Hesitancy toward the Full COVID-19 Vaccination among Kidney, Liver and Lung Transplant Recipients in Italy

COVID-19 Vaccine Perception in Liver Transplant Recipients: Patient-Reported Outcomes and Real-Life Experience from the Bergamo Center

BACKGROUND

Bergamo was the most severely affected Italian province at the onset of the 2020 COVID-19 pandemic. The liver transplant (LT) patient population should be among the more sensitized to the concept of health prevention. Long-term data on both perception and outcomes of SARS-CoV-2 vaccination in LT recipients since the COVID-19 vaccine became available in Italy are still lacking.

METHODS

From May to October 2023, a survey on actively followed LT recipients at our institution was carried on by the local patient' advocacy (Associazione Amici del Trapianto di Fegato) to define the rate of vaccinated subjects, SARS-CoV-2 infections and self-reported COVID-19-related outcomes.

RESULTS

Out of the consecutive 753 adult LT recipients invited to the survey, 356 responded (47.3%) [71% male, 63 years old (20-85), LT performed a mean of 9 years (1-26) before vaccination] and were included in the analysis. All patients received the first vaccine dose between December 2020 and January 2022 (81.7% Cominarty®, 17.7% Spikevax®, 0.3% Vaxzevria® and 0.3% Jcovden®). In the following years, adherence to the vaccination policy decreased progressively over time: the second, third, fourth, and fifth vaccine doses were administered to 99%, 94%, 72%, and 22% of the LT population by October, 2023. In total, 43 (12%) and 93 (26%) patients reported a COVID-19 episode before and after [13 (7-21) months] the first vaccination, respectively; none of the LT recipients reported a second COVID-19 infection after the following vaccination cycles. Forty-six (13%) reported short-term post-vaccination mild adverse events but none developed either acute or chronic rejection episodes or hospitalization for COVID-19-related symptoms. A total of 64% of LT recipients resulted positive for anti-nucleocapsid serological test in 2023.

CONCLUSIONS

COVID-19 vaccines are safe and effective in LT recipients, underlining once again the importance of vaccination in this special population at higher risk of complications from communicable infectious diseases.

High Rate of Antibody Response to Multiple Doses of the COVID-19 Vaccine in Liver Transplant Recipients: Analysis of Predictive Factors

BACKGROUND

The COVID-19 pandemic highlighted the vulnerability of immunocompromised individuals, including liver transplant recipients (LTRs), who often exhibit reduced vaccine immunogenicity. While initial vaccine doses and subsequent boosters improved immune response, LTRs were prioritized for vaccination. Studies have shown increased antibody response after each booster dose. Vaccine hesitancy, defined as delayed or refused vaccination despite availability, poses a public health challenge, often fueled by misinformation. This study aimed to evaluate anti-spike antibody responses in vaccinated LTRs after two initial doses and at least one booster, also assessing adherence to subsequent doses.

METHODS

We conducted a retrospective observational study at a transplant center in Milan, Italy, between January 2021 and December 2023. LTRs who had received four or more doses of mRNA vaccines (Pfizer or Moderna) were included. Anti-spike antibody levels were measured 60-80 days after each dose. Data on vaccination status were collected in January 2024. Statistical analysis was performed to compare antibody responses and identify predictive factors.

RESULTS

LTRs showed a significant increase in anti-spike antibody responses after the first booster compared to the second dose with a trend versus a further increase following the fourth dose in a subgroup of the patients receiving two booster doses. However, adherence to booster doses decreased over time. In LTRs, predictors of a weaker response after the second dose were chronic kidney disease and metabolic etiology at transplant.

CONCLUSIONS

The study highlighted that in LTRs, multiple doses of the COVID-19 vaccine led to a continuous increase in anti-spike antibody responses. The progressive decline in adherence of LTRs "to further booster doses" should be related to the fact that after the spread of vaccination programs worldwide, COVID-19 is still a current infection, but it is much less severe than before.

Perceptions of COVID-19 Vaccination Among Organ Transplant Recipients

BACKGROUND

Understanding COVID-19 vaccine hesitancy in organ transplant recipients (OTRs) is critical given clear-albeit attenuated-benefits from vaccination.

METHODS

Adult OTRs were surveyed regarding sociodemographic data, medical history, and vaccine-related values. A novel outcome variable called the Vaccine Acceptance Composite Score (VACS) was built as the average Likert score of seven domains of vaccine confidence. To examine its association with several factors and individual adherence to COVID-19 vaccine recommendations, univariable odds ratios and relative operating characteristic areas under the curve (AUC) values were calculated.

