COVID-19 vaccines in CKD patients has not been widely evaluated.

METHODS

In the present study, three hundred and eight chronic dialysis patients received ChAdOx1 nCoV-19 (Oxford-AstraZeneca, AZ). Blood tests using an antibody against the receptor-binding domain (RBD) of the S1 subunit of the SARS-CoV-2 spike protein had performed at four designed time points before and after the first and second vaccine.

RESULTS

The mean age of patients was 65.5 ± 12.38 years, and the male/female ratio was 61.4%:38.6% (189/119). Two weeks after the first vaccination, only 37.66% of patients had a positive antibody response (>50 AU/mL). However, 65.58% of the participants showed a delayed antibody response ten weeks after the first vaccine. Four weeks after the second vaccine, 94.16% of participants had positive antibody levels. Age was the most significant factor associated with antibody response. Flow cytometry analysis revealed that immune-naïve patients had significantly lower early active B cells and proliferative B cells than the age- and sex-matched immune responders.

CONCLUSION

Despite a delayed response, 94.16% of chronic dialysis patients achieved a positive antibody response after two doses of the AZ vaccine. Age is the most significant factor associated with antibody response.

Analysis of Experiences in Preventing COVID-19 in Hemodialysis Centers of the North of Poland before the Era of Vaccination

BACKGROUND

The appearance of very contagious SARS-CoV-2 variants and waning vaccine immunity may indicate the need to return to using universal methods of preventing the spread of COVID-19.

METHODS

We performed a multicenter retrospective cohort survey study to describe the methods used in dialysis units to prevent and control the spread of SARS-CoV-2 and also the association between these methods and the incidence of COVID-19 among hemodialyzed (HD) patients before the era of vaccination. The study population included all maintenance HD patients (n = 1569) in 14 dialysis units in the Pomeranian Voivodeship.

RESULTS

The group of 352 patients (199 men, 153 female) were confirmed for COVID-19. The absolute cumulative incidence in the studied period was 22.4%. It varied widely by dialysis units, ranging from 9.4% to 36.9%. Universal preventive methods were applied by all units. Different additional methods were implemented in some stations with varying frequency (36-86%). In order to quantify the scale of the applied additional preventive methods, we calculated a summary prevention index (PI), i.e., one point for one additional method. Lower incidence was found in centers applying dialysis in isolation of patients hospitalized due to diseases requiring hospitalization (17.42% ± 6.89 vs. 26.54 ± 6.34; p = 0.028) and higher incidence in medium-size dialysis centers (ANOVA F: p = 0.017). Significant inverse correlation between PI and incidence was demonstrated as well (r = -0.759; p = 0.002).

CONCLUSIONS

The higher the number of implemented preventive measures, the lower the risk of COVID-19 infection in HD patients. Among applied procedures the isolation of hospitalized patients is of significant importance. The measures proved to be effective in prevention before the vaccination era should be continued, as the threat of SARS-CoV-2 still exists.

Neutralization Assessments Reveal High Cardiothoracic Ratio and Old Age as Independent Predictors of Low Neutralizing Antibody Titers in Hemodialysis Patients Receiving a Single Dose of COVID-19 Vaccine

BACKGROUND

Data are lacking regarding predictors of quantification of neutralizing antibodies (nAbs) based on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 50% neutralization titer (NT50) after a single dose of COVID-19 vaccine in hemodialysis (HD) patients.

METHODS

This prospective single-center study enrolled 200 HD patients and 82 healthy subjects to estimate antibodies against the SARS-CoV-2 viral spike protein 1 and receptor-binding domain after a first dose of a COVID-19 vaccine (ChAdOx1 or mRNA-1273), measured by enzyme-linked immunosorbent assay and applied spline-based generalized additive model regression analysis to predict NT50 converted to international units.

RESULTS

After the first dose of ChAdOx1, multiple linear regression showed that age (p = 0.011) and cardiothoracic ratio (p = 0.002) were negatively associated with NT50. Older age (OR = 0.958, p = 0.052) and higher cardiothoracic ratio (OR < 0.001, p = 0.037) could predict negative humoral response (NT50 < 35.13 IU/mL). NT50 was lower in HD patients compared with healthy controls receiving ChAdOx1 (10.68 vs. 43.01 IU/m, p < 0.001) or mRNA-1273 (36.39 vs. 262.2 IU/mL, p < 0.001). ChAdOx1 elicited lower GMTs than mRNA-1273 in the HD cohort (10.68 vs. 36.39 IU/mL, p < 0.001) and in healthy controls (43.01 vs. 262.22 IU/mL, p < 0.001).

