Should vaccination against COVID-19 be mandated in patients on the transplant waiting list?
Authors: Didier Ducloux, Cécile Courivaud
Journal: Kidney International (2021)

Concordant studies report a very high mortality rate during coronavirus disease 2019 (COVID-19) infection in kidney transplant recipients (KTRs). The 30-day cumulative incidence of death is 18% in a French national cohort.1Caillard S. Chavarot N. Francois H. et al.French SOT COVID RegistryIs COVID-19 infection more severe in kidney transplant recipients?.Am J Transplant. 2021; 21: 1295-1303Crossref PubMed Scopus (179) Google Scholar Another study reported a mortality incidence of 32% among KTRs hospitalized for COVID-19 infection.2Cravedi P. Mothi S.S. Azzi Y. et al.COVID-19 and kidney transplantation: results from the TANGO International Transplant Consortium.Am J Transplant. 2020; 20: 3140-3148Crossref PubMed Scopus (299) Google Scholar Just as misfortunes never come one at a time, these patients, along with having vulnerability to infection, experienced a low rate of immunization after complete vaccination.3Grupper A. Rabinowich L. Schwartz D. et al.Reduced humoral response to mRNA SARS-CoV-2 BNT162b2 vaccine in kidney transplant recipients without prior exposure to the virus.Am J Transplant. 2021; 21: 2719-2726Crossref PubMed Scopus (282) Google Scholar,4Rozen-Zvi B. Yahav D. Agur T. et al.Antibody response to SARS-CoV-2 mRNA vaccine among kidney transplant recipients: a prospective cohort study.Clin Microbiol Infect. 2021; 27: 1173.e1-1173.e4Abstract Full Text Full Text PDF Scopus (165) Google Scholar Moreover, cases of severe COVID-19 occurring after complete vaccination have been reported in KTRs.5Caillard S. Chavarot N. Bertrand D. et al.French Society of TransplantationOccurrence of severe COVID-19 in vaccinated transplant patients.Kidney Int. 2021; 100: 477-479Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar By contrast, dialysis patients, even when older and frail, have a robust and sustained response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine.6Jahn M. Korth J. Dorsch O. et al.Humoral response to SARS-CoV-2 vaccination with BNT162b2 (Pfizer-BioNTech) in patients on hemodialysis.Vaccines (Basel). 2021; 9: 360Crossref PubMed Scopus (77) Google Scholar, 7Frantzen L, Cavaille G, Thibeaut S, El-Haik Y. Efficacy of the BNT162b2 mRNA Covid-19 vaccine in a hemodialysis cohort [e-pub ahead of print]. Nephrol Dial Transplant. https://doi.org/10.1093/ndt/gfab165Google Scholar, 8Lacson E, Argyropoulos CP, Manley HJ, et al. Immunogenicity of SARS-CoV-2 vaccine in dialysis [preprint]. medRxiv. https://doi.org/10.1101/2021.04.08.21254779Google Scholar, 9Danthu C, Hantz S, Dahlem A, et al. Humoral response after SARS-Cov-2 mRNA vaccination in a cohort of hemodialysis patients and kidney transplant recipients [e-pub ahead of print]. J Am Soc Nephrol. https://doi.org/10.1681/ASN.2021040490Google Scholar, 10Simon B, Rubey H, Treipl A, et al. Haemodialysis patients show a highly diminished antibody response after COVID-19 mRNA vaccination compared to healthy controls [e-pub ahead of print]. Nephrol Dial Transplant. https://doi.org/10.1093/ndt/gfab179Google Scholar, 11Ducloux D, Colladant M, Chabannes M, et al. Humoral response after 3 doses of BNT162b2 mRNA COVID-19 vaccine in patients on hemodialysis. Kidney Int. 2021;100:702–704.Google Scholar, 12Longlune N, Nogier MB, Miedougé M, et al. High immunogenicity of a messenger RNA–based vaccine against SARS-CoV-2 in chronic dialysis patients [e-pub ahead of print]. Nephrol Dial Transplant. https://doi.org/10.1093/ndt/gfab193Google Scholar, 13Kwok H.F. Review of COVID-19 vaccine clinical trials—a puzzle with missing pieces.Int J Biol Sci. 2021; 17: 1461-1468Crossref PubMed Scopus (38) Google Scholar Even though hemodialysis patients may have significantly lower anti–SARS-CoV-2 