SARS-CoV-2 Infection After Full Vaccination in Kidney Transplant Recipients.

Abstract

Since the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), several vaccines have been developed and approved for human use in the United States and Europe.1 In our center, coronavirus disease 2019 (COVID-19) vaccination of kidney transplant recipients (KTRs) started in February 2021, with about 800 KTRs fully vaccinated in May 2021. Among the different vaccines, mRNA vaccines BNT162b2 (Pfizer/BioNTech) and mRNA-1273 (Moderna) have demonstrated an effectiveness of up to 95% in preventing COVID-19 in immunocompetent population. However, the effectiveness in KTRs to induce an immunological response has been reported to be significantly lower (up to 65%), and information about the risk and severity of a postvaccination COVID-19 is scarce in these patients.1-6 Herein, we describe 21 cases of KTRs (20 KTRs and 1 simultaneous pancreas-kidney recipient) who developed a polymerase chain reaction–proven COVID-19 after a full vaccination course. The study was approved by the ethics committee from our center. From the 21 KTRs, 2 patients (9%) received a 2-dose regimen of the BNT162b2 vaccine and 19 (91%) the mRNA-1273 vaccine. Only 1 patient (5%) developed SARS-CoV-2 immunoglobulin G antibodies after vaccination (which were assessed >15 d after the second dose). All patients were diagnosed with COVID-19 through a nasopharyngeal swab after a mean time of 84.71 ± 27.43 d from the second vaccine dose (52% with pneumonia). SARS-CoV-2 variants could be determined in 5 patients: 2 patients were infected with the Alpha variant and 3 with the Delta one. Table 1 summarizes demographic, transplantation immunosuppression, and COVID-19 characteristics of the analyzed patients. Two patients (9%) were asymptomatic. TABLE 1. - Demographic, transplantation, and COVID-19 characteristics of the analyzed patients Kidney transplant recipients (n = 21) Gender, male 9 (43) Age at COVID-19 diagnosis, y 57.61 ± 11.96 Transplant type Kidney transplant 20 (95) Simultaneous pancreas-kidney transplant 1 (5) Time from transplant to COVID-19 diagnosis, y 3.79 (1.83–13.12) Induction immunosuppression No induction 6 (29) Basiliximab 6 (29) Thymoglobulin 9 (42) Maintenance immunosuppression Tacrolimus 21 (100) Mycophenolate 15 (71) Everolimus 6 (29) Prednisone 21 (100) SARS-CoV-2 vaccine BNT162b2, Pfizer/BioNTech 2 (9) mRNA-1273, Moderna 19 (91) SARS-CoV-2 IgG antibodies after vaccination, yes 1 (5) Time from second vaccine dose to COVID-19 diagnosis, d 84.71 ± 27.43 SARS-CoV-2 variant Alpha 2 (9) Delta 3 (14) Symptoms at COVID-19 diagnosis Asymptomatic 2 (9) Fever 16 (76) Cough 11 (52) Dyspnea 8 (38) Diarrhea 4 (19) Patient hospital admission, yes 11 (52) ICU admission with MV, yes 6 (29) COVID-19 treatment Dexamethasone 6 (29) Remdesivir 5 (24) Remdesivir plus baricitinib 1 (5) Remdesivir plus anakinra 1 (5) Tocilizumab 3 (14) ≥1 immunosuppressant withdrawn, yes 16 (76) Patient outcomes Discharged 13 (62) Dead 1 (5) Hospital stay, d 11 (7–20) Data are presented as mean ± SD, median (IQR), or n (%), unless otherwise specified.COVID-19, coronavirus disease 2019; ICU, intensive care unit; IgG, immunoglobulin G; IQR, interquartile range; MV, mechanical ventilation; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. Regarding patient management, 11 patients (52%) required hospital admission, and 7 (33%) required intensive care unit (ICU) admission with the need for mechanical ventilation in 6. Ten (48%) were managed as outpatients (Table 1). Of the 21 patients, 1 (5%) died, 7 (33%) are still admitted (5 of them in the ICU), and 13 (62%) have been already discharged. Current median hospital stay is 11 (7–20) d. With this letter, we would like to provide preliminary information about a single-center kidney transplant population in Spain after a full COVID-19 vaccination regimen and reinforce the apparently less efficient immunization effect that COVID-19 vaccines provide in KTRs and the need to vaccinate their close relatives, as well as to still maintain precautions against COVID-19 in this population (especially against the Delta variant), even after full vaccination course. Nevertheless, actual hospital and ICU admission rates are lower compared with a nonvaccinated cohort of KTRs (79% and 52% for hospital and ICU admission, respectively) from our center. Larger studies are needed to provide robust information on the prognosis and management of KTRs with COVID-19 after vaccination, as well as the potential need for a third dose to increase the immunization rate.