RESULTS

Of 46 OTRs included, 32.6% identified as female, 13.3% as Black, and 6.77% as Hispanic or Latino/a/x. The median age was 58 years old. 93.5% of patients were kidney transplant recipients, and 63.0% previously had COVID-19. Patients were most concerned about COVID-19 vaccine-associated risks (46.3%), its potential effect on allograft (47.6%), and motives of government officials involved with vaccine policy (55.6%). Politically conservative patients were likelier to have lower VACS, whereas those who lived with someone ≥65 years old were likelier to have higher VACS. The VACS was not significantly associated with race, income, religious beliefs, comorbidities, COVID-19 history, or influenza vaccination status. Higher VACS was associated with ≥3 and ≥4 COVID-19 immunizations.

CONCLUSIONS

This study highlighted political beliefs and elderly household members as correlates of vaccine acceptance among OTRs. The VACS may be a useful tool to help standardize multifaceted analyses in vaccination-focused behavioral research. In clinical practice, it could help identify individuals and groups at risk for vaccine hesitancy, who may benefit from tailored outreach and educational interventions.

Impact of cultural diversity on COVID-19 vaccination hesitancy in kidney transplant recipients

AIM

To study COVID-19 vaccination status in kidney transplant recipients (KTRs), reasons for incomplete vaccination and the clinical impact of vaccination on patient outcomes.

METHODS

A single-centre retrospective analysis of KTR (n = 543) conducted between 1970 and December 2022. Data included baseline demographics, number of vaccinations, reason for incomplete vaccination and patient outcomes following COVID-19 infection. A completed course of COVID-19 vaccination was defined as four or more vaccine doses.

EXCLUSION CRITERIA

those deceased prior December 2019, managed by another health service, failed graft, or deceased secondary to non-COVID cause.

RESULTS

273 of 543 patients met inclusion criteria. Mean age was 58.1 ± 12.2 years, 66% were male. 58.2% of patients were fully vaccinated, 22.7% received three doses, 7.7% received two doses, 0.7% received one dose, 0.7% received zero doses, and 10% incomplete records. The most common reasons for incomplete vaccination were COVID-19 infection, concern for side effects, and patient unawareness of booster recommendations. Vaccination uptake was greater in Australian born patients compared with those born overseas, odds ratio 0.40 (95% CI 0.23-0.69). KTR with incomplete vaccination had poorer outcomes, higher rate of AKI, long COVID, and increased hospitalization.

CONCLUSION

The majority of KTR were fully vaccinated. KTR with incomplete vaccination status had poorer outcomes with COVID-19 infection and other issues. Patient education is a major area for improvement targeting patients born overseas and better information regarding side effects. Potential interventions need to address improved communication, cultural relevancy, and language.

Clinical Features and Prognostic Predictors in Patients with Renal Transplant Complicated by SARS-CoV-2 Infection, a Retrospective Single-Center Study

Background

This study examines the clinical outcomes and prognostic factors of COVID-19 in renal transplant recipients. Given their immunosuppressed status, these patients are at higher risk of severe complications from COVID-19. The study aims to provide healthcare professionals with critical insights for diagnosing and managing this vulnerable population.

Patients and methods

This retrospective cohort study included adult renal transplant recipients diagnosed with COVID-19. Data on demographics, medical history, laboratory results, and patient outcomes were analyzed to identify clinical characteristics and prognostic factors.

Results

This study included 115 renal transplant recipients with COVID-19, predominantly male, with a mortality rate of 10.4% (12 deaths). The overall vaccination rate was 20%. Univariate analysis showed significant differences between survivors and non-survivors in initial serum creatinine levels, and percentages of neutrophils, monocytes, and lymphocytes, along with CRP levels on day 3. Additionally, CRP levels, hemoglobin, and platelet counts on day 7 also differed significantly. Multivariate analysis identified CRP levels on days 3 and 7, day 7 hemoglobin and platelet counts, and concurrent bacterial infections as independent risk factors for mortality.

Conclusion

Elevated CRP levels, renal impairment, and bacterial co-infections play a significant role in the outcomes of COVID-19 in kidney transplant recipients. This study highlights the importance of monitoring these factors for early identification and management of high-risk patients.

