key: cord-0693530-eurrpp66 authors: Giot, Matthieu; Fourié, Toscane; Lano, Guillaume; Villarroel, Paola Mariela Saba; de Lamballeri, Xavier; Gully, Marion; Samson, Laurent; Farault, Julien; Bouchouareb, Dammar; Jehel, Océane; Brunet, Philippe; Jourde-Chiche, Noémie; Ninove, Laetitia; Robert, Thomas title: Spike and neutralizing antibodies response to COVID-19 vaccination in hemodialysis patients date: 2021-07-06 journal: Clin Kidney J DOI: 10.1093/ckj/sfab128 sha: d6129b2ce1960ad6adcfa0fd688961ce7beeec36 doc_id: 693530 cord_uid: eurrpp66 BACKGROUND: Humoral response to the SARS-COV-2 vaccines needs to be evaluated in the fragile population of patients on maintenance hemodialysis. METHODS: We analyzed the antibody response to the spike (S) antigen of SARS-CoV-2 before and after each dose of the mRNA Comirnaty Vaccine (BNT162b2; BioNTech & Pfizer) in patients from a single dialysis center, and detected the presence of neutralizing antibodies. RESULTS: Among the 90 vaccinated HD patients (mean age 69 years, 61% male), 19 (21%) had a history of SARS-CoV-2 infection. A seroconversion with anti-S IgG antibodies (Sab) was documented in 20% of patients after the first dose (early responders) and in 77% after the second dose, while 23% were non-responders. Cardiac disease, cirrhosis and gamma-globulin levels were independently predictive of the absence of seroconversion. Neutralizing antibodies (Nab) were detected in 15% of early responders after the first dose, and in 90% of early responders and 58% of late responders after the second dose. Sab titers after the second dose were higher in patients with Nab than without Nab (598 [IQR, 246-882] versus 134 [IQR, 61-390], p < 0.0001). All patients with a history of SARS-CoV-2 infection developed both Sab and Nab, and their titers of Sab and Nab were higher than in late responders CONCLUSIONS: Most HD patients develop a substantial humoral response against SARS-COV2, with neutralizing antibodies, following the mRNA vaccine. Whether this immunity persists over time, and is able to efficiently protect patients from COVID-19, remains to be determined. The coronavirus disease 2019 which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has emerged in China in December 2019 and was declared as pandemic by WHO in March 2020. Chronic hemodialysis (HD) patients have a 20-30% risk of death in case of COVID-19 [1] [2] [3] . The messenger RNA-based Comirnaty Vaccine (BNT162b2; BioNTech and & Pfizer) has been developed and approved in Europe in December 2020 4 . Given the vulnerability of HD patients to SARS-CoV-2 severe infection, international guidelines call for priority vaccination of HD patients 5, 6 . In a population of in-center HD patients, we recently documented the favorable safety profile of the Comirnaty vaccine administration during the dialysis session regarding bleeding risk 7 . However, since HD patients were broadly excluded from Phase 3 studies evaluating efficacy and safety of COVID-19 vaccines, the determinants of antibody responses to vaccine remain poorly understood in this specific population. In particular, no data is currently available on the ability of vaccinated patients' serum to inhibit SARS-CoV-2 replication (sero-neutralization ability). HD patients are known to commonly exhibit an impaired immune response against pathogens and vaccines. For example, detectable humoral responses following virus hepatitis B (VHB) vaccine are estimated at 69% in HD patients, and at 30-80% following influenza vaccine, which is far lower than in the general population 8, 9 . Unexpectedly, a recent study in Israël showed a detectable sero-conversion (circulating antispike IgG antibody (Sab)) with the Comirnaty Vaccine in a vast majority of hemodialysis patients (96.4 %) 10 . This report has been confirmed in others HD patient cohort [11] [12] [13] . Interestingly, older age and lower lymphocyte counts were associated with lower response to vaccine. Concerning the neutralizing ability after the seroconversion, a recent report suggests that about one third of HD patients develop neutralizing antibodies (Nab), at low titers, after the first dose of Comminarty vaccine. 14 Furthermore, another team showed that HD patients are able to generate efficient T cell immunity by SARS-CoV-2 reactive T cells 15 . Here, we present results of the serological response follow-up of HD patients receiving the Comirnaty vaccine in our HD centre. We studied Nab and Sab before and following vaccination. The study included HD patients who accepted and received the BNT162b2 (Pfizer-BioNTech) vaccination with the recommended dosing interval of 21 days between the first and second 4 doses. All patients included in this study received the first dose on February 10 th and 11 th and the second dose on March 24 th and 25 th . Patients with a history of symptomatic COVID-19 documented by PCR received only one vaccine dose. Patients with a history of asymptomatic COVID-19 (documented either by rapid serological test in the past 12 months or a positive serology the day of the vaccination) received two doses of vaccine three weeks apart. Exclusion criteria were age < 18 years, active or recent COVID (in the past 3 months). As part of the care, we monitored serological response to vaccination in this population considered at risk of severe COVID. Serum samples were obtained from all included patients at the beginning of the dialysis session the day of the vaccination, the day of the second dose and at least 3 weeks after the second dose. For the previously infected symptomatic HD patients, serum samples were obtained at the beginning of the dialysis session the day of the vaccination