Humoral Response in Hemodialysis Patients Following COVID-19 Vaccination and Breakthrough Infections during Delta and Omicron Variant Predominance

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.

Immunogenicity and Safety of the Three-Dose COVID-19 Vaccine Regimen in Patients Receiving Renal Replacement Therapy: A Systematic Review and Meta-Analysis

Background

A three-dose regimen is the current standard for COVID-19 vaccination, but systematic data on immunogenicity and safety in chronic kidney disease patients remains limited.

Objectives

We conducted a meta-analysis on the immunogenicity and safety of three-dose COVID-19 vaccination in patients on renal replacement therapy (RRT).

Methods

Systematic literature search in four electronic databases yielded twenty eligible studies (2,117 patients, 94% of whom received mRNA vaccines) for meta-analysis.

Results

The overall seropositivity rate of anti-SARS-CoV-2 was 74.2% (95% CI: 65.0-83.4%) after three-dose COVID-19 vaccination. The seropositivity rate of anti-SARS-CoV-2 in kidney transplant recipients (KTRs) was 64.6% (95% CI: 58.7-70.5%), and 43.5% (95% CI: 38.5-48.6%) of non-responders after second dose became seropositive after third dose. The seropositivity rate of anti-SARS-CoV-2 was 92.9% (95% CI: 89.5-96.2%) in dialysis patients, and 64.6% (95% CI: 46.8-82.3%) of non-responders after second dose became seropositive after third dose. In KTRs, each year increase in transplant vintage was associated with 35.6% increase in anti-SARS-CoV-2 seropositivity (95% CI: 15.9-55.4%, p = 0.01). There were no serious adverse events attributed to vaccination in KTRs, and the commonest local and systemic adverse events were injection site pain and fatigue, respectively.

Conclusion

Three-dose COVID-19 vaccination regimen in patients on RRT is associated with reduced immunogenicity, especially in KTRs. There are no adverse events associated with third-dose COVID-19 vaccine in KTRs.

Two versus three doses of COVID-19 vaccine and post-vaccination COVID-19 infection in hemodialysis patients

Background and aim

Patients with chronic kidney disease including those undergoing hemodialysis (HD) constitute a particularly challenging group regarding COVID-19 vaccination. The present study aimed to compare the rate of reinfection after two and three doses of Sinopharm COVID-19 vaccine in HD patients.

Patients and methods

The study included 80 HD patients who received three doses of Sinopharm COVID-19 vaccine. In addition, there were another 80 patients who received only two doses of the vaccine. Patients in the latter group were selected based on propensity matching score with 1:1 ratio. Patients were monitored for post-vaccination COVID-19 infection using PCR examination of nasopharyngeal swabs. Patients were also monitored for post-vaccination complications including general complaints (headache, fever, fatigue), injection site complaints (arm pain, swelling, itching, rash), musculoskeletal complaints (muscle spasm or pain, joint pain) and others. All patients were followed for six months.

Results

The present study included 80 patients submitted to COVID-19 vaccination with two doses of Sinopharm vaccine (GI) and other 80 patients who received three doses of the same vaccine (GII). At the end of follow up, 11 patients (13.8 %) in GI caught COVID-19 infection. In contrast, no patient in GII had infection (P<0.001). Comparison between patients who had COVID-19 infection and those without infection revealed that the former subgroup had significantly lower BMI (23.3 ± 2.3 versus 27.5 ± 8.1 Kg/m2), higher frequency of associated Hepatitis C (HCV) infection (54.6 % versus 2.9 %, P<0.001) and higher serum ferritin levels [median (IQR): 1101.0 (836.0-1564.0) versus 675.0 (467.0-767.7) ng/mL, P=0.01]. Binary logistic regression analysis identified high serum ferritin levels [OR (95% CI): 0.014 (0.001-0.15), P<0.001] and associated HCV infection [OR (95% CI): 0.99 (0.98-1.01), P=0.02] as significant predictors of post-vaccination COVID-19 infection in multivariate analysis.

Conclusions

A three dose regime of Sinopharm COVID-19 vaccine associated with significantly lower rate of reinfection COVID-19 infection in HD patients. Infected patients had significantly lower BMI, higher frequency of HCV and higher ferritin levels.

