COVID-19 in kidney transplantation-implications for immunosuppression and vaccination

Abstract

COVID-19 pandemic continues to challenge the transplant community, given increased morbidity and mortality associated with the disease and poor response to prevention measures such as vaccination. Transplant recipients have a diminished response to both mRNA and vector-based vaccines compared to dialysis and the general population. The currently available assays to measure response to vaccination includes commercially available antibody assays for anti-Spike Ab, or anti- Receptor Binding Domain Ab. Positive antibody testing on the assays does not always correlate with neutralizing antibodies unless the antibody levels are high. Vaccinations help with boosting polyfunctional CD4+ T cell response, which continues to improve with subsequent booster doses. Ongoing efforts to improve vaccine response by using additional booster doses and heterologous vaccine combinations are underway. There is improved antibody response in moderate responders; however, the ones with poor response to initial vaccination doses, continue to have a poor response to sequential boosters. Factors associated with poor vaccine response include diabetes, older age, specific immunosuppressants such as belatacept, and high dose mycophenolate. In poor responders, a decrease in immunosuppression can increase response to vaccination. COVID infection or vaccination has not been associated with an increased risk of rejection. Pre- and Post-exposure monoclonal antibodies are available to provide further protection against COVID infection, especially in poor vaccine responders. However, the efficacy is challenged by the emergence of new viral strains. A recently approved bivalent vaccine offers better protection against the Omicron variant.

BNT162b2 Elicited an Efficient Cell-Mediated Response against SARS-CoV-2 in Kidney Transplant Recipients and Common Variable Immunodeficiency Patients

“…Similarly, IgG production in vaccinated CVID and KTR patients was lower than hybrid immunized patients. Regarding cellular immune response, there is growing evidence showing that cellular immune response is much more preserved in solid organ transplant recipients than humoral immunity [ 24 ].…”

“…Similarly, IgG production in vaccinated CVID and KTR patients was lower than hybrid immunized patients. Regarding cellular immune response, there is growing evidence showing that cellular immune response is much more preserved in solid organ transplant recipients than humoral immunity [24]. Some authors showed a severely impaired humoral response in immunodepressed and immunosuppressed patients even after several exposures of vaccine, but with a strong T-cell response.…”

Prevention and treatment strategies for kidney transplant recipients in the context of long-term existence of COVID-19

“…Vaccine administration was found to reduce the mortality rate among SARS-CoV-2-infected KTRs ( 100 , 101 ). Mosconi et al ( 102 ) also confirmed the efficacy of COVID-19 vaccines in managing the risk of infection and enhancing clinical outcomes in individuals with compromised immune systems.…”

Seroconversion and safety of Covid-19 vaccines in patients with chronic liver disease and liver transplant: A systematic review

“…Covid-19 results in a strong humoral and cellular immune response. 18 Antibodies (IgG and IgM) are classically detected in the second week of symptom onset, with IgM antibody appearing first and IgG being the most durable. Among the Covid-19 structural proteins, the Spike (S) and the Nucleocapsid (N) proteins are the main immunogens.…”