S antibody titers than do healthy individuals,10Simon B, Rubey H, Treipl A, et al. Haemodialysis patients show a highly diminished antibody response after COVID-19 mRNA vaccination compared to healthy controls [e-pub ahead of print]. Nephrol Dial Transplant. https://doi.org/10.1093/ndt/gfab179Google Scholar we reported that a third dose enhanced the humoral response in almost all patients.11Ducloux D, Colladant M, Chabannes M, et al. Humoral response after 3 doses of BNT162b2 mRNA COVID-19 vaccine in patients on hemodialysis. Kidney Int. 2021;100:702–704.Google Scholar Thus, it is possible that patients vaccinated after transplantation would have only a 1 in 2 chance of responding as expected to the vaccine. Risks associated with mRNA vaccines are low. In randomized studies, the frequency of serious and severe adverse events (SAEs) was similar for vaccinated participants and those who received a placebo.13Kwok H.F. Review of COVID-19 vaccine clinical trials—a puzzle with missing pieces.Int J Biol Sci. 2021; 17: 1461-1468Crossref PubMed Scopus (38) Google Scholar A very recent study reports only 33 SAEs (0.005%) after 704,003 first doses of mRNA vaccine.14García-Grimshaw M. Ceballos-Liceaga S.E. Hernández-Vanegas L.E. et al.Neurologic adverse events among 704,003 first-dose recipients of the BNT162b2 mRNA COVID-19 vaccine in Mexico: a nationwide descriptive study.Clin Immunol. 2021; 229: 108786Crossref PubMed Scopus (74) Google Scholar In 7 studies, including 820 dialysis patients,6Jahn M. Korth J. Dorsch O. et al.Humoral response to SARS-CoV-2 vaccination with BNT162b2 (Pfizer-BioNTech) in patients on hemodialysis.Vaccines (Basel). 2021; 9: 360Crossref PubMed Scopus (77) Google Scholar, 7Frantzen L, Cavaille G, Thibeaut S, El-Haik Y. Efficacy of the BNT162b2 mRNA Covid-19 vaccine in a hemodialysis cohort [e-pub ahead of print]. Nephrol Dial Transplant. https://doi.org/10.1093/ndt/gfab165Google Scholar, 8Lacson E, Argyropoulos CP, Manley HJ, et al. Immunogenicity of SARS-CoV-2 vaccine in dialysis [preprint]. medRxiv. https://doi.org/10.1101/2021.04.08.21254779Google Scholar, 9Danthu C, Hantz S, Dahlem A, et al. Humoral response after SARS-Cov-2 mRNA vaccination in a cohort of hemodialysis patients and kidney transplant recipients [e-pub ahead of print]. J Am Soc Nephrol. https://doi.org/10.1681/ASN.2021040490Google Scholar, 10Simon B, Rubey H, Treipl A, et al. Haemodialysis patients show a highly diminished antibody response after COVID-19 mRNA vaccination compared to healthy controls [e-pub ahead of print]. Nephrol Dial Transplant. https://doi.org/10.1093/ndt/gfab179Google Scholar, 11Ducloux D, Colladant M, Chabannes M, et al. Humoral response after 3 doses of BNT162b2 mRNA COVID-19 vaccine in patients on hemodialysis. Kidney Int. 2021;100:702–704.Google Scholar, 12Longlune N, Nogier MB, Miedougé M, et al. High immunogenicity of a messenger RNA–based vaccine against SARS-CoV-2 in chronic dialysis patients [e-pub ahead of print]. Nephrol Dial Transplant. https://doi.org/10.1093/ndt/gfab193Google Scholar, 13Kwok H.F. Review of COVID-19 vaccine clinical trials—a puzzle with missing pieces.Int J Biol Sci. 2021; 17: 1461-1468Crossref PubMed Scopus (38) Google Scholar no SAEs were reported. Although very low, the incidence of SAEs is obviously not zero. Nevertheless, this concern has to be balanced with the high morbidity and mortality incidence of COVID-19 in dialysis patients.15Ng J.H. Hirsch J.S. Wanchoo R. et al.Outcomes of patients with end-stage kidney disease hospitalized with COVID-19.Kidney Int. 2020; 98: 1530-1539Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar A recent report indicated that 20% of hemodialysis patients were hesitant to seek out the COVID-19 vaccine.16Garcia P, Montez-Rath ME, Moore H, et al. SARS-CoV-2 vaccine acceptability in patients on hemodialysis: a nationwide survey [e-pub ahead of print]. J Am Soc Nephrol. https://doi.org/10.1681/ASN.2021010104Google Scholar The proportion increased to 29% in patients aged 18–44 years. A majority of hesitancy was due to concerns about side effects. For these patients, the main source of information on the COVID-19 vaccine was television, and not dialysis-center staff.16Garcia P, Montez-Rath ME, Moore H, et al. SARS-CoV-2 vaccine acceptability in patients on hemodialysis: a nationwide survey [e-pub ahead of print]. J Am Soc Nephrol. https://doi.org/10.1681/ASN.2021010104Google Scholar Providing better information regarding vaccine safety is a major issue for physicians. It should be also noted that vaccine hesitancy is substantially reduced if the vaccine is offered at a dialysis facility. Thus, the role of dialysis centers is crucial in patient adherence to vaccination guidance. Respect of personhood and autonomy of choice are fundamental principles of health care. The right to decline vaccination cannot be denied, but patients must know all consequences of their choice. Patients often perceive risks differently from physicians. Hesitant individuals consider that they are at low risk of COVID-19 infection while being at high risk of suffering adverse effects from the vaccine. Communication based on empowerment and trust should be brought to the forefront of the battle against the disease. An open reflection and discussion about the issues of anti–COVID-19 vaccination for patients on the transplant waiting list are necessary to facilitate both patients' information gathering and decision-making and physician guidance of hesitant patients. Whether vaccination should be a prerequisite for referral to a waiting list is a difficult question to answer, and related issues regarding patients' rights, physicians' knowledge, and societal issues are intertwined, creating the dilemma we currently face. Humoral response after 3 doses of the BNT162b2 mRNA COVID-19 vaccine in patients on hemodialysisKidney InternationalVol. 100Issue 3PreviewDialysis patients are at increased risk of severe coronavirus disease 2019 (COVID-19) infections.1 Therefore, they are considered as being a priority population for COVID-19 vaccination. Because immune responses against vaccines are considerably reduced in this population,2 a vaccination strategy including 3 doses of vaccine has been recommended for dialysis patients. However, few data exist concerning humoral response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination with 3 doses of BNT162b2 (Pfizer–BioNTech) in patients on hemodialysis (HD). Full-Text PDF Outcomes of patients with end-stage kidney disease hospitalized with COVID-19Kidney InternationalVol. 98Issue 6PreviewGiven the high risk of infection-related mortality, patients with end-stage kidney disease (ESKD) may be at increased risk with COVID-19. To assess this, we compared outcomes of patients with and without ESKD, hospitalized with COVID-19. This was a retrospective study of patients admitted with COVID-19 from 13 New York hospitals from March 1, 2020, to April 27, 2020, and followed through May 27, 2020. We measured primary outcome (in-hospital death), and secondary outcomes (mechanical ventilation and length of stay). Full-Text PDF Occurrence of severe COVID-19 in vaccinated transplant patientsKidney InternationalVol. 100Issue 2PreviewVaccination plays a paramount role in the current coronavirus disease 2019 (COVID-19) pandemic response. Although mRNA-based vaccines elicit a strong immune response in the general population, the immunization rates of immunocompromised patients—including solid organ transplant recipients—have not been specifically investigated in mRNA-1273 and BNT162b2 pivotal trials.1,2 This knowledge gap should be addressed urgently, as these patients are highly prone to developing severe COVID-19. Full-Text PDF