CONCLUSION

High cardiothoracic ratio and old age could independently predict a decline in nAb titers in an HD cohort vaccinated with a single dose of ChAdOx1.

Comparison of antibody response to two different mRNA Covid-19 vaccines in patients on hemodialysis

Introduction

In hemodialysis patients, coronavirus disease 2019 is associated with high morbidity and mortality. Aim of the study was to evaluate the antibody level against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients treated with two different mRNA-based vaccines, in a multicenter survey.

Patients and methods

Since April 2020, in the 5 participating Centers, periodic screening of all patients with PCR testing has been performed every 2 weeks. The study included two cohorts of patients on maintenance hemodialysis treated with the BNT162b2 or with the mRNA-1273 Covid-19 vaccine. The tests for antibodies against the receptor-binding domain was performed by the anti–SARS-CoV-2 S enzyme immunoassay (Roche Elecsys).

Results

Of the 398 included patients, 303 received the BNT162b2 and 95 the mRNA-1273 vaccine. In patients without previous infection, the median levels of anti-S antibodies were 297 U/mL and 1,032 U/mL for those treated with BNT162b2 or mRNA-1273, respectively (p < 0.001). In patients with previous infection, the median levels of SARS-CoV-2 anti-S antibodies were 7,516 U/mL and 17,495 U/mL for those treated with BNT162b2 or mRNA-1273, respectively (p = 0.005). The Charlson comorbidity index (CCI) was significantly associated with protective levels of anti-spike IgG, with 3.6% of low- or non-responders having a CCI of 2–4 versus 18.9% in those with a CCI of 8 or more. The adjusted OR of developing a sufficient antibody level between the two vaccines was 3.91 (p = 0.0766) in favor of mRNA-1273.

Conclusions

Both of the evaluated mRNA-based vaccines for SARS-CoV-2 showed good efficacy. Preliminary data may data suggest a  higher antibody response to the mRNA-1273 vaccine.

Graphical abstract

Immunogenicity of the BNT162b2 Vaccine in Patients Undergoing Maintenance Hemodialysis Is Associated with Medical Conditions

BACKGROUND AND OBJECTIVES

Patients undergoing maintenance hemodialysis have an attenuated immune response to vaccination. The aim of our study was to determine the predictive factors for humoral response to vaccination with the BNT162b2 mRNA vaccine (Pfizer-BioNTech) in patients on maintenance hemodialysis.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

In this retrospective, single-center study, we included patients on maintenance hemodialysis already vaccinated with two doses of the BNT162b2 vaccine (Pfizer-BioNTech) and with a post-vaccination serological follow-up.

RESULTS

252 patients were included for study with a mean age of 71.9 (±14.4) years. Twelve patients (4.7%) were under immunosuppressive therapy (calcineurin inhibitors: n = 4; chemotherapy for myeloma: n = 3; last infusion of rituximab over the previous 4 years: n = 2; abatacept: n = 2; adalimumab n = 1). Three of these patients were under immunosuppressive therapy for nonrenal solid organ transplantation. Multivariate analysis identified immunosuppressive therapy (OR 4.73 [1.38-16.17], p = 0.013) and lower baseline albumin levels (OR 1.23 [1.09-1.38], p < 0.001) as independent predictive factors of nonresponse to vaccination. Older age (β = -0.59 ± 0.21, p = 0.006) and immunosuppressive therapy (β = 40.33 ± 13.33, p = 0.003) were significantly associated with lower humoral response to vaccination.

CONCLUSIONS

Approximately 90% of patients under maintenance hemodialysis developed specific antibodies to the BNT162b2 mRNA vaccine. Immunosuppressive therapy, malnutrition, and older age were associated with a higher risk of nonseroconversion or lower humoral response to mRNA-based vaccination against SARS-CoV-2. We strongly recommend serological monitoring after vaccination to determine booster timing, especially for patients with malnutrition or on immunosuppressive therapy.

The global impact of the Coronavirus 2019 pandemic on in-centre haemodialysis services: an International Society of Nephrology -Dialysis Outcomes Practice Patterns Study survey

Introduction

To assess the impact of the COVID-19 pandemic impact on hemodialysis (HD) centers, The Dialysis Outcomes and Practice Patterns Study and ISN collaborated on a web-survey of centers.

Methods

A combined approach of random sampling and open invitation was used between March 2020 and March 2021. Responses were obtained from 412 centers in 78 countries and all 10 ISN regions.

