Humoral Response to mRNA-1273 SARS-CoV-2 Vaccine in Peritoneal Dialysis Patients: Is Boostering After Six Months Adequate?

COVID-19 Vaccination Among Patients Receiving Maintenance Renal Replacement Therapy: Immune Response, Real-World Effectiveness, and Implications for the Future

Chronic kidney disease affects more than 800 million people worldwide and often progresses to end-stage renal disease, which requires maintenance dialysis. Patients receiving dialysis are at higher risk for severe respiratory infections, including SARS-CoV-2 (the causative agent of COVID-19). In addition, many patients who receive dialysis also receive immunosuppressive treatments for conditions such as systemic vasculitis, systemic lupus erythematosus, or malignancies. Many studies have shown that while mRNA COVID-19 vaccines induce some level of immune response in patients receiving dialysis, the magnitude of response is often lower than that of healthy individuals, and responses rapidly wane. Importantly, the risk of COVID-19-related hospitalization and mortality for patients receiving dialysis is 4- to 8-fold higher compared with the general population. In this article, we summarize recent immunogenicity and real-world outcomes of COVID-19 mRNA vaccination among patients receiving dialysis, with a focus on the 3-dose extended primary series and additional (fourth) doses.

Durable Anti-SARS-CoV-2 Antibody Response after mRNA-1273 Booster in Peritoneal Dialysis Patients during the Omicron Wave

Anti-SARS-CoV-2 vaccination of dialysis patients has been proven to be safe and effective to reduce COVID-19-related morbidity and mortality. However, data on the durability of anti-SARS-CoV-2 antibodies post-vaccination in peritoneal dialysis (PD) patients are scarce. In this prospective single-center cohort study we measured anti-SARS-CoV-2 RBD antibodies 3 and 6 months after the 3rd dose of the mRNA-1273 vaccine in 27 adult PD patients and recorded breakthrough infections. Furthermore, in a mixed model analysis, we analyzed potential factors influencing the humoral response following vaccination. Anti-SARS-CoV-2 RBD antibody levels declined from 21,424 BAU/mL at 1 month to 8397 BAU/mL at 3 months and to 5120 BAU/mL at 6 months after the 3rd dose, but remained higher than pre-3rd dose levels (212 BAU/mL). Eight patients (29.6%) were infected with SARS-CoV-2 within six months from the 3rd dose during the Omicron wave. Previous high antibody levels, high glomerular filtration rate (GFR) and low Davies Comorbidity Score were associated with higher anti-SARS-CoV-2 antibody levels after the booster. In conclusion, PD patients exhibited a robust and durable humoral response after a third dose of the mRNA-1273 vaccine. A high GFR and low comorbidity as well as previous high antibody levels predicted a better humoral response to vaccination.

Impact of COVID-19 on maintenance peritoneal dialysis patients and providers: A review

The COVID-19 pandemic exerted complex pressures on the nephrology community. Despite multiple prior reviews on acute peritoneal dialysis during the pandemic, the effects of COVID-19 on maintenance peritoneal dialysis patients remain underexamined. This review synthesizes and reports findings from 29 total cases of chronic peritoneal dialysis patients with COVID-19, encompassing 3 case reports, 13 case series, and 13 cohort studies. When available, data for patients with COVID-19 on maintenance hemodialysis are also discussed. Finally, we present a chronological timeline of evidence regarding the presence of SARS-CoV-2 in spent peritoneal dialysate and explore trends in telehealth as they relate to peritoneal dialysis patients during the pandemic. We conclude that the COVID-19 pandemic has underscored the efficacy, flexibility, and utility of peritoneal dialysis.

Efficacy and safety of booster vaccination against SARS-CoV-2 in dialysis and renal transplant patients: systematic review and meta-analysis

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.

Vaccination and mortality from COVID-19: a comparative study between hemodialysis, peritoneal dialysis, and non-dialysis adult population in Panama

PURPOSE

Dialysis patients have a different response than the non-dialysis population to infection with COVID-19. This study evaluates the prevalence of infection and lethality in patients receiving hemodialysis or peritoneal dialysis in Panama, compared to non-dialysis adult population, and reports of adverse events of vaccination.

METHODS

This is a prospective, multi-center cohort study of spatients aged 18 years or older and receiving in-center hemodialysis or ambulatory peritoneal dialysis in 13 centers in Panama from March 2021 to 2022. For comparison with general population, the study used an extended period of two years.

RESULTS

A total of 1531 patients receiving dialysis treatment accepted to participate. PD patients represented an 18% of study patients. Lethality was higher in peritoneal dialysis patients with COVID-19 infection than in hemodialysis in the study group (p 0.02). Total deaths in dialysis patients for 2020 were 156 patients, before vaccination; 79 in 2021; and 25 for the first trimester of 2022. Lethality for the period of 2020-2022 was 9.3% for dialysis patients and 0.2% for non-dialysis population. There was no difference in symptoms in first dose, but with second dose, hemodialysis patients reported fewer symptoms than peritoneal dialysis patients (p < 0.0001).

