Immune responses to SARS-CoV-2 in dialysis and kidney transplantation

Lay Summary People with end-stage kidney disease, both those on dialysis and the recipients of a kidney transplant, are at high risk of coronavirus disease 2019-related complications. Their lower rate of response to vaccination is a matter of concern and, when prevention strategies fail, infection is often severe. Chronic kidney failure per se and immunosuppressive therapies have been shown to impair their immune responses against the virus. A more in-depth understanding of how their immune system responds to severe acute respiratory syndrome coronavirus 2 infection and vaccination is critical to identify effective prevention and treatment strategies. Despite progressive improvements in the management of patients with coronavirus disease 2019 (COVID-19), individuals with end-stage kidney disease (ESKD) are still at high risk of infection-related complications. Although the risk of infection in these patients is comparable to that of the general population, their lower rate of response to vaccination is a matter of concern. When prevention strategies fail, infection is often severe. Comorbidities affecting patients on maintenance dialysis and kidney transplant recipients clearly account for the increased risk of severe COVID-19, while the role of uremia and chronic immunosuppression is less clear. Immune monitoring studies have identified differences in the innate and adaptive immune response against the virus that could contribute to the increased disease severity. In particular, individuals on dialysis show signs of T cell exhaustion that may impair antiviral response. Similar to kidney transplant recipients, antibody production in these patients occurs, but with delayed kinetics compared with the general population, leaving them more exposed to viral expansion during the early phases of infection. Overall, unique features of the immune response during COVID-19 in individuals with ESKD may occur with severe comorbidities affecting these individuals in explaining their poor outcomes.

Automated summary

People with end-stage kidney disease have a lower rate of response to COVID-19 vaccination, increasing their risk of severe infection. Chronic kidney failure and immunosuppressive therapies impair their immune responses, leading to poor outcomes.