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Letter to the Editor

Kidney Transplant Recipients Rarely Show an Early Antibody Response Following the First COVID-19 Vaccine Administration

Yi, Stephanie G. MD, MPH, FACS1,2; Knight, Richard J. MD, FACS1,2; Graviss, Edward A. PhD1,3; Moore, Linda W. PhD, RDN, CCRP1; Nguyen, Duc T. MD, PhD3; Ghobrial, R. Mark MD, PhD, FACS1,2; Gaber, A. Osama MD, FACS1,2; Huang, Howard J. MD2,4

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doi: 10.1097/TP.0000000000003764
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The availability and administration of the coronavirus disease 2019 (COVID-19) vaccine have provided an optimistic outlook for the pandemic in solid organ transplant recipients (SOTRs). Early clinical trials report serologic responses against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) following vaccination in the general population1; however, it is unclear if and when SOTRs can mount an antibody response to the COVID-19 vaccine. Kidney transplant recipients (KTRs) seem especially vulnerable, as data show decay and loss of antibodies by 6 months after COVID-19 infection.2 We report our initial findings of antibody response following 1 dose of the COVID-19 vaccine in KTRs compared with nonimmunosuppressed end-stage renal disease (ESRD) patients on the waitlist.

To date, we have vaccinated 1130 SOTRs at our institution, of which 461 received 2 doses of either the Pfizer-BioNTech or Moderna mRNA-1273 vaccine per manufacturer guidelines. One hundred forty-five SOTRs were KTRs, with a median time from transplant of 5 years (interquartile range, 3–10). To understand vaccine efficacy, we performed an institutional review board-approved prospective study at our institution to determine antibody response at the time of both vaccine doses. Laboratory test results were obtained at the time of each vaccine dose and included presence of anti-SARS-CoV-2 immunoglobulin (IgG) and total antibody, anti-SARS-CoV-2 nucleocapsid IgG, and antispike IgG titer. We also collected antibody data from waitlisted ESRD patients who had received the COVID-19 vaccine. Those with a positive COVID-19 polymerase chain reaction test or who showed anti-SARS-CoV-2 antibodies at the time of their first vaccine were excluded from the analysis. Comparisons between groups were conducted using the chi-square or Fisher exact test as appropriate, where P < 0.05 was considered statistically significant. Statistics were performed using Stata MP V.16.0 (StataCorp LLC, College Station, TX).

Of the 145 KTR who had received their first COVID-19 vaccine, only 6.2% (n = 9) showed an antibody response before the second vaccine administration (Table 1). Seventy-three percent (n = 8) of these patients had total SARS-CoV-2 IgG antibodies, with 8 developing antispike IgG antibody titers ranging from 1:50 to <1:450. No patients demonstrated anti-SARS-CoV-2 nucleocapsid IgG antibodies. In contrast, among the 31 waitlisted ESRD patients who received the first vaccine dose, fully 87% (n = 27) produced an antibody response at the time of the second dose (P < 0.05). Antispike IgG titers ranged from 1:50 to >1:1350. Interestingly, the 4 patients with no antibody response were all maintained on low-dose immunosuppression for management of their kidney disease.

TABLE 1. - Patients with anti-SARS-CoV-2 antibodies after first COVID-19 vaccine dose
Kidney transplant recipients (N = 145) Kidney waitlist patients (N = 31) P
Anti-SARS-CoV-2 total antibody, n (%) 9 (6.2) 27 (87.1) <0.001
Anti-SARS-CoV-2 IgG, n (%) 8 (5.5) 26 (83.9) <0.001
COVID-19 antispike antibody titer, n (%) <0.001
 <1:50 137 (94.5) 4 (12.9)
 1:50 3 (2.1) 4 (12.9)
 1:150 4 (2.8) 13 (41.9)
 1:450 1 (0.7) 9 (29.0)
 ≥1:1350 0 (0.0) 1 (3.2)
Comparisons between groups were conducted using the chi-square or Fisher exact test as appropriate.
COVID-19, coronavirus disease 2019; IgG, immunoglobulin; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

KTRs or those maintained on immunosuppression were mostly unable to mount an early antibody response after a single dose of the COVID-19 mRNA vaccine. This is in contrast to nonimmunosuppressed waitlisted ESRD patients, all of whom were able to show an antibody response. Similar to that seen with other vaccines, our findings suggest that this blunted response to the COVID-19 vaccine may be associated with the immunosuppressed state in KTRs. Ongoing studies include continued antibody surveillance and evaluation of the impact of immunosuppression on vaccine response.


1. Walsh EE, Frenck RW Jr, Falsey AR, et al. Safety and immunogenicity of two RNA-based Covid-19 vaccine candidates. N Engl J Med. 2020; 383:2439–2450
2. Chavarot N, Leruez-Ville M, Scemla A, et al. Decline and loss of anti-SARS-CoV-2 antibodies in kidney transplant recipients in the 6 months following SARS-CoV-2 infection. Kidney Int. 2021; 99:486–488
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