Impaired humoral immune response to hepatitis B vaccine in patients on maintenance hemodialysis

Abstract

Hepatitis B virus (HBV) infection is a worldwide health problem. We aimed in this study to investigate the humoral immune response derived to HBV vaccine following completing the vaccine series in Madinah. Two hundred and two Saudi hemodialysis (HD) patients were included in this cross-sectional study. Mean concentration of Hepatitis B surface antibody (anti-HBs) was significantly higher among patients who received the vaccination twice compared to patients who received the vaccination only after starting hemodialysis (252 ± 489 mIU/mL vs. 144 ± 327 mIU/mL, respectively, p = 0.008). Almost half of the study sample were non-protected and showed anti-HBs concentration < 10 mlU/mL. In contrast, 20.3% (n = 41) were identified as poor responders (10–100 mlU/mL) and only 28.2% (n = 57) were identified as good responders (10–100 mlU/mL). However, the latter two groups were accounted as protected (48.5%, n = 98). Patients sex was associated with anti-HBs concentration (non-responders; poor responders; good responders), where significantly higher proportion of good responders were females compared to males (p = 0.007). In conclusion, HBV vaccine is efficient to elicit humoral immune response in hemodialysis patients.

1. Introduction

HBV infection is a worldwide health problem. In 2019, the World Health Organization (WHO) reported a total number of people living with chronic HBV infection as three million. The report also indicated that one and a half million new cases of the HBV are reported annually (https://www.who.int/news-room/fact-sheets/detail/hepatitis-b). HBV is the most predominant cause of viremia and one of the main reasons of liver disease as well as cirrhosis.(“Characteristics of persons with chronic hepatitis B--San Francisco, California, 2006,” 2007).

Impaired renal function is a substantial risk factor for cardiovascular disease, infections and death in chronic kidney disease (CKD) patients. (Ishigami and Matsushita, 2019, Kato et al., 2008) Renal disease is simultaneously related with systemic inflammation and immune deficiency. (Carrero & Stenvinkel, 2010) Numerous reports have verified unusual immune response to viral infection upon vaccination of hemodialysis patients. (Betjes, 2013, Eleftheriadis et al., 2007, Mahallawi et al., 2021).

For those immunocompromised patients, consistent analysis for the presence of protective levels of anti-HBs antibody, and a booster dose while the concentration drops under 10 mIU/mL, is recommended. Therefore, continuous monitoring of anti-HBs antibody would be preferred and similarly those non-responders to a primary course of vaccine to continuously monitored. (European, 2000).

Saudi Arabia has adopted universal administration of HBV vaccine to all infants as of 1990. (Memish et al., 2010) From 1990 to 1995, this vaccine was also consistently administered to children at school entry. (Madani, 2007).

No specific studies in Saudi Arabia focused on the effectiveness of HBV vaccine and persistency of HBV vaccine–induced antibody among Saudi hemodialysis patients. We aimed in this study to investigate the humoral immune response derived from HBV vaccine following completing the vaccine series among Saudi hemodialysis patients in Madinah, Saudi Arabia. Additionally, investigating the sustainability of anti-HBs antibody levels up to six months after receiving the last vaccine dose was conducted. We correlated the anti-HBs concentrations with sex, age, and number of dialysis performed per week.

2. Methods

2.1. Study population

Patients included in this study were Saudis from multi dialysis centres namely; King Abdulaziz Kidney Center, Hasan Tahir Hemodialysis Center and Hayat Organization Hemodialysis Center. Based on the HBV vaccine implementation in Saudi Arabia, we divided the patients into two groups. First, group comprised of adults aged 18–31 who had received HBV vaccine at birth and during dialysis. Second, group included adults over 31 years vaccination for them accounted as primary series (no prior vaccination). Both groups had received the full vaccination course following the start of dialysis according to their medical records. We excluded participants (n = 23)who were identified as previously exposed to HBV (negative for anti-HBc IgG and IgM antibodies) and human immunodeficiency virus infection (HIV).

