CJASN ePress. Published on May 16, 2022 as doi: 10.2215/CJN.
00890122
SARS-CoV-2 Booster Vaccine Response among Patients
Receiving Dialysis
Pablo Garcia,1 Jialin Han ,1 Maria E. Montez-Rath,1 Sumi Sun,2 Tiffany