Humoral and cellular immunity against different SARS-CoV-2 variants in patients with chronic kidney disease

Chronic kidney disease (CKD) patients are at higher risk of severe COVID-19. Humoral and cellular immunity from prior infection or vaccination are important for protection, but the neutralizing antibody (nAb) response against SARS-CoV-2 variants is impaired. We investigated the variant-specific nAb and T cell immunity among CKD patients. Adult CKD patients were recruited between August and October 2022. nAb against the SARS-CoV-2 (ancestral strains and four Omicron sublineages) and T cell response were measured using the live virus neutralization assay and interferon-gamma release assay (IGRA). The correlation between nAb/T-cell response and subsequent infection after recruitment were also determined. Among the 88 recruited patients, 95.5% had prior infection or had completed the primary vaccine series. However, only 77.3% had detectable nAb against at least one SARS-CoV-2 strains, 59.1% tested positive in IGRA, and 52.3% had detectable nAb and tested positive in the IGRA. The nAb geometic mean titers (GMTs) against XBB.1, BA.5 and BA.2.3.20 were significantly lower than those against BA.2 and ancestral strain. Prior SARS-CoV-2 infection was associated with elevated nAb and T cell response. More kidney transplant recipients (KTRs) showed absent nAb and T cell response (36.8% vs. 10.1%), despite a higher prevalence of vaccine booster in this population (94.7% vs. 50.7%). Lower levels of nAb titer and T cell response were significantly associated with subsequent infection. A considerable proportion of CKD patients, especially KTRs, showed absence of humoral and cellular protective immunity against SARS-CoV-2. Strategies to improve immunogenicity in this population are urgently needed.

Response to Immunization against SARS-CoV-2 and Risk of Omicron Infection in Dialysis Patients: A Prospective Cohort Study

It is not well established to what extent previous immunizations offer protection against infections with the SARS-CoV-2 Omicron variant in dialysis patients. We aimed to define the relevant humoral response in dialysis patients using a SARS-CoV-2 IgG chemiluminescence microparticle immunoassay (CMIA) compared to the activity of neutralizing antibodies assessed by a virus neutralization test. Next, we aimed to determine differences in humoral and cellular response levels over time among patients infected or not infected by the Omicron variant of SARS-CoV-2. Immunological parameters of cellular and humoral response to SARS-CoV-2 were analyzed at baseline and after 3 (T3), 6 (T6) and 14 months (T14). In this monocentric cohort study, we followed 110 dialysis patients (mean age 68.4 ± 13.7 years, 60.9% male) for a median of 545 days. We determined an anti-SARS-CoV-2 IgG level of 56.7 BAU/mL as an ideal cut-off value with a J-index of 90.7. Patients infected during the Omicron era had significantly lower (p < 0.001) mean antibody levels at T0 (3.5 vs. 111.2 BAU/mL), T3 (269.8 vs. 699.8 BAU/mL) and T6 (260.2 vs. 513.9 BAU/mL) than patients without Omicron infection. Patients who developed higher antibody levels at the time of the basic immunizations were less likely to become infected with SARS-CoV-2 during the Omicron era. There is a need to adjust the cut-off values for anti-SARS-CoV-2 IgG levels in dialysis patients.

The predictive markers of severity and mortality in hospitalized hemodialysis patients with COVID-19 during Omicron epidemic

INTRODUCTION

Predictive markers and prognosis remain unclear in hospitalized hemodialysis (HD) patients with coronavirus disease 2019 (COVID-19) during the Omicron epidemic.

METHODS

We evaluated characteristics, laboratory parameters, and outcomes in hospitalized HD patients with COVID-19 (n = 102) at two centers between January and April 2022.

RESULTS

The 30-day mortality rate was higher in moderate-critical group (n = 43) than mild group (n = 59) (16.3% vs. 1.7%; p = 0.007), and higher in patients with lower CC chemokine ligand 17 (CCL17) levels (<95.0 pg/mL) compared with normal CCL17 levels (19.0% versus 4.9%; p = 0.03). In multivariate analyses, a low CCL17 level (p = 0.003) was associated with moderate-critical conditions, and moderate-critical conditions (p = 0.04) were associated with 30-day mortality, whereas CCL17 was not associated with 30-day mortality.

CONCLUSIONS

COVID-19 remains a fatal complication, and CCL17 was a predictive marker of severity in hospitalized HD patients during the Omicron epidemic.

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.

Correlation of Breakthrough Infection During the Omicron Wave With Seropositivity of Vaccinated Patients Undergoing Hemodialysis

Background

Patients with chronic kidney disease and undergoing hemodialysis are at greater risk of developing COVID-19. In spite of vaccine efficacy, SARS-CoV-2 breakthrough infection has been reported in several studies. This study was carried out to assess if seroconversion could predict SARS-CoV-2 breakthrough infection in a cohort of vaccinated patients undergoing hemodialysis.

Methodology

Patients undergoing maintenance hemodialysis for at least three months and who had received two doses of BBV152 or AZD1222 vaccine were included in the study. Their baseline IgG antibodies to SARS-CoV-2 were measured and followed up for a median of three months during the third wave of COVID-19 in India with SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) to detect breakthrough infections.

Results

Of 80 patients enrolled, seroconversion was seen in 81% of the cases, and SARS-CoV-2 breakthrough cases have been detected in 16% (13/80; 95% CI 8.95-26.18) patients undergoing hemodialysis. Of the 13 patients, seven patients required hospitalization and others had a mild outcome. There was no correlation of baseline seropositivity with breakthrough infections or hospitalization.