Results

In 8 regions, rates of SARS-CoV-2 infection were <20% in most centers, but in North East Asia (NE Asia) and Newly Independent States and Russia (NIS & Russia), rates were ≥20% and ≥30%, respectively. Mortality was ≥10% in most centers in 8 regions, although lower in North America and Caribbean (N America & Caribbean) and NE Asia. Diagnostic testing was not available in 33%, 37%, and 61% of centers in Latin America, Africa, and East and Central Europe, respectively. Surgical masks were widely available, but severe shortages of particulate-air filter masks were reported in Latin America (18%) and Africa (30%). Rates of infection in staff ranged from 0% in 90% of centers in NE Asia to ≥50% in 63% of centers in the Middle East and 68% of centers in NIS & Russia. In most centers, <10% of staff died, but in Africa and South Asia (S Asia), 2% and 6% of centers reported ≥50% mortality, respectively.

Conclusion

There has been wide global variation in SARS-CoV-2 infection rates among HD patients and staff, personal protective equipment (PPE) availability, and testing, and the ways in which services have been redesigned in response to the pandemic.

SARS-CoV-2 Antibodies in Hemodialysis Patients Six Months after Infection Compared to Healthcare Workers

Background

The humoral response to SARS-CoV-2 infection in hemodialysis patients needs to be clarified.

Methods

In this retrospective study performed in two dialysis facilities, we measured the circulating levels of SARS-CoV-2 antibodies in patients who were on maintenance hemodialysis during the first wave of the epidemic in March and April 2020 and were still alive 6 months later. We also investigated associations between the patients diagnosed as infected during the first wave and several clinical, biological, and radiological parameters of COVID-19. Finally, we compared these circulating levels of SARS-CoV-2 antibodies with those of a control group of healthcare workers infected during the same period.

Results

Of the 299 hemodialysis patients who recovered from the first wave of the epidemic 6 months before, 59 had a positive SARS-CoV-2 antibody whereas only 45 patients were diagnosed as infected during the first wave of the epidemic. All infected hemodialysis patients developed circulating antibodies. Using a clustering method, a significant correlation was identified between the cluster with the lowest circulating levels of SARS-CoV-2 antibodies and the severity of COVID-19 based on several parameters including CRP, BNP, lymphocyte count, neutrophil-lymphocyte ratio, and oxygen requirements, as well as pulmonary involvement on chest scan. Moreover, the circulating levels of the SARS-CoV-2 antibodies in surviving hemodialysis patients (n = 59) were similar to those of the control group (n = 17).

Conclusion

The main finding of this study is that all of the surviving hemodialysis patients who were diagnosed with SARS-CoV-2 infection from March to April 2020 developed a persistent humoral response with significant circulating levels of SARS-CoV-2 antibodies, 6 months later. Another important finding is that surviving hemodialysis patients who had more severe disease had lower circulating levels of SARS-CoV-2 antibodies. Finally, circulating levels of SARS-CoV-2 antibodies were similar in surviving hemodialysis patients and healthcare workers without kidney disease.

Preventing the Next Pandemic: The Case for Investing in Circulatory Health - A Global Coalition for Circulatory Health Position Paper

The Coronavirus Disease 2019 (COVID-19) has had a continuous and robust impact on world health. The resulting COVID-19 pandemic has had a devastating physical, mental and fiscal impact on the millions of people living with noncommunicable diseases (NCDs). In addition to older age, people living with CVD, stroke, obesity, diabetes, kidney disease, and hypertension are at a particularly greater risk for severe forms of COVID-19 and its consequences. Meta-analysis indicates that hypertension, diabetes, chronic kidney disease, and thrombotic complications have been observed as both the most prevalent and most dangerous co-morbidities in COVID-19 patients. And despite the nearly incalculable physical, mental, emotional, and economic toll of this pandemic, forthcoming public health figures continue to place cardiovascular disease as the number one cause of death across the globe in the year 2020. The world simply cannot wait for the next pandemic to invest in NCDs. Social determinants of health cannot be addressed only through the healthcare system, but a more holistic multisectoral approach with at its basis the Sustainable Development Goals (SDGs) is needed to truly address social and economic inequalities and build more resilient systems. Yet there is reason for hope: the 2019 UN Political Declaration on UHC provides a strong framework for building more resilient health systems, with explicit calls for investment in NCDs and references to fiscal policies that put such investment firmly within reach. By further cementing the importance of addressing circulatory health in a future Framework Convention on Emergency Preparedness, WHO Member States can take concrete steps towards a pandemic-free future. As the chief representatives of the global circulatory health community and patients, the Global Coalition for Circulatory Health calls for increased support for the healthcare workforce, global vaccine equity, embracing new models of care and digital health solutions, as well as fiscal policies on unhealthy commodities to support these investments.

