End-stage renal disease negatively impacts COVID-19 vaccine response

The immune response of people on dialysis after being vaccinated against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has not yet to be addressed. In a recent JAMA Network Open study, researchers performed a systematic review and meta-analysis of people with end-stage kidney disease (ESKD) receiving SARS-CoV-2 vaccines to assess their immunogenicity rates.

Study: Immunogenicity Rates After SARS-CoV-2 Vaccination in People With End-stage Kidney Disease: A Systematic Review and Meta-analysis. Image Credit: mailsonpignata / Shutterstock.com

The researchers reported that the overall immunogenicity rate in patients receiving dialysis was 86% with high heterogeneity. Further, they found that the patients receiving dialysis presented lower immunogenicity rates after both the first and second doses of the vaccine as compared to patients who do not receive dialysis.

The researchers also noted that the prevalence of diabetes in the patients had an inverse linear association with the immunogenicity rate, in that the presence of diabetes appeared to be correlated with lower immunogenicity.


Previous studies have reported that patients on dialysis are more susceptible to mortality following SARS-CoV-2 infection as compared to those who are not receiving dialysis. Several studies have also identified certain risk factors for vaccine non-responsiveness among patients receiving dialysis, some of which include old age, nonresponse to hepatitis B vaccination, low serum albumin levels, or the use of immunosuppressant drugs.

However, the risk factors in individuals receiving dialysis remain unknown. In fact, there are no clinical trials that include people with end-stage kidney disease (ESKD). Therefore, assessing the immunogenicity helps to determine the efficacy of SARS-CoV-2 vaccines in this population.

The present study systematically reviews the immunogenicity rates among people with EKSD after receiving both SARS-CoV-2 vaccines, the potential risk factors for vaccine nonresponse, and any significant differences in antibody response rates between adults receiving dialysis and those not receiving dialysis.

About the study

The data source for this study came from 32 studies, including 6 preprint articles, that were obtained from databases like PubMed, Medline, and Embase and were published before July 30, 2021, as well as articles on the medRxiv preprint server. The keywords used for the selection of preprint articles from the medRxiv server included dialysis, end-stage renal disease, SARS-CoV-2 vaccine, ChAdOx1 nCoV-19, Oxford–AstraZeneca, messenger ribonucleic acid (mRNA) vaccines, BNT162b2, and mRNA-1273.

The researchers selected only the studies that evaluated the immunogenicity rate according to the postvaccine antibody response rate in patients with ESKD receiving either hemodialysis or peritoneal dialysis.

Furthermore, the researchers were interested in the primary outcome of the pooled antibody postvaccine response in the patients with ESKD, as well as the secondary outcome of the pooled antibody postvaccine response in the patients with ESKD receiving dialysis as compared with those of people without ESKD, not receiving dialysis. In most of the studies, the control group included health care workers in a dialysis facility.

Study findings

From the selected studies, the researchers tabulated the key characteristics including vaccine type and vaccine protocols, as well as patient outcomes including the type of generated antibodies (neutralizing, anti-receptor binding domain (RBD) immunoglobulin G (IgG), or anti-spike (S) IgG), dose, and number of patients receiving dialysis, to name a few.

The current study found the overall immunogenicity rate of the dialysis group to be 86%. Notably, this immunogenicity rate rose from 41% after the first dose to 89% after the second dose.

However, the immunogenicity rates after the first dose and the second dose were both significantly lower in individuals receiving dialysis as compared to those not receiving dialysis. This difference was smaller after 2 doses.

The researchers observed that the immune response of people with a history of SARS-CoV-2 infection was significantly higher than those without the infection. This increase was significantly higher after the second and the third booster dose as compared with the immunogenicity rates observed after the first dose.

No difference between the immune response of patients who received hemodialysis versus peritoneal dialysis was observed.

Interestingly, the researchers noted a significant inverse association between diabetes prevalence and the response rate. To examine this association, the researchers suggest the need for larger, well-designed studies. Unlike previous reports, they detected no inverse linear association between age and immunogenicity rates.

Based on the findings in this study, the researchers, therefore, recommend a scheduled, earlier second vaccination in the dialysis population, rather than a delayed second COVID-19 vaccine dose protocol.

Because the findings are assessed based on humoral immunity rather than cellular immunity, the comparison conducted in this meta-analysis cannot completely reflect the protective effect of vaccination.


Notably, the current study found that patients receiving dialysis had a poorer antibody response rate than did the individuals not receiving dialysis, particularly after the first dose. However,  after the second dose, the difference was less apparent. Additionally, diabetes might be a risk factor for nonresponse in the population undergoing dialysis.

Journal reference:
  • Chen, J., Lee, T. H., Tian, Y., et al. (2021). Immunogenicity Rates After SARS-CoV-2 Vaccination in People With End-stage Kidney Disease: A Systematic Review and Meta-analysis. JAMA Network Open 4(10). doi:10.1001/jamanetworkopen.2021.31749.
Dr. Ramya Dwivedi

Written by

Dr. Ramya Dwivedi

Ramya has a Ph.D. in Biotechnology from the National Chemical Laboratories (CSIR-NCL), in Pune. Her work consisted of functionalizing nanoparticles with different molecules of biological interest, studying the reaction system and establishing useful applications.


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