Conclusions

A majority of patients who underwent hemodialysis are seropositive post-vaccination. The breakthrough infection did not correlate with baseline seroconversion. Thus, there would be other predictors of breakthrough COVID-19 infections that need to be recognized in this susceptible population.

Increasing Uptake of COVID-19 Vaccination and Reducing Health Inequalities in Patients on Renal Replacement Therapy-Experience from a Single Tertiary Centre

BACKGROUND

COVID-19 vaccination has changed the landscape of the COVID-19 pandemic; however, decreased uptake due to vaccine hesitancy has been observed, particularly in patients from minority ethnic backgrounds and socially deprived areas. These patient characteristics are common in patients on Renal Replacement Therapy (RRT), a population at extremely high risk of developing serious illness from COVID-19 and who would thus benefit the most from the vaccination programme. We designed a bespoke COVID-19 vaccination programme for our RRT population with the aim of decreasing health inequalities and increasing vaccination uptake.

METHODS

Key interventions included addressing vaccine hesitancy by deploying the respective clinical teams as trusted messengers, prompt eligible patient identification and notification, the deployment of resources to optimise vaccine administration in a manner convenient to patients, and the timely collection and analysis of local safety and efficacy data. First, COVID-19 vaccination data in relation to ethnicity and social deprivation in our RRT population, measured by the multiple deprivation index, were analysed and compared to uptake data in the total regional adult clinically extremely vulnerable (CEV) population in Greater Manchester (GM). Univariate logistic regression analysis was used to explore the factors associated with not receiving a vaccine.

RESULTS

Out of 1156 RRT patients included in this analysis, 96.7% received the first dose of the vaccination compared to 93% in the cohort of CEV patients in the GM. Age, gender, ethnicity, and a lower index of multiple deprivation were not identified as significant risk factors for poor first dose vaccine uptake in our cohort. Vaccine uptake in Asian and Black RRT patients was 94.9% and 92.3%, respectively, compared to 93% and 76.2% for the same ethnic groups in the reference CEV GM. Vaccine uptake was 96.1% for RRT patients in the lowest quartile of the multiple deprivation index, compared to 90.5% in the GM reference population.

CONCLUSION

Bespoke COVID-19 vaccination programmes based on local clinical teams as trusted messengers can improve negative attitudes towards vaccination and reduce health inequalities.

Effect of Third and Fourth mRNA-Based Booster Vaccinations on SARS-CoV-2 Neutralizing Antibody Titer Formation, Risk Factors for Non-Response, and Outcome after SARS-CoV-2 Omicron Breakthrough Infections in Patients on Chronic Hemodialysis: A Prospective Multicenter Cohort Study

The aim of this study is to determine the effect of repeated vaccinations on neutralizing SARS-CoV-2 IgG antibody titers, evaluate risk factors for immunological non-response, and to report breakthrough infections in chronic hemodialysis patients. Methods: A prospective, multi-center cohort study in 163 chronic hemodialysis patients was conducted. Antibody titers were measured three months after second, third, and fourth (10 pts) booster vaccinations. SARS-CoV-2 neutralizing antibody titers in BAU/mL and % inhibition were divided into three categories (<216, 216–433, >433 and <33, 33–66, and >66%). Somers’s test, paired t-test, and univariable and multivariable logistic regression analysis were applied to evaluate differences in antibody levels and search for risk factors for vaccination failure defined as neutralizing titers <50% and/or need for repeated booster vaccinations. Furthermore, we report on a case series to describe characteristics of patients after four vaccinations (n = 10) and breakthrough infections (n = 20). Results: Third dose boosters resulted in higher proportions of patients with neutralizing antibody levels >66% as compared to after the second dose (64.7% after second dose vs. 88.9% after third dose, p = 0.003), as well as in a respective increase in neutralizing titer levels in % from 68 ± 33% to 89 ± 24 (p < 0.001). The proportion of patients with IgG-titers below 216 BAU/mL decreased from 38.6 to 10.5% (p ≤ 0.001). Age (p = 0.004, OR 1.066, 95% CI 1.020–1.114) and presence of immunosuppressive medications (p = 0.002, OR 8.267, 95% CI 2.206–30.975) were identified as major risk factors for vaccination failure. Repeated booster vaccinations ≥4 times were effective in 8 out of 10 former low-responders (80%) without any side effects or safety concerns. Breakthrough infections showed a clinically mild course but were associated with prolonged viral shedding on PCR-testing ranging 7–29 (mean 13) days. Conclusions: Third and fourth mRNA-based booster vaccinations resulted in higher and longer lasting SARS-CoV-2 antibody levels as compared to after two dosages. The presence of immunosuppressive medication and repeat vaccinations are major potentially modifiable measures to increase antibody levels in non-or low-responders. Breakthrough infections with SARS-CoV-2 Omicron were associated with prolonged viral shedding but clinically mild disease courses.