2.2. Data collection

Official letters were sent to all dialysis centers to announce about the study to all patients. The blood samples were collected from 01/02/2022 to 29/01/2023. Personal data including age, sex, frequency of dialysis per week and other information were collected from patients file. The Ethical Review Board at King Salman Medical City approved the study (H-03-M−11).

2.3. Samples collection

5 ml of blood was obtained from the participants, followed by serum samples separation process.

2.4. Measurement of anti-HBs by enzyme-linked immunosorbent assay (ELISA)

Anti-HBs were determined quantitatively with Monolisa Anti-HBs PLUS enzyme immunoassay (EIA) kit (Bio-Rad, Marnes-la-Coquette, France) on Behring ELISA Processor (Marburg, Germany) according to the manufacturers' procedures. Apart from the sampling step, all the other assay steps were performed with the full-automated machine. Following manual dispensing of samples, controls and calibrators, the BEP III system automatically completed the subsequent steps for processing and evaluation of tests. Absorbance values were then measured at 450/620 nm and 405/620 nm. Anti-HBs level is considered protective (reactive) when the concentration ≥ 10 mIU/mL and when it < 10 mIU/mL is considered negative (non– reactive).

2.5. Statistical analysis

Continuous variables were described as mean ± standard deviation. Fisher’s exact test was used to assess the association between two categories. Mann-Whitney U test and Kruskal-Wallis test were used to compare the mean anti-HBs concentration across patients in different groups. Spearman’s correlation was used to assess the association between anti-HBs concentration and age of participants.

3. Results

3.1. Sample characteristics

Mean age of patients (n = 202) was 48.9 ± 13.4 years. Almost fifteen percent of patients (n = 31) received the vaccine at birth and after starting hemodialysis (18–31 years), whereas 84.7% (n = 171) of them received the vaccine after starting hemodialysis (>31 years). Proportion of male patients was 45.0% (n = 91). Hypertension was reported by 58.4% (n = 118) of patients as the cause of renal failure, whereas hypertension and diabetes were reported to be the cause of renal failure by 36.6% (n = 74) of patients. Seventy-eight percent (n = 158) of patients indicated they performed hemodialysis three times per week. Mean time since the initiation hemodialysis was 5.32 ± 3.41 years. Fifty-four percent (n = 108) of patients reported performing hemodialysis for<5 years. Mean anti-HBs concentration was 160 ± 357 mIU/mL. Half of the study sample were non-protective (<10 mlU/mL) to HBV (51.5%, n = 104), while 20.3% (n = 41) were identified as poor responders (10–100 mlU/mL) and only 28.2% (n = 57) were identified as good responders (10–100 mlU/mL). However, the latter two groups were accounted as protected (48.5%, n = 98). Table 1 provides detailed description of the characteristics of patients.

Table 1.

Characteristics of renal failure patients included in the study (n = 202).

	n	%
Age group
18–31 years (patients vaccinated at birth and after starting hemodialysis)	31	15.3
> 31 years (patients vaccinated only after starting hemodialysis)	171	84.7
Sex
Male	91	45.0
Female	111	55.0
Cause of renal failure
Hypertension	118	58.4
Diabetes	6	3.00
Hypertension and diabetes	74	36.6
Hypertension and ischemic heart disease	4	2.00
Frequency of hemodialysis
2 times per week	44	21.8
3 times per week	158	78.2
Time since stating dialysis
0–5 years	108	53.5
> 5 years	94	46.5
Vaccination status
Vaccinated at birth and after starting hemodialysis (anti-HBs status)
Non-reactive	10	32.3
Reactive	21	67.7
Vaccinated only after starting hemodialysis
Non-reactive	94	55.0
Reactive	77	45.0
Vaccinated at birth and after starting hemodialysis (anti-HBs status)
Non-responders (<10 mlU/mL)	10	32.3
Poor responders (10–100 mlU/mL)	5	16.1
Good responders (>100 mlU/mL)	16	51.6
Vaccinated only after starting hemodialysis
Non-responders (<10 mlU/mL)	94	55.0
Poor responders (10–100 mlU/mL)	36	21.0
Good responders (>100 mlU/mL)	41	24.0

