Should Patients be Required to Receive COVID Vaccine to be Listed for Kidney Transplant?: COMMENTARY

A major debate we have faced in the recent past addresses the requirement for coronavirus disease 2019 (COVID-19) vaccination for kidney transplant candidates.

In the wake of the global pandemic, which essentially brought transplantation to a halt for months because of an overwhelmed medical system, a lack of resources, and concern for newly immunosuppressing patients, the arrival of the COVID-19 vaccine has presented both new opportunities and challenges.

Patients with chronic illnesses such as kidney disease, heart disease, diabetes, and those on immunosuppression have been some of the most affected by COVID-19, with increased risk of mortality and long-term morbidity. Between March 2020 and March 2021, there were 3739 excess deaths among kidney transplant recipients, representing a 41.2% increase above expected deaths.¹ Most excess deaths occurred among Black or Hispanic patients and those who had survived ≥5 years post-transplant. It is probable that solid organ transplant recipients will continue to remain at elevated mortality risk until the COVID-19 pandemic can be controlled.

COVID-19 vaccination remains the most effective way to prevent severe acute respiratory distress syndrome secondary to coronavirus infection and should be considered the first line of prevention in the general population. Recent evidence suggests that the new format of mRNA vaccines were successful in reducing the mortality of COVID-19 in kidney transplant recipients, highlighting the importance of mRNA vaccination for organ transplant recipients.² The American Society of Transplantation, the National Institute of Health, and the Centers for Disease and Prevention recommend COVID-19 vaccination for kidney transplant candidates and recipients.^3–6 Because vaccine response rates may be lower in moderately or severely immunocompromised patients, specific guidance on administering vaccines to these individuals is provided by CDC.⁵

• Ideally, kidney organ transplant candidates should receive COVID-19 vaccines (either the primary series or booster doses) while they are awaiting transplant.

• In general, the last vaccine should be administered at least 2 weeks before a solid organ transplant, or vaccination should be started 1 month after a solid organ transplant.

• If possible, patients who are scheduled to receive cytotoxic or B-cell–depleting therapies should receive their COVID-19 vaccination before initiating these therapies or between cycles of these therapies. In certain situations, it may be appropriate to delay the primary series of vaccinations or booster doses until 3 months after kidney transplant, such as when T-cell—or B-cell—ablative therapy (with antithymocyte globulin or rituximab) is used at the time of transplant.⁶

• Reducing the dose of immunosuppressants and withholding immunosuppressants before vaccination are not recommended.

• After receiving the primary series of vaccinations or booster doses, people who are immunocompromised should be advised to continue to exercise precautions to reduce their risk of severe acute respiratory syndrome coronavirus 2 exposure and infection (e.g., they should wear a mask, maintain a distance of 6 feet from others, and avoid crowds and poorly ventilated spaces).⁵

Based on this evidence, widespread vaccination combined with masking and social distancing is highly recommended. However, a vaccination mandate may come at some expense to shared decision making, as highlighted in this edition of Kidney360, where the pros and cons of this requirement are explored by perspectives from two patients, LaMorgan Smith and Curtis Warfield.

LaMorgan Smith, who argues in favor of the COVID-19 vaccine requirement, received a kidney transplant during the pandemic before the vaccine mandate, but she elected in favor of the COVID-19 vaccine and boosters as soon as possible.⁷ She points out that the shortage of kidney transplants and selection of transplant recipients is an already stringent process; thus, the addition of a vaccine requirement before transplant is not unreasonable. Furthermore, LaMorgan argues that COVID vaccination is integral in protecting one's health and transplant, and it should be expected from all patients undergoing a life-saving solid organ transplantation.

Conversely, Curtis Warfield points out that about 1/3 of the general population has made the personal decision not to get vaccinated, a decision that they are at liberty to make and should be respected.⁸ Similarly, he emphasizes that potential transplant recipients should not be denied a chance at improved quality and quantity of life based on this decision alone. He further points out that the COVID-19 vaccine is not 100% effective and furthermore that there are no studies that prove that receiving the vaccine will improve the chances of a person keeping their kidney nor data regarding the duration of protection for these patients. Finally, Curtis highlights that this requirement would disadvantage African American and Latinx patients who already receive transplants at a lower rate, facing discrimination in the medical community leading to further mistrust in the medical field. These are the very patients that we must work to give the same opportunities as other potential recipients, rather than add additional barriers.

These two contrasting patient perspectives reflect the contrasting opinions in our society as evidence evolves. While there is no doubt that transplant physicians and providers should encourage kidney transplant candidates to undergo COVID-19 vaccination, a mandate may not be a wise approach. We should consider the unintended consequences of our policy decisions as mandating COVID-19 vaccination for transplant candidates may come at the expense of shared decision making and entrench existing inequities in access to transplantation.⁹

Disclosures

A. Djamali reports the following—Employer: MaineHealth and Maine Medical Center; Consultancy: CareDx and CSL; Research Funding: CareDx and Takeda; Honoraria: CareDx and CSL; and Advisory or Leadership Role: CareDx and CSL. The remaining author has nothing to disclose.

Funding

None.

Author Contributions

Conceptualization: Arjang Djamali, Emily Joachim.

Writing – original draft: Arjang Djamali, Emily Joachim.

Writing – review & editing: Arjang Djamali, Emily Joachim.