Diligence required in management of COVID-19 among patients with kidney disease
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It has been almost 3 years since the beginning of the COVID-19 pandemic. Much has changed since then, yet still this virus and its variants pose a threat.
In particular, patients treated with dialysis and those living with a kidney transplant must remain diligent to avoid contracting the virus.
Pandemic
It is not yet the right time to put the pandemic behind us. Between 2020 and 2021, before vaccines were available and before effective treatments for infections, transplant patients and patients on dialysis were particularly susceptible to complications and death if they contracted SARS-CoV-2. Early studies showed that one out of five patients on dialysis and kidney transplant patients hospitalized with COVID-19 died within 28 days of hospitalization.
As a result, the number of patients on dialysis in the United States decreased for the first time.
With most patients and staff now being immunized from COVID-19 and many boosted, survival after infection is better — more than 95%. While this is a major improvement, hospitalization and complications following COVID-19 infection are still more common in patients on dialysis and with a transplant than in the general population. So, while many politicians and some medical experts have declared that the pandemic is over, susceptible patients and their caregivers should continue to take evidence-based steps to stay safe.
Vaccination
mRNA vaccines and booster shots have clearly proven to be safe and effective in patients on dialysis and with a transplant. The likelihood of SARS-CoV-2 is lower among immunized people compared with unimmunized, and the likelihood of severe disease, hospitalization and death is less.
It is now rare that those with immunity from vaccine or from native infection with COVID-19 experience serious illness if they contract the SARS-CoV-2 viral infection. “Breakthrough infection,” defined as COVID-19 infection in people who have been immunized, is common, particularly with the viral variants like omicron BA.5, which have mutated to get around the body’s immune protection. While local infections in the upper airway are common, even in immunized individuals, the systemic protection provided by vaccination makes serious or life-threatening infections rare. It is therefore still important to get vaccinated and to get timely booster shots, which can be lifesaving for patients on dialysis and with a transplant.
Antibody testing
Some have questioned whether testing for levels of antibody to SARS-CoV-2 would be helpful in guiding the use of immunization and boosters. Early in the pandemic after vaccines were first introduced, it was unclear which antibodies were protective. That made it difficult to assess to predict clinical immunity. We now know that antibodies protect against infection but are probably less important than cellular immunity of T-cells to prevent serious complications or death from infection. Thus, measuring antibodies does not necessarily give an accurate picture of protection against the most serious complications of SARS-CoV-2 infection.
We know that neutralizing antibody levels fall with time after vaccinations (including boosters), with evidence that titers fall by as much as 90%, 6 months after immunization. It therefore seems prudent to receive booster shots, particularly those engineered to fight the current viral variants. The bi-valent vaccines developed to offer immunity to the current omicron BA.4 and BA.5 variants, in addition to the original strain of the virus, are available and recommended for all patients on dialysis and those with a transplant who are at least 2 months since their last immunization or infection with COVID-19.
Breakthrough infections
As noted earlier in this article, people who are immunized and boosted can still experience breakthrough infections. That relates to the first line of defense against respiratory viruses like SARS-CoV-2: the mucous lining of the mouth, throat, nose, tongue and upper airway. There is evidence that these tissues develop different antibodies and resident T-cells than the rest of the body.
Vaccines do a great job to promote systemic protection of circulating antibodies and T-cells, but do not effectively promote these protective proteins and cells in mucosal tissues. To promote mucosal immunity, researchers have hypothesized a possible nasal spray, particularly engineered to promote mucosal immunity.
It is important to remember that even among people who suffer breakthrough COVID-19 infection, systemic immunization remains highly protective against serious complications and death.
Treatment
Antiviral medications, such as Paxlovid (Pfizer) and Remdesivir (Gilead Sciences), have proven effective in limiting infections and reducing complications. Paxlovid, used most often, is particularly problematic for patients on dialysis and transplant patients. There are many drug-drug interactions, and consultation with a pharmacist is wise when the drug is prescribed. Both Paxlovid and Remdesivir are currently not approved for people with eGFR less than 30 mL/min per 1.73 m2, which of course includes patients on dialysis.
Nonetheless, some publications have shared recommended dose reductions for patients on dialysis and transplant patients if prescribing physicians choose to use these. Monoclonal antibodies have also proven useful, particularly for unimmunized people and those with impaired immune responsiveness, such as transplant patients. This treatment, if given promptly after infection, can limit disease and reduce complications.
Monoclonal antibodies can be used to treat COVID-19-infected patients on dialysis. Studies have shown these patients develop antibodies nearly as effectively as people with normal kidney function after vaccination. Their development of T-cell immunity is not as vigorous as in controls. However, for any given patient on dialysis, it is unclear how effectively antibodies develop. It is therefore reasonable to give monoclonal antibody treatment to vulnerable patients infected with SARS-CoV-2 who are on dialysis.
As we finish 3 years of COVID-19 prevention and treatment, many would like to declare that this pandemic has ended and is in the rear-view mirror. For patients on dialysis and transplant patients, more vulnerable to infection and complication than the general population, it is more prudent to continue preventive measures, such as universal masking indoors, vaccination and appropriate boosters, and monoclonal antibody treatment for vulnerable patients on dialysis and with a transplant.
- References:
- Jager K, et al. Kidney Int. 2020;doi:10.1016/j.kint.2020.09.006.
- Barough DH. New Engl Med. 2022:doi:10.1056/NEJMra2206573.
- www.drugs.com/pro/remdesivir.html. Accessed Oct. 10, 2022.
- www.medlibrary.org/lib/rx/meds/paxlovid. Accessed Oct. 10, 2022.
- For more information:
- Alan S. Kliger, MD, is a clinical professor of medicine at Yale University School of Medicine and serves as chair of the American Society of Nephrology’s Excellence in Patient Care Advisory Group. He can be reached at askliger@gmail.com.
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