3.2. Association between the anti-HBs concentration and characteristics of the study sample

Mean concentration of anti-HBs was significantly higher among patients who received the vaccination twice compared to patients who received the vaccination only after starting hemodialysis (252 ± 489 mIU/mL vs. 144 ± 327 mIU/mL, respectively, p = 0.008). Mean concentration of anti-HBs was similar among non-responders who received the vaccine twice and patients who received the vaccine only after starting hemodialysis (5.80 ± 2.62 mIU/mL vs. 5.91 ± 1.97 mIU/mL, respectively, p = 0.947). Also, mean concentration of anti-HBs was similar among poor-responders who received the vaccine twice and patients who received the vaccine only after starting HD (41.4 ± 28.0 mIU/mL vs. 29.8 ± 20.7 mIU/mL, respectively, p = 0.301).

Mean concentration of anti-HBs was similar among good-responders who received the vaccine twice and patients who received the vaccine only after starting hemodialysis (472 ± 609 mIU/mL vs. 560 ± 469 mIU/mL, respectively, p = 0.570). Mean concentration of anti-HBs was not significantly different across the groups of sex, cause of renal failure, frequency of hemodialysis, and time since starting hemodialysis (p > 0.05). Associations between anti-HBs concentration (non-responders; poor responders; good responders) and characteristics of patients are presented in Table 2. Age of patients was associated with anti-HBs concentration, where significantly higher proportion of good responders aged between 18 and 31 years compared to patients aged > 31 years (51.6% vs. 24.0%, respectively, p = 0.010).(See Table 3).

Table 2.

Associations between anti-HBs concentration and responses to HBV vaccine (n = 202).

	Non-responders < 10 mlU/mL (n = 104)	Poor responders 10–100 mlU/mL (n = 41)	Good responders > 100 mlU/mL (n = 57)	p-value
Age group
18–31 years	10 (32.3)	5 (16.1)	16 (51.6)	0.010*
> 31 years	94 (55.0)	36 (21.1)	41 (24.0)
Sex
Male	58 (63.7)	13 (14.3)	20 (22.0)	0.007*
Female	46 (41.4)	28 (25.2)	37 (33.3)
Cause of renal failure
Hypertension	64 (54.2)	22 (18.6)	33 (52.4)	0.907
Diabetes	2 (3.33)	2 (33.3)	2 (33.3)
Hypertension and diabetes	36 (48.6)	16 (21.6)	22 (29.7)
Hypertension and ischemic heart disease	2 (50.0)	1 (25.0)	1 (25.0)
Frequency of hemodialysis
2 times per week	21 (47.7)	12 (27.3)	11 (25.0)	0.463
3 times per week	83 (52.5)	29 (18.4)	46 (29.1)
Time since stating dialysis
0–5 years	59 (54.6)	21 (19.4)	28 (25.9)	0.644
> 5 years	45 (47.9)	20 (21.3)	29 (30.9)

* Statistically significant at the 95% confidence level.

Table 3.

Associations between anti-HBs concentration and characteristics of patients (n = 202).

	Non-reactive < 10 mlU/mL (n = 104)	Reactive ≥ 10 mlU/mL (n = 98)	p-value
Age group
18–31 years	10 (32.3)	21 (67.7)	0.031*
> 31 years	94 (55.0)	77 (45.0)
Sex
Male	58 (63.7)	33 (36.3)	0.002*
Female	46 (41.4)	65 (58.6)
Cause of renal failure
Hypertension	64 (54.2)	54 (45.8)	0.719
Diabetes	2 (3.33)	4 (66.7)
Hypertension and diabetes	36 (48.6)	68 (51.4)
Hypertension and ischemic heart disease	2 (50.0)	2 (50.0)
Frequency of hemodialysis
2 times per week	21 (47.7)	23 (52.3)	0.612
3 times per week	83 (52.5)	75 (45.5)
Time since stating dialysis
0–5 years	59 (54.6)	49 (45.4)	0.397
> 5 years	45 (47.9)	49 (52.1)

* Statistically significant at the 95% confidence level.