Humoral response after SARS-CoV-2 mRNA vaccines in dialysis patients: Integrating anti-SARS-CoV-2 Spike-Protein-RBD antibody monitoring to manage dialysis centers in pandemic times

Dialysis patients are both the most likely to benefit from vaccine protection against SARS-CoV-2 and at the highest risk of not developing an immune response. Data from the medical field are thus mandatory. We report our experience with a BNT162b2-mRNA vaccine in a retrospective analysis of 241 dialysis patients including 193 who underwent anti-Spike-Protein-Receptor-Binding-Domain (RBD) IgG analysis. We show that a pro-active vaccine campaign is effective in convincing most patients to be vaccinated (95%) and frequently elicits a specific antibody response (94.3% after two doses and 98.4% after three doses). Only immunocompromised Status is associated with lack of seroconversion (OR 7.6 [1.5–38.2], p = 0.02). We also identify factors associated with low response (last quartile; IgG<500AU/mL): immunocompromised status, age, absence of RAAS inhibitors, low lymphocytes count, high C Reactive Protein; and with high response (high quartile; IgG>7000AU/mL): age; previous SARS-CoV-2 infection and active Cancer. From this experience, we propose a strategy integrating anti-spike IgG monitoring to guide revaccination and dialysis center management in pandemic times.

Spike and neutralizing antibodies response to COVID-19 vaccination in haemodialysis patients

Background

Humoral response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines needs to be evaluated in the fragile population of patients on maintenance haemodialysis (HD).

Methods

We analysed the antibody response to the spike (S) antigen of SARS-CoV-2 before and after each dose of the messenger RNA (mRNA) Comirnaty vaccine (BNT162b2; BioNTech & Pfizer) in patients from a single dialysis centre and detected the presence of neutralizing antibodies (Nabs).

Results

Among the 90 vaccinated HD patients (mean age 69 years, 61% male), 19 (21%) had a history of SARS-CoV-2 infection. A seroconversion with anti-S immunoglobulin G antibodies (Sabs) was documented in 20% of patients after the first dose (early responders) and in 77% after the second dose, while 23% were non-responders. Cardiac disease, cirrhosis and gamma globulin levels were independently predictive of the absence of seroconversion. Nabs were detected in 15.4% of early responders after the first dose and in 84.6% of early responders and 57.9% of late responders after the second dose. Sab titres after the second dose were higher in patients with Nab than without Nab {598 [interquartile range (IQR) 246–882]) versus 134 [IQR 61–390]; P < 0.0001}. All patients with a history of SARS-CoV-2 infection developed both Sabs and Nabs and their titres for Sabs and Nabs were higher than in late responders.

Conclusions

Most HD patients develop a substantial humoral response against SARS-CoV2, with Nabs, following the mRNA vaccine. Whether this immunity persists over time and is able to efficiently protect patients from coronavirus disease 2019 remains to be determined.

Review of Early Immune Response to SARS-CoV-2 Vaccination Among Patients With CKD

The effects of the coronavirus disease-2019 (COVID-19) pandemic, particularly among those with chronic kidney disease (CKD), who commonly have defects in humoral and cellular immunity, and the efficacy of vaccinations against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are uncertain. To inform public health and clinical practice, we synthesized published studies and preprints evaluating surrogate measures of immunity after SARS-CoV-2 vaccination in patients with CKD, including those receiving dialysis or with a kidney transplant. We found 35 studies (28 published, 7 preprints), with sample sizes ranging from 23 to 1140 participants and follow-up ranging from 1 week to 1 month after vaccination. Seventeen of these studies enrolled a control group. In the 22 studies of patients receiving dialysis, the development of antibodies was observed in 18% to 53% after 1 dose and in 70% to 96% after 2 doses of mRNA vaccine. In the 14 studies of transplant recipients, 3% to 59% mounted detectable humoral or cellular responses after 2 doses of mRNA vaccine. After vaccination, there were a few reported cases of relapse or de novo glomerulonephritis, and acute transplant rejection, suggesting a need for ongoing surveillance. Studies are needed to better evaluate the effectiveness of SARS-CoV-2 vaccination in these populations. Rigorous surveillance is necessary for detection of long-term adverse effects in patients with autoimmune disease and transplant recipients. For transplant recipients and those with suboptimal immune responses, alternate vaccination platforms and strategies should be considered. As additional data arise, the NephJC COVID-19 page will continue to be updated (http://www.nephjc.com/news/covid-vaccine).