and at least 3 weeks and 6 weeks after the single dose vaccine. The data included in this study were anonymized, approved according to General Data Protection Regulation and registered at the Health Data Portal and Data Protection Commission of APHM under the PADS references X8RF2T. The patients were provided with oral information about this study. Sera samples were tested for anti-SARS-CoV-2 IgG antibodies directed against the S1 domain of the spike protein of the virus using a commercial ELISA kit (Euroimmun, Lübeck, Germany) and quantitative results were expressed in standardised units (binding antibody units (BAU) per mL 16 ) as recommended by the manufacturer. For all samples with a semi-quantitative ratio result ≥0.7, neutralizing antibodies against SARS-CoV-2 were detected using a virus neutralization test (VNT100), with 4 dilutions of each serum (1/20 to 1/160) as previously described 17, 18 . Seropositive patients were defined by detectable Sab. We defined as early responders patients who were seropositive after the first vaccine dose, as late responders patients who were seropositive after the second dose, and as non-responders patients with the absence of seroconversion after two doses. The following patients' baseline characteristics were collected from electronic medical records: age, gender, body mass index (BMI), obesity (BMI>30 kg/m2), previous transplantation and history or active cancer and classical comorbidities. Their significant usual treatments [corticosteroids and immunosuppressive therapies] were also registered. We collected the routine trimestral blood test monitoring (complete blood count, albuminemia, gammaglobulin level, C-reactive protein (CRP), Predialysis Beta-2-microglobulinemia) results from March 2021. Hypogammaglobulinemia was defined as a gammaglobulin level below 8 g/L assessed 5 by serum protein electrophoresis. Lymphopenia was defined as a lymphocyte count below 1.2 G/L. Serum albumin level was measured by immunonephelemetry. Virus hepatits B (VHB) responders were defined by the presence of Hbs antibodies after VHB vaccination. Continuous and categorical variables were presented as median [interquartile range (IQR)] or mean (standard error) and n (%), respectively. We used the Mann-Whitney U-test, χ² test or Fisher's exact test to compare differences between groups when appropriate. All test were two-tailed. Multiple logistic regression analysis was used to determine whether each variable was an independent factor for vaccine response. Covariates of interest for the multivariate logistic regression analysis were selected based on a p value < 0.1 in a univariate analysis. Performance accuracy of the ELISA test to predict effective seroneutralization was assessed using the receiver operating characteristic area under curve (ROC AUC). Cut-off values showing the greatest accuracy were determined using sensitivity/specificity. A value of p < 0.05 was considered statistically significant. The data were analyzed using Prism software (GraphPad Prism Software, San Diego, CA, USA) and JMP Pro V14 software. From March to April 2021, 90 HD patients were vaccinated against SARS-CoV-2 in our centre. Among the nineteen (21.1%) previously infected HD patients: eleven were symptomatic and eight were asymptomatic. Baseline characteristics are presented in Table 1 . Mean age was 68.9 years (±13.7), 54 (60%) patients were male. The mean dialysis vintage was 5.9 years (±8.7). 7 (7.8%) HD patients were treated with corticosteroid and/or immunosuppressant, and 30 (33.3%) had a previous history of organ transplantation and/or history or active cancer; 31 (35.2%) patients had hypogammaglobulinemia and 49 (54.4%) had lymphopenia. Before the first vaccine dose, none of the HD patients had detectable Sab. After the first vaccine dose, a seroconversion was observed in 13/65 (20%) HD patients (early responder group). 3 weeks after the second dose (late responder group) a seroconversion was observed in 54/70 (77.1%), while among those tested16/70 (22.8%) were non-responders (Figure 1 ). Nab were detected in 15.4% of the early responder group after the first dose, and increased to 84.6 % after the second dose. In the late responder group, Nab were detected in 57.9% of patients after the second dose ( Figure 2) . In this group, median Sab titers were higher in patients with Nab (597. 8 Figure 3 ). Non-responders were more likely to be treated with corticosteroid and/or immunosuppressants, to have chronic respiratory disease, ischemic/rhythmic cardiac disease, cirrhosis and a previous transplantation and/or history or active cancer compared to responders ( Table 2) . Gamma-globulin levels were significantly lower in non-responders (7.3 (±0.8) g/L) compared to responders (early responder group, 11.1 (±0.8) g/L; late responder group, 9.1 (±0.5) g/L) (p=0.006). Standard Binary Logistic Regression to predict vaccine response show that ischemic/rhythmic cardiac disease, cirrhosis and Gamma-globulin levels were independently associated with the absence of seropositivity ( Table 3) . Among the 19 previously infected HD patients, 11 (57.9%) patients had a persistent Sab seropositivity before the first vaccine dose. They were younger, tended to have a shorter time between SARS-CoV-2 infection and the vaccine day (120.5 [IQR, 87.5 to 239] vs 275 [IQR, 169.5 to 317.8] days, p=0.061) and a higher pre-dialysis Beta-2-microglobulin level than 7 patients in whom Sab were undetectable at the time of the first vaccine dose ( Table 4) . Six weeks after the vaccination, all the patients had both detectable Sab and Nab. We observed a significant difference for both Sab and Nab titers respectively, between