Sex of patients was also associated with anti-HBs concentration (non-responders; poor responders; good responders), where significantly higher proportion of good responders were females compared to males (33.3% vs. 22.0%, respectively, p = 0.007).

Associations between anti-HBs concentration (non-reactive vs. reactive) and characteristics of patients are presented in Table 2. Age of patients was associated with anti-HBs concentration, where significantly higher proportion of reactive patients aged between 18 and 31 years compared to patients aged > 31 years (67.7% vs. 45.0%, respectively, p = 0.031). Sex of patients was also associated with anti-HBs concentration (non-reactive vs. reactive), where significantly higher proportion of reactive patients were females compared to males (58.6% vs. 36.3%, respectively, p = 0.002). Cause of renal failure, frequency of hemodialysis, and time since stating dialysis were not associated with anti-HBs concentration (non-reactive vs. reactive).

Spearman’s correlation showed no correlation between anti-HBs concentration and age in years among participants who received the vaccine only after starting hemodialysis (r_s = -0.08, p = 0.272), while low negative correlation was found between anti-HBs concentration and age of participants who received the vaccine twice after birth and after starting hemodialysis (r_s = -0.31, p = 0.088).

3.3. Predictors of anti-HBs concentration among renal failure patients

Multiple linear regression analysis show that, after adjusting for patients age group and sex, cause of renal failure predicted anti-HBs concentration (B = 51.0, SE = 24.7 (95% Confidence Interval: 2.27 to 99.7). This model explained 5.00% of the change in the anti-HBs concentration. In addition, multiple linear regression analysis show that the frequency of hemodialysis and time since starting dialysis among renal failure patients did not predict anti-HBs concentration (see Table 4).

Table 4.

Predictors of anti-HBs concentration among renal failure patients on hemodialysis.

	B	SE	95% Confidence Interval	p-value	R-square
Cause of renal failure (hypertension = 1; diabetes = 2; hypertension and diabetes = 3; hypertension and ischemic heart disease = 4)	51.0	24.7	2.27 to 99.7	0.040*	0.05
Frequency of hemodialysis (two times per week = 2; three times per week = 3)	−31.8	60.4	−151 to 87.3	0.599	0.03
Time since stating dialysis (0–5 years = 1; > 5 years = 2)	61.7	50.2	−37.3 to 161	0.220	0.04

* Alpha = 0.05. All models were adjusted for patient’s age and sex.

4. Discussion

Hemodialysis patients may need blood transfusion, repeated hospitalizations, which increase the probability of nosocomial infection.(Karkar et al., 2006) The furthermost recurrent viral infections faced in hemodialysis units due to HBV, HCV and, to a smaller degree, HIV.(Bernieh, 2015, Fabrizi et al., 2021).

Hemodialysis has been reported to show a poor antibody levels in addition to an incapability to sustain sufficient antibody titers during their life.(Bel'eed et al., 2002) Moreover, patients with impaired kidney function who were vaccinated before they needed dialysis have been revealed to have greater seroprotection degrees as well as antibody titers (https://www.cdc.gov/dialysis/pdfs/vaccinating_dialysis_patients_and_patients_dec2012.pdf) accessed on 01–04-2023.

