“But what is liberty without wisdom, and without virtue? It is the greatest of all possible evils; for it is folly, vice, and madness, without tuition or restraint.”
Edmund Burke
Twenty months after the World Health Organization officially declared coronavirus disease 2019 (COVID-19) a pandemic, 22 medical professionals at the University Hospital Heidelberg, Germany, put forth a paper with important findings on COVID-19 vaccine effectiveness among immunosuppressed kidney transplant recipients. The authors of “Neutralization of SARS-CoV-2 Variants of Concern in Kidney Transplant Recipients after Standard COVID-19 Vaccination,” published in this issue of CJASN, engaged 173 kidney transplant patients and 166 healthy controls and found that a large percentage of transplant patients mount less of an immune response after standard COVID-19 vaccination and that an additional vaccination dose is necessary, especially with the emerging threat posed by new variants, including the Delta variant (1). Transplant patient susceptibility to COVID-19 infection, even with vaccines, is well documented, and the authors suggest that, even though a higher level of antibodies can be achieved among some transplant recipients, it is dependent upon additional vaccinations, and further studies are required.
These findings are not a surprise to kidney transplant recipients and allied kidney professionals. Organizations including the American Association of Kidney Patients, the American Society of Nephrology, the Renal Physicians Association, the American Society of Transplant Surgeons, the American Society of Transplantation, and the National Kidney Foundation have tracked the serious risks posed by COVID-19 since the outset of the pandemic. Frustratingly, kidney transplant patients were not included in original COVID-19 vaccine clinical trials or vaccine development. This lack of inclusion was such an outlier that the Kidney Health Initiative, under the leadership of Dr. Ray Harris at the Vanderbilt Center for Kidney Diseases, issued public statements in 2020 reminding researchers and industry of the ongoing risks posed to these highly vulnerable people and that their insights are valuable to efforts aimed at combatting COVID-19.
Nonetheless, Benning et al. should be applauded for their research (1). Kidney professionals and advocates will use their findings in ongoing clinical guidance and to inform our advocacy for greater investments in COVID-19 research and accelerated innovations in therapeutics targeted at organ transplant recipients. Just as importantly, the authors have contributed to the expanding arsenal of data our community can draw upon as we battle disinformation being used to undermine established scientific truths about the nature of the COVID-19 virus and its demonstrated capacity to infect, sideline, incapacitate, and kill the most medically vulnerable citizens in our society.
When vaccines were first deployed and research established the lack of immune response among kidney transplant recipients through standard therapies, our community took decisive action. We collaborated with researchers and scientists across the globe to synthesize evidence, presented it to decision makers and the public, and pushed for federal authorization of a third dose for organ transplant recipients and other immunocompromised populations. Our position was advanced tremendously by journalists including Elizabeth Cohen, senior medical correspondent for CNN, and a broad network of media savvy medical professionals including transplant medicine pioneer Dr. Dorry Segev at Johns Hopkins University and transplant surgeon Dr. Robert Montgomery at New York Langone Medical Center, an immunosuppressed heart transplant recipient. We publicly applauded as the US Food and Drug Administration (FDA) authorized a third dose in August of 2021.
The FDA’s decision marked the first of many milestones yet to come for immunosuppressed organ transplant recipients. Tens of thousands continue to live in fear knowing their lives are unprotected. The stress on families and friends has been immense. For these patients, COVID-19 safety regimens severely limit normal activities, far beyond what their fellow citizens have endured. Many live in near isolation with daily routines devoid of any normal human interaction, let alone work or travel. In my case, as a 41-year kidney patient and 25-year transplant recipient, I have followed the safety advice of my transplant and cardiac experts Dr. Dominic Raj, Dr. Muralidharan Jagadeesan, and Dr. Jonathan Reiner at the George Washington University School of Medicine and Health Sciences. I have taken over 160,000 pills for immunosuppression and related conditions since my transplant, and I am reminded daily of the catastrophic risks of COVID-19. Despite being well-accustomed to a strict medical regimen, the past 20 months have presented unique challenges as I protect myself from infection and creatively work to remain in the policy arena.
The national dialogue remains dominated by debates over how freedoms have been gained or lost over decisions related to masks, social distancing, monoclonal antibodies, and vaccinations. The US Declaration of Independence says, “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” As a community, we must be more aggressive to inject research into social media and COVID-19 debates, so citizens and leaders can make wise decisions. And we must remain unequivocal in stating the virtue that every life and the promise of liberty for every individual, no matter how afflicted by disease or vulnerability, is worth defending.
Disclosures
P.T. Conway is Chair, Policy and Global Affairs, Immediate Past President of American Association of Kidney Patients (AAKP). P.T. Conway also reports roles with the following entities: Chair, Patient Engagement Advisory Committee, US Food and Drug Administration; Co-Chair, Global Innovations in Patient-Centered Kidney Care Summit, American Association of Kidney Patients/George Washington University School of Medicine and Health Sciences; Board Member, Kidney Health Initiative; External Expert Panel, Kidney Precision Medicine Project (KPMP), National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (NIH/NIDDK); Contract Management Board, NIH/NIDDK, United States Renal Data System (USRDS); Member, Nephrology Specialty Board, American Board of Internal Medicine; Member, Patient Advisory Board, Center for Dialysis Innovation, University of Washington; Moderator/Participant, KidneyX 2019–2021 Summits; Policy Stakeholder, Executive Order on Advancing American Kidney Health; and Novartis Patient Advisory Council for Patient Reported Outcome Measures.
Funding
None.
Acknowledgments
The author dedicates this editorial in memory to all who have lost their lives or suffered the impacts of COVID-19, their families, and to all immunocompromised or immunosuppressed Americans whose disease or transplant has left them more vulnerable to infection. We salute all medical professionals, researchers, private sector leaders, and civil servants engaged in the noble fight to protect Americans from COVID-19. The content of this article reflects the personal experience and views of the author(s) and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or CJASN. Responsibility for the information and views expressed herein lies entirely with the author(s).
References
1. Benning L, Morath C, Bartenschlager M, Nusshag C, Kälble F, Buylaert M, Schaier M, Beimler J, Klein K, Grenz J, Reichel P, Hidmark A, Ponath G, Töllner M, Reineke M, Rieger S, Tönshoff B, Schnitzler P, Zeier M, Süsal C, Bartenschlager R, Speer C: Neutralization of SARS-CoV-2 variants of concern in kidney transplant recipients after standard COVID-19 vaccination. Clin J Am Soc Nephrol 17: 98–106, 2022