CONCLUSION

Ninety one percent of people in the country received BNT162b2 Pfizer BionTech vaccine. Lethality decreased from 30 to 5% once vaccination was available. There were no severe adverse effects and symptoms reported were less frequent than in general population, probably due to low reactogenicity in dialysis patients, or better tolerance to pain.

Immunogenicity Rates after SARS-CoV-2 Three-Dose Vaccination in Patients under Dialysis: A Systematic Review and Meta-Analysis

BACKGROUND

Considering the indeterminate effects following the administration of three doses of the SARS-CoV-2 vaccine to patients under dialysis, the present study aimed to evaluate the immunogenicity rates of patients who received the three-dose vaccine.

METHODS

MEDLINE, Web of Science, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register for Controlled Trials were searched to select the relevant literature to perform the present review. We included randomized controlled trials, non-randomized trials, prospective, observational cohort, and case-control studies to assess the humoral and cellular immune responses following the administration of the three-dose SARS-CoV-2 vaccine to patients receiving dialysis.

RESULTS

Overall, 38 studies are included in the meta-analysis presented in this paper. For patients on dialysis, the overall humoral antibody response rate is 97% following three doses of mRNA or viral vector vaccines and 100% following four doses of the SARS-CoV-2 vaccine. A subgroup analysis shows that the antibody response rate is 96% for patients on hemodialysis (HD) and 100% for those receiving peritoneal dialysis (PD). The antibody response rate in the different immunogen-vaccinated groups tends to be higher than that in the same immunogen-vaccinated group (99% vs. 96%). For those who exhibit no response following two doses of the vaccine, the third and fourth doses can elevate the antibody response rate to 81%, and that number for low responders increases to 96%. However, the pooled results obtained from the relatively few trials conducted indicate that the positive T-cell response rate only increases to 59% following three doses of the vaccine. The antibody response rate is not different between dialysis and non-dialysis groups (relative risk = 0.95, 95% CI 0.90-1.02) following three doses of the vaccine. The relative risks for a SARS-CoV-2 breakthrough infection, all-cause mortality, and hospital admissions are 0.59 (95% CI 0.30-1.04), 0.63 (95% CI 0.35-1.12), and 0.53 (95% CI 0.37-0.74), respectively, when comparing three doses with two doses of the vaccine administered to the dialysis population.

CONCLUSIONS

The third or fourth dose of the SARS-CoV-2 vaccine significantly increases the immunogenicity rates in dialysis patients, and this beneficial effect does not vary with the type of vaccine (the same or different immunogen vaccination), dialysis modality (HD or PD), or previous low response following the administration two doses of the vaccine. We believe that healthcare workers should encourage patients receiving dialysis to receive a third or fourth vaccine dose to strengthen their immunity against SARS-CoV-2.

Long-Term Dynamic Humoral Response to SARS-CoV-2 mRNA Vaccines in Patients on Peritoneal Dialysis

Introduction. Patients on peritoneal dialysis (PD) present an impaired humoral response against SARS-CoV-2, at least after the initial vaccination and booster dose. Until now, the effect of a fourth dose has not been established. The aim of the present study is to evaluate the long-term dynamics of the humoral response of PD patients to multiple doses of SARS-CoV-2 vaccines, focusing on the effect of the fourth dose. Methods. This is an analysis of the prospective and multicentric SENCOVAC study. We included patients on PD without additional immunosuppression that had received at least 3 SARS-CoV-2 mRNA vaccine doses. We evaluated anti-spike antibody titers after the initial vaccination, third and fourth doses, using prespecified fixed assessments (i.e., baseline, 28 days, 3, 6, and 12 months after completing the initial vaccine schedule). Breakthrough infections were also collected. Results. We included 164 patients on PD (69% males, 62 ± 13 years old). In patients who had received only two doses, the rates of positive humoral response progressively decreased from 96% at 28 days to 80% at 6 months, as did with anti-spike antibody titers. At 6 months, 102 (62%) patients had received the third vaccine dose. Patients with the third dose had higher rates of positive humoral response (p = 0.01) and higher anti-spike antibody titers (p < 0.001) at 6 months than those with only 2 doses. At 12 months, the whole cohort had received 3 vaccine doses, and 44 (27%) patients had an additional fourth dose. The fourth dose was not associated to higher rates of positive humoral response (100 vs. 97%, p = 0.466) or to statistically significant differences in anti-spike antibody titers as compared to three doses (p = 0.371) at 12 months. Prior antibody titers were the only predictor for subsequent higher anti-spike antibody titer (B 0.53 [95%CI 0.27−0.78], p < 0.001). The 2 (1.2%) patients that developed COVID-19 during follow-up had mild disease. Conclusions. PD presents an acceptable humoral response with three doses of SARS-CoV-2 vaccines that improve the progressive loss of anti-spike antibody titers following two vaccine doses.