Interestingly, the current study showed that mean concentration of anti-HBs was significantly higher among patients who received the vaccination twice compared to patients who received the vaccination only after starting hemodialysis. The given series of HBV vaccine worked as booster for the memory immune response derived from the primary HBV vaccine that was administered at birth. Thus, they most likely developed vaccine-induced recall responses.(Weinberger et al., 2018) In contrast, those patients who had not received the vaccine at birth and were not previously infected with the virus showed lower anti-HBs antibody levels and hence the HBV vaccine that they received after starting the hemodialysis was primary series for them. Our result is in a full agreement with a report of ACIP that showed greater seroprotection proportions in patients with chronic renal failure who were vaccinated before developing the state of being dialysis dependent.(Mast et al., 2006) Therefore, recommendation of booster for hemodialysis patients seems to be important for maintaining protective levels of the antiviral antibody against the infection. As a result, the level increases subsequent to booster doses; protective anti-HBs titres wane quickly, then annual antibody follow-up booster doses will be essential to maintain seroprotection.(Bel'eed et al., 2002) Numerous global studies have revealed that over 30 % of these patients do not respond effectively to HBV vaccines.(Pin et al., 2009) In contrast to hemodialysis patients, several studies in healthy individuals have showed that about 20–30% of them who received primary immunization at infancy retained protective anti-HBs levels when they attained 18 years old.(Bassal et al., 2017, Spada et al., 2014).

Several studies on healthy individuals investigating effectiveness of HBV vaccines and sustainability of protective anti-HBs. They have reported very high vaccine efficacy and prolonged protective titers of anti-HBs antibody levels.(Cocchio et al., 2021, Dini et al., 2017) In contrast, several reports have shown declined anti-HBs concentration in healthy individuals with time.(Mahallawi, 2018, Wu et al., 2013) Consequently, waning of vaccine-induced anti-HBs antibody levels has been reported(Coates et al., 2001) and primary vaccination may not offer lifetime protection as vaccine-induced immunity fades over time.(Phattraprayoon et al., 2022). Additionally, kidney transplant recipients who were vaccinated with COVID-19 vaccines showed a significant and dramatic decline of antibody levels over time (Mahallawi et al., 2023).

We showed that age of patients was associated with anti-HBs concentration. We found significantly higher proportion of good responders aged between 18 and 31 years compared to patients aged > 31 years. Our result is supporting the previous one as it proves those aged less who and who received the vaccine at birth are superior in antibody concentrations than those over 31 years.

In the current study we showed that sex of patients was associated with anti-HBs concentration (non-responders; poor responders; good responders), where significantly higher proportion of good responders were females compared to males (33.3% vs. 22.0%, respectively, p = 0.007). Our result is consistent with a study that revealed superior anti-HBs antibody level in females who were hemodialysis dependent than that seen in male patients.(Shatat et al., 2000) The same trend was seen in healthy individuals in several studies that reveal stronger immune response in female who respond to HBV vaccine. (Sangfelt et al., 2008, Yang et al., 2016).

We have shown that cause of renal failure predicted anti-HBs concentration. Diabetes mellitus patients were showed higher proportion of sero-negativities to HBV vaccine. Our result is in agreement with a study showed that amongst hemodialysis patients, the average percentage protected was about sixty percent for those with diabetes mellitus, while for those without diabetes mellitus it was over seventy percent.(Schillie et al., 2012).

The current findings would have implications that could be used from the healthcare providers who are caring those patients. It is recommended to continuous monitoring of anti-HBs antibody in those non-responders to a primary course of vaccine. Additionally, those with waned immunity over the time after receiving the HBV vaccine series are of high concern to be boosted to maintain protective anti-HBs antibody levels.

Ours is the first study conducted in Saudi Arabia that aims to investigate the seropositivity of anti-HBs in Saudi hemodialysis patients six months post HBV vaccine in relation to sex, primary vaccine series status and disease leading to renal failure. However, this study is limited by the inability to measure the anti-HBs titers at different time intervals.

Funding

The authors extend their appreciation to the Deputyship for Research & Innovation, Ministry of Education in Saudi Arabia for funding this research work through the project number (445-9-193).

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.