POS0256 CLINICAL PREDICTORS OF ATTENUATED ANTIBODY RESPONSE TO PRIMARY SARS-CoV-2 VACCINATION IN A LARGE PROSPECTIVE STUDY OF PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background

An attenuated humoral response to SARS-CoV-2 vaccination has been observed in some patients with rheumatic and musculoskeletal diseases (RMD) (1). We sought to identify clinical factors associated with poor humoral response following primary (two-dose mRNA or single adenoviral vector dose) SARS-COV-2 vaccination in patients with RMD on immunosuppression.

Objectives

To identify clinical predictors of an attenuated antibody response to primary SARS-CoV-2 vaccination in RMD patients on immunosuppression.

Methods

We included patients ≥18 years old with RMD on immunosuppression who received either two-dose mRNA or single dose Janssen/Johnson and Johnson (J&J) vaccination. Demographics, diagnoses, and therapeutic regimens were collected via participant report; those with prior COVID-19 infection were excluded. One month after vaccination, participants underwent SARS-CoV-2 antibody testing on the semi-quantitative Roche Elecsys anti-SARS-CoV-2 S enzyme immunoassay, which measures antibody to the SARS-CoV-2 S-receptor binding domain (RBD) protein (ceiling >250U/mL later expanded to >2500U/mL). Associations were evaluated using Fisher’s exact and Wilcoxon rank sum tests. Logistic regression analyses were performed to evaluate for clinical factors associated with antibody response. We adapted survival methods to address right-truncation of titers; this methodology was used to calculate medians. Participants provided informed consent electronically and the study was approved by the local Institutional Review Board.

Results

We studied 1138 RMD participants on immunosuppression; most were female (93%) and white (91%) (Table 1). One-hundred and fifteen (10%) had anti-RBD response in the negative range at a median (IQR) of 29 days (28-34) following completion of vaccine series. A greater proportion of participants with negative response were non-white, received J&J vaccine, reported use of mycophenolate, rituximab, or glucocorticoids. Antibody response differed by immunosuppressive regimen, with those receiving rituximab having poorest response (Figure 1). Use of mycophenolate (aOR 9.92, p=0.001), rituximab (aOR 56.99, p=0.001), glucocorticoids (aOR 2.99, p=0.001) or receipt of J&J (aOR 3.13, p=0.039) were associated with negative antibody response.

Table 1.

Clinical characteristics stratified by anti-SARS-CoV-2 RBD response

Negative (n=115)*Positive (n=1023)*p-value†Age,median(IQR)49(42, 58)47(37, 58)0.07Female sex,no.(%)108(94%)952(93%)0.78Non-white,no.(%)16(13.9%)83(8.1%)0.04Diagnosis,no.(%)Inflammatory arthritis22(19.1%)469(45.8%)<0.01SLE27(23.5%)193(18.9%)0.27Sjὅgren’s syndrome5(4.3%)46(4.5%)0.53Myositis13(11.3%)49(4.8%)<0.01Systemic sclerosis2(1.7%)9(0.9%)0.55Vasculitis12(10.4%)16(1.6%)<0.01Overlap connective tissue disease¶34(29.5%)24(23.6%)0.65  Vaccine,no.(%) Pfizer/BioNTech66(57.4%)548(53.6%)0.01Moderna38(33.0%)438(42.8%)J&J11(9.6%)37(3.6%)Non-biologic in regimen89(77.4%)725(70.9%)0.52Biologic in regimen84(73.0%)570(55.7%)0.01 Mycophenolate**56(48.7%)120(11.7%)<0.01 Rituximab54(47.0%)29(2.8%)<0.01 Glucocorticoid**61(53.0%)284(27.8%)<0.01Withheld immunosuppression18(21.2%)260(39.6%)<0.01

* Negative defined as anti-RBD titer <0.8 U/mL.

† Comparisons between negative and positive groups.

¶ Denotes a combination of two or more of the above conditions

** Mycophenolate: mycophenolic acid and mycophenolate mofetil. Corticosteroid: prednisone and prednisone equivalents

Figure 1.

Conclusion

Use of mycophenolate, glucocorticoids, rituximab and receipt of J&J vaccine were the strongest predictors of an attenuated antibody response to primary SARS-CoV-2 vaccination; these data support use of an additional primary dose in RMD patients.

References

[1]Deepak P, Kim W, Paley MA, et al. Effect of Immunosuppression on the Immunogenicity of mRNA Vaccines to SARS-CoV-2: A Prospective Cohort Study. Ann Intern Med. 2021.

Acknowledgements

We would like to acknowledge the contributions of: Brian J. Boyarsky MD, PhD, Jake A. Ruddy BS, and Jacqueline M. Garonzik-Wang MD PhD.

