COVID-19 Vaccination for Patients Undergoing Long-Term Hemodialysis

In this issue of CJASN, the authors of “Severity of COVID-19 after Vaccination among Hemodialysis Patients” present the severity of coronavirus disease 2019 (COVID-19) after vaccination among patients with CKD on hemodialysis in centers (1). Only a few studies have described the clinical efficacy of vaccinations in patients on hemodialysis and the severity of disease after an infection. The multicenter observational study by Ashby et al. gives an overview on the effects of the COVID-19 vaccination.

More than 500 million people have already contracted COVID-19 (as of mid-April 2022) worldwide, and COVID-19 has resulted in >6.2 million (in the United States, >1 million) total deaths (2). The risk of getting infected is very high. This fact is especially valid for patients on dialysis, who have a high mortality risk due to COVID-19 and a reduced immunologic response to vaccines.

History

The coronavirus that causes COVID-19 is one of several known to infect humans and was identified in 2019. The common understanding is that it was first detected in Wuhan, China, and then quickly became a global pandemic. The World Health Organization declared it a pandemic in 2020.

After infection, the virus attaches to our cells, gets inside them, makes copies of their RNA, and spreads. If mistakes are made during this process, then the RNA changes and mutations are spread around the globe. Thus far, we have seen the delta (identified in India, November 2021) and omicron variants.

Vaccinations

The COVID-19 vaccines were developed quite fast and, in December 2020, the US Food and Drug Administration (3) and European Union’s European Medicines Agency (4) granted an emergency-use authorization for the mRNA vaccines developed by Pfizer-BioNTech and Moderna. Shortly thereafter, additional vaccines were approved. Unfortunately, the vaccination rate worldwide is only 65% (5).

Observational Study and Results

Kidney failure is associated with a significantly higher morbidity and mortality rate, and patients with kidney failure demonstrate impaired immune responses to vaccines.

In London, Ashby et al. conducted an observational study in which patients on hemodialysis underwent surveillance PCR testing (1). Patients were tested weekly, or more often if they experienced symptoms or had close contact with a person infected with COVID-19. A total of 1323 patients were infected (79% without vaccination, 7% after one vaccination, and 14% at least 10 days after the second vaccination). A mild course of COVID-19 was observed in 61% of the patients, 29% required oxygen, and 13% died.

Compared with patients who were unvaccinated, severe COVID-19 outcomes were observed less than half as often in patients testing positive for severe acute respiratory syndrome coronavirus 2 at least 10 days after the second dose of the vaccine. Patients who were vaccinated had a 75% lower hospitalization risk and 88% lower risk of death. Another study (6) confirmed that vaccination protected patients on dialysis.

Unfortunately, the observational study by Ashby et al. did not identify where the infection came from. Patients on dialysis cannot remain safely in their homes, they have to travel to and from their dialysis centers and meet with the staff. The study does not report on how patients who had been infected were managed at the centers, and what measures were taken to avoid spreading the infection.

Patient Involvement

After vaccinations were approved, there was a lot of skepticism in the general population. Numerous questions and concerns were raised, for example:

• Was it tested enough (it was an emergency authorization)?

• Long-term side effects (e.g., infertility, allergies, immune problems) are unknown.

• “Don’t think it is safe for my age group.”

• “I’m worried that it will change my DNA.”

• Microchips may be included and other such conspiracy theories.

• The government cannot be trusted.

• Rules of conduct during the pandemic are not fully clear.

Among different social media groups, false information was circulated, and experts were not trusted. From the very beginning, there was not enough patient-integrated support and training about the vaccine, how it works, and why it is necessary. More communication regarding the necessity of the vaccination would have been better and more effective.

Trust in the vaccination needs to be increased because some research suggests that vaccine mandates can decrease trust in government or in science (7,8,9).

Furthermore, patients need to be informed about how to behave safely in public during the pandemic and how to avoid contact with persons who are infected.

Summary

COVID-19 is a daily reminder of how fragile life is for people with CKD. Daily, the virus continues its horrific and unprecedented course through immunocompromised and immunosuppressed patients with kidney disease.

Additional education for patients, nurses, doctors, and the public is essential to increase vaccine acceptance. The necessity of vaccinations is scientifically proven, and not only for patients with kidney disease. More research is needed to better understand the virus, the causes of infection, how to avoid infections, the long-term effects, and what treatments are best for the patients. And, finally, patients need to express their needs, and physicians need to listen to their patients’ voices.

Disclosures

U.K.H. Korst reports serving as a current cochair of ERKNET and as a board member of National Kidney Patients Association (Bundesverband Niere e.V.), being the founder of PKD Germany and serving as chairman for 18 years, and being a founding member of PKD International (www.pkdinternational.org).

Funding

None.

Author Contributions

U.K.H. Korst wrote the original draft.