Long-Term Assessment of Antibody Response to COVID-19 Vaccination in People with Cystic Fibrosis and Solid Organ Transplantation

With the worldwide spread of SARS-CoV-2 disease, people with cystic fibrosis (CF), especially solid organ transplant recipients, have quickly been identified as a risk group for severe disease. Studies have shown low antibody response to SARS-CoV-2 vaccines in recipients of solid organ transplant compared to the healthy population. Information on immune response in CF patients with solid organ transplantation is limited, especially regarding long-term efficacy. The aim of this real-world study was a long-term assessment of humoral immune response induced by three and four doses of the SARS-CoV-2 mRNA vaccine. S1RBD and IgG antibodies were measured every 12 weeks over a period of 27 months in twelve CF patients (five liver and seven lung transplantation recipients). A total of 83.3% of our patients showed a positive antibody response after three doses of the SARS-CoV-2 mRNA vaccine. A sustained immune response was observed in both groups over the observation period, with liver transplant recipients showing higher levels than lung transplant recipients. This study is among the first to show long-term data with constantly elevated or even increasing antibody levels. We conclude that this effect is most likely associated with repeated boostering in terms of infections and booster vaccinations.

Understanding Concerns about COVID-19 and Vaccination: Perspectives from Kidney Transplant Recipients

The COVID-19 pandemic poses a significant risk for immunosuppressed groups such as transplant patients. The purpose of this study was to improve our understanding of the impact of the COVID-19 pandemic on kidney transplant recipients, including their views on COVID-19 vaccination. Semi-structured interviews were conducted from December 2021 to August 2022 with 38 kidney transplant recipients who had an appointment with their transplant care team within the previous 6 months. We used qualitative thematic analysis to characterize the perspectives of interviewees. Regardless of COVID-19 vaccination status, most interviewees reported utilizing public health measures such as masking, hand washing, and avoiding crowds to protect themselves against COVID-19. Vaccinated interviewees (n = 31) noted that they chose to receive a COVID-19 vaccine because of their increased risk due to their immunocompromised state. For unvaccinated interviewees (n = 7), reasons for not receiving a COVID-19 vaccine included concerns about the safety and efficacy of the vaccine. Both vaccinated and unvaccinated interviewees expressed concerns about the lack of adequate testing of the vaccine in transplant patients and questioned if the vaccine might have unknown side effects for transplant recipients. Regardless of the vaccination status, most interviewees noted having trust in their healthcare team. Interviewees also described interpersonal tensions that arose during the pandemic, many of which surrounded vaccination and other preventive measures that were important to participants to protect their health. Together, these data demonstrate differing concerns and experiences related to the COVID-19 pandemic for vaccinated and unvaccinated transplant recipients. These findings highlight the unique needs of transplant recipients and reveal opportunities to support this vulnerable patient population in efforts to protect their health as the COVID-19 pandemic evolves.

Effect of COVID-19 Pandemic on Patients Who Have Undergone Liver Transplantation Because of Hepatocellular Carcinoma

BACKGROUND AND AIM

Many clinical studies have shown that the COVID-19 case fatality rate is higher in older patients, those with comorbidities, those with immunosuppressive conditions, and those who stay in the intensive care unit. This study aims to evaluate the clinical outcomes of 66 liver transplant (LT) patients with primary liver cancer who were exposed to COVID-19 infection.

METHODS

Demographic and clinical data of 66 patients with primary liver cancer (hepatocellular carcinoma = 64, hepatoblastoma = 1, cholangiocarcinoma = 1) who underwent LT in our institute and were exposed to COVID-19 infection between March 2020 and November 2021 were analyzed in this cross-sectional study. The following data of the patients were recorded: age, sex, body mass index (kg/m2), blood group, underlying primary liver disease, smoking, tumor characteristics, post-transplant immunosuppressive agents, COVID-19 symptoms, hospitalization, intensive care unit stay, intubation, and other clinical features.

RESULTS

There were 55 (83.3%) male and 11 (16.7%) female patients, with a median age of 58 years. Sixty-four patients were exposed to COVID-19 only once, whereas the remaining 2 patients were exposed 2 and 4 times, respectively. After exposure to COVID-19, it was determined that 37 patients used antiviral drugs, 25 were hospitalized, 9 were followed in the intensive care unit, and 3 were intubated. One intubated patient was under hospital follow-up because of biliary complications before exposure to COVID-19, and this patient died from sepsis.

CONCLUSION

The low mortality rate of LT patients with primary liver cancer exposed to COVID-19 infection can be attributed to background immunosuppression that prevents cytokine storm. However, it is appropriate to support this study with multicenter studies to make strong comments on this issue.

Managing the "Sword of Damocles" of Immunosuppression: Prevention, Early Diagnosis, and Treatment of Infectious Diseases in Kidney Transplantation

The careful tailoring of the most appropriate immunosuppressive strategy for recipients of a kidney transplant (KT) regularly faces a risk of complications that may harm the actual graft and affect patient survival [...].