the previously infected HD patients ( (Figure 4) . Conversely, no significant difference for both Sab and Nab titers was observed in previously infected HD patients compared to the previously uninfected early responder HD patients (median level, 3121 [IQR, 2028 to 4255] BAU/ml and 160 [IQR, 80 to 160 ] dilution level). (Figure 4) . In the current study, we report the step-by-step humoral response analysis following COVID-19 vaccination with the Cominarty vaccine in HD patients. To our knowledge, we are the first to described the efficacy of COVID-19 vaccine in a HD patients with both Sab and Nab titer 10 . Grupper et al reported a good efficacy in dialysis patients, about 96%, comparable to the results of the pivotal trial. However, in their cohort, Sab were lower in HD patients than in healthy controls. In our HD patient's cohort, the overall immunogenicity of the Cominarty vaccine three weeks after the last dose is 100% and 77.2% in those with and without a history of SARS-CoV-2 infection, respectively. We could provide the first data related to the evolution of humoral response after the first and the second vaccine doses according to COVID-19 history in HD patients and showed that only 20% HD patients developed IgG antibody response to the spike antigen after the first dose, but 77 % after the second dose. This serologic profile allows us to conclude to the immunogenicity of the vaccination scheme with two doses in COVID-19-naïve HD patients. Immunogenicity was yet lower in the present cohort than in the recent findings reported by Grupper et al in Israel, which could be due in part to the absence of knowledge on previous SARS-CoV-2 infection in their cohort, and/or to the older age and higher burden of comorbidities in patients from our center 10 . The overall humoral response of our patients is close from that reported in a recent study in which previous COVID-19 disease was documented before the vaccination 13 . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Interestingly, only three fourths of the seropositive patients had detectable neutralizing antibodies after two vaccine doses. Whether seropositive whose sera display no effective seroneutralization ability are efficiently protected against COVID-19, or remain at high risk and could benefit from a third dose of vaccine, remains to be elucidated. Indeed, our study highlighted some factors that can predict a lower response to vaccination. First, treatment with gamma-globulin levels was associated with lower response to vaccination, as reported in transplant recipients 19 . Second, ischemic/rhythmic cardiac disease and cirrhosis seems also associated with lower response. Unexpectedly, others factors like corticosteroid, immunosuppressant and age were not independently associated with a lower response but should be interpreted with caution given the small size of the study. It has been recently reported that the humoral response against SARS-CoV-2 in the general population with history of SARS-CoV-2 infection is greater than the response in previously uninfected patients who have received a second dose. 20 Our study shows that the early responder HD patients have similar Sab and Nab titers after the second dose compared to the previously infected HD patients. Furthermore, the late responders have significant lower Sab and Nab titer after the second dose compared to the early responder and the previously infected HD patients. These findings provide evidence that in previously uninfected patients, a third dose seems necessary in 18 % of our HD patient's cohort. It is unclear how the Nab titers protect against the COVID-19 disease and influence the ability of the host to transmit the virus. Accordingly, it remains to be determined if the late responders without Nab need a third vaccine dose. Our study can allow an improvement of the vaccination strategy in HD patients. Serological survey of the COVID-19-naïve HD patients may allow rational third vaccine dose prescription by identifying non-responders after two doses. In HD patients with a history of symptomatic COVID-19, we show 100% of seropositivity after a single dose, as observed in the general population. Whether patients with history of asymptomatic COVID need 2 doses remain to be determined. HD patients develop a substantial humoral immune response following mRNA vaccination. Protection afforded by SARS-CoV-2 seropositivity, kinetics of antibodies and serological basis usable to establish correlates of protection remain to be clarified in this high-risk population. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 20 In each box-and-whisker plot, the horizontal line represents the median, the top and bottom of the box the interquartile range, and the whiskers the minimum and maximum values. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Risk factors for severity of COVID-19 in chronic dialysis patients from a multicentre French cohort Results from the ERA-EDTA Registry indicate a high mortality due to COVID-19 in dialysis patients and kidney transplant recipients across Europe COVID-19-related mortality in kidney transplant and dialysis patients: results of the ERACODA collaboration Chronic kidney disease is a key risk factor for severe COVID-19: a call to action by the ERA-EDTA The urgent need to vaccinate dialysis patients against severe acute respiratory syndrome coronavirus 2: a call to action High Prevalence of Asymptomatic COVID-19 Infection in Hemodialysis Patients Detected Using Serologic Screening Vaccination against COVID-19 in a haemodialysis centre: what is the risk of bleeding complications? 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