Serial COVID-19 vaccination in dialysis patients produced strong antibody responses, but titers waned substantially unless boosted by breakthrough infection.
Evidence
This prospective cohort study followed 498 dialysis patients for neutralizing and anti-RBD antibodies up to 15 months after repeated vaccinations or infection.
Caveat
The study measured humoral immunity rather than direct protection from severe COVID-19, and vaccine schedules were dominated by specific ChAdOx1 and Moderna platforms.
Simplified
Patients with end-stage kidney disease (ESKD) undergoing dialysis have impaired vaccine responses. Many countries recommend extended primary series and regular COVID-19 boosters for this group, but data on long-term humoral responses after repeated doses or breakthrough infection are limited. In this prospective cohort study of 498 dialysis patients, most received homologous ChAdOx1 nCoV-19 as a primary series, mRNA-1273 for the third and fourth doses, and bivalent Moderna vaccines for later doses. Neutralizing antibodies (via surrogate virus neutralization test) and anti - receptor-binding domain (RBD) antibodies were measured up to 15 months post-vaccination or infection. The primary endpoint was seroprotection (neutralization inhibition ≥30%); the secondary was anti-RBD seroprotection (≥100 U/mL). Seroprotection increased from 16% (neutralizing) and 2% (anti-RBD) after the first dose to ~100% after the third and subsequent doses. Neutralizing inhibition rose from 5% (dose 1) to ~90% (doses 4-6). Anti-RBD titers declined 66%-85% by 6 months and >90% by 12-15 months. Younger age, receipt of a fourth dose, and vaccine platform were significant predictors of neutralizing titers. Breakthrough infection led to higher and more sustained anti-RBD titers, particularly in patients with . Patients with stronger immunity had fewer symptoms. In conclusion, serial COVID-19 vaccinations elicited robust humoral responses in dialysis patients, with younger age, receipt of a booster dose, and vaccine platform, emerging as significant predictors. Although antibody titers declined over time, they were better maintained in those with hybrid immunity. These findings support the implementation of personalized booster strategies to optimize protection in immunocompromised populations.
Key numbers
~100%
Increase in Neutralizing Antibody Seroprotection
Seroprotection rates after the third vaccine dose
>90%
Decline in Anti- Titers
Decline observed by 12-15 months post-vaccination
67%
Higher Anti- Titers Post-Breakthrough Infection
Decline in anti- titers at 6 months post-infection followed by vaccination
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