Disclosure of Interests

Caoilfhionn Connolly: None declared, Teresa Po-Yu Chiang: None declared, Mayan Teles: None declared, Sarah Frey: None declared, Jennifer Alejo: None declared, Allan Massie: None declared, Lisa Christopher Stine Consultant of: Janssen, Boehringer-Ingelheim, Mallinckrodt, EMD-Serono, Allogene, and ArgenX., William Werbel: None declared, Dorry Segev Speakers bureau: Sanofi, Novartis, CSL Behring, Jazz Pharmaceuticals, Veloxis, Mallincrodt, Thermo Fisher Scientific, Regeneron, and Astra-Zeneca, Consultant of: Sanofi, Novartis, CSL Behring, Jazz Pharmaceuticals, Veloxis, Mallincrodt, Thermo Fisher Scientific, Regeneron, and Astra-Zeneca, Julie Paik: None declared

Recipient age and outcomes following simultaneous pancreas-kidney transplantation in the new millennium: Single-center experience and review of the literature

The influence of recipient age on outcomes following simultaneous pancreas-kidney transplantation (SPKT) in the modern era is uncertain.

METHODS

We retrospectively studied 255 patients undergoing SPKT from 11/01 to 8/20. Recipients were stratified according to age group: age <30 years (n = 16); age 30-39 years (n = 91); age 40-49 years (n = 86) and age ≥50 years (n = 62 [24.3%], including 9 patients ≥60 years of age).

RESULTS

Three-month and one-year outcomes were comparable. The eight-year patient survival rate was lowest in the oldest age group (47.6% vs 78% in the 3 younger groups combined, p < .001). However, eight-year kidney and pancreas graft survival rates were comparable in the youngest and oldest age groups combined (36.5% and 32.7%, respectively), but inferior to those in the middle 2 groups combined (62% and 50%, respectively, both p < .05). Death-censored kidney and pancreas graft survival rates increased from youngest to oldest recipient age category because of a higher incidence of death with functioning grafts (22.6% in oldest group compared to 8.3% in the 3 younger groups combined, p = .005).

CONCLUSIONS

Recipient age did not appear to significantly influence early outcomes following SPKT. Late outcomes are similar in younger and older recipients, but inferior to the middle 2 age groups.

General and acute care surgical procedures in patients with left ventricular assist devices

BACKGROUND

Left ventricular assist devices (LVADs) have become common as a bridge to heart transplant as well as destination therapy. Acute care surgical (ACS) problems in this population are prevalent but remain ill-defined. Therefore, we reviewed our experience with ACS interventions in LVAD patients.

METHODS

A total of 173 patients who received HeartMate(®) XVE or HeartMate(®) II (HMII) LVADs between December 2001 and March 2010 were studied. Patient demographics, presentation of ACS problem, operative intervention, co-morbidities, transplantation, complications, and survival were analyzed.

RESULTS

A total of 47 (27 %) patients underwent 67 ACS procedures at a median of 38 days after device implant (interquartile range 15-110), with a peri-operative mortality rate of 5 % (N = 3). Demographics, device type, and acuity were comparable between the ACS and non-ACS groups. A total of 21 ACS procedures were performed emergently, eight were urgent, and 38 were elective. Of 29 urgent and emergent procedures, 28 were for abdominal pathology. In eight patients, the cause of the ACS problem was related to LVADs or anticoagulation. Cumulative survival estimates revealed no survival differences if patients underwent ACS procedures (p = 0.17). Among HMII patients, transplantation rates were unaffected by an ACS intervention (p = 0.2).

CONCLUSIONS

ACS problems occur frequently in LVAD patients and are not associated with adverse outcomes in HMII patients. The acute care surgeon is an integral member of a comprehensive approach to effective LVAD management.

Experiences obtaining insurance after live kidney donation

The impact of kidney donation on the ability to change or initiate health or life insurance following donation is unknown. To quantify this risk, we surveyed 1046 individuals who donated a kidney at our center between 1970 and 2011. Participants were asked whether they changed or initiated health or life insurance after donation, and if they had any difficulty doing so. Among 395 donors who changed or initiated health insurance after donation, 27 (7%) reported difficulty; among those who reported difficulty, 15 were denied altogether, 12 were charged a higher premium and 8 were told they had a preexisting condition because they were kidney donors. Among 186 donors who changed or initiated life insurance after donation, 46 (25%) reported difficulty; among those who reported difficulty, 23 were denied altogether, 27 were charged a higher premium and 17 were told they had a preexisting condition because they were kidney donors. In this single-center study, a high proportion of kidney donors reported difficulty changing or initiating insurance, particularly life insurance. These practices by insurers create unnecessary burden and stress for those choosing to donate and could negatively impact the likelihood of live kidney donation among those considering donation.

Transient nonketotic hyperglycinaemia: ultrasound, CT and MRI: case report

We report a case of transient nonketotic hyperglycinaemia in which radiography correlated closely with clinical and biochemical findings. Only 5 patients have been previously described with this transient from of nonketotic hyperglycinaemia. Among the radiographic findings, thinning of the corpus callosum is the most characteristic.

[Non-ketotic hyperglycinemia. Transient neonatal form]

We report a patient with neonatal epilepsy, with no pattern of burst-suppression, secondary to the transient form of nonketotic hyperglycinemia. Biochemical normalization at two weeks of age was followed by a good clinical evolution and neurological normality at one year of age. The patient showed markedly retarded myelination and microcysts in the frontal white matter, both transitory and with subsequent neuroradiological normalization. Only five patients have been previously described with this clinical variant, there being suspicion of a glycine cleavage system deficiency due to neonatal enzymatic immaturity.