In the present retrospective study evaluation humoral response after the second BNT162b2 mRNA vaccination in KT recipients in Japan, we found that only 24% of the KT recipients had anti–SARS-CoV-2 IgG antibody titers of ≥15 U/mL and that the rate of anti–SARS-CoV-2 IgG seropositivity was 98% in healthy controls. This finding is comparable to previous studies reporting impaired humoral response in KT recipients. However, the rate of anti–SARS-CoV-2 IgG seropositivity varies across the studies, ranging from 4.1–40.3%, due to differences in study population, sample size and measurement methods. Korh et al. and Danthu et al. reported anti–SARS-CoV-2 IgG seroprevalence rates of 22% (5/23) and 4.1% (3/74), respectively, in KT recipients, based on the LIAISON® SARS-CoV-2 Trimetric-S IgG assay (Diasorin, Italy) with a positive cutoff value of 13.0 arbitrary units/mL3,7. Kolb et al. reported a seroprevalence of 37% (10/28) using the Anti-SARS-CoV-2 QuantiVac ELISA for spike protein (Euroimmun, Germany) with a positive cutoff value of 35.2 binding antibody units/mL6. Benomane et al. and Bertrand et al. reported seroprevalence rates of 40.3% (64/159) and 17.8% (8/45 recipients), respectively, using the ARCHITECT® IgG II Quant test for spike protein (Abbott Laboratories) with a positive cutoff value of 50.0 arbitrary units/mL2,5. Although our observation of impaired humoral response in KT recipients (22%) is consistent with previous studies, the wide range of antibody tests and different cutoffs employed across the studies may contribute to the different results reported by the studies. One study investigated the agreement of three serological tests from Abbott, Roche, and Diasorin14 and found a good agreement among the three tests (Cohen’s kappa, 0.71–0.87). However, that study also reported that the clinical performance of these tests was insufficient in studies with low seroprevalence14. Overall, these findings highlight the need for careful interpretation of the results from different tests, especially in KT recipients. Additionally, the efficacy of SARS-CoV-2 vaccines cannot be measured by IgG antibody titers alone15. As the determination of protective IgG antibody levels remains unclear, further studies are necessary for optimal methods and cutoff values to determine the efficacy of SARS-CoV-2 mRNA vaccines.
The current study findings suggest that humoral response after SARS-CoV-2 mRNA vaccination is strongly inhibited in KT recipients >53 years of age, those treated with rituximab or MMF, and those with a KT vintage of < 7 years. Interestingly, similar factors were reported to be associated with weaker humoral response in a recent study that investigated the SARS-CoV-2 S IgG antibody in 142 KT recipients using the LIAISON® assay and showed age ≥54 years, KT vintage ≤8 years, and treatment with ≥2 immunosuppressants were significantly associated with seroconversion 16. These results suggest that combination immunosuppressive therapy may induce strong immunosuppression which might interfere with antiviral antibody production for 7−8 years. Factors that impact antibody response in KT recipients should be further investigated.
Among the immunosuppressive agents, rituximab and MMF exhibited a significant impact on humoral response in not only KT recipients but also patients with other chronic clinical conditions. Several studies reported the negative effects of rituximab and MMF use on anti–SARS-CoV-2 IgG seropositivity in KT recipients17,18 and in patients with autoimmune inflammatory rheumatic diseases 19. Kantauskaite et al. showed that MMF-free immunosuppressive regimens were significantly associated with seroconversion (OR 13.25, 95% CI 3.22−54.6, P < 0.001) 17. The authors suggested that MMF had a dose-dependent unfavorable effect on antibody titers, such as MMF levels of >1000 mg/day. We also examined the association between anti–SARS-CoV-2 IgG seropositivity and MMF dose and found that the seropositivity was lower in those treated with MMF doses > 1000 mg (6.3%) compared to those who were not treated with MMF (59%) and those treated with 500–1000 mg MMF (16%), which indicated that MMF dose modification might improve immune response to the SARS-CoV-2 vaccine. However, further investigation is warranted to address the balance between rejection and immune acquisition.
Rituximab use was also significantly associated with impaired humoral response in the current study. A multicenter observational study examining SARS-CoV-2 seropositivity in adult patients with autoimmune inflammatory rheumatic diseases (n = 686) reported that rituximab use was significantly associated with impaired humoral response to the BNT162b2 mRNA vaccine19. As B cell depletion is associated with a lack of serological response, those findings are reasonable regarding the negative impact of rituximab on humoral response to various vaccines20. Therefore, these results emphasize the importance of SARS-CoV-2 vaccination before the administration of MMF and /or rituximab in KT recipients.
The impact of ABOi KT on humoral response to SARS-CoV-2 vaccines should be addressed. Albeit uncommon across the globe, ABOi KT is a common alternative for donor exchange programs in Japan. As it requires extensive immunosuppression including rituximab and therapeutic apheresis, we hypothesized that ABOi KT might also have a great impact on anti–SARS-CoV-2 IgG seropositivity. However, we found that ABOi KT had a limited impact on seropositivity in the present study; this result might be associated with the lower statistical power due to the limited sample size, which should be addressed in future studies.
The major limitations of the present study include the limited sample size and retrospective study design. The IgG antibody titers were determined during the early phase of mass immunization in Japan. ABOi KT and rituximab use in immunologically high-risk recipients might not be common worldwide. Additionally, measurement of antibody titers is one of the several methods to assess immunologic response to vaccination. Despite those limitations, this is the first study evaluated the seroprevalence of SARS-CoV-2 IgG antibodies after the second BNT162b2 mRNA vaccine in Japanese KT recipients.
In conclusion, we confirmed that the rate of anti–SARS-CoV-2 IgG seroconversion was low in KT recipients after the second BNT162b2 mRNA vaccine. However, several outstanding questions remain and further investigation is warranted to determine the duration of immunity under immunosuppressive therapy, the effect of reduced titers on the protective activity of vaccines against breakthrough infections, and the efficacy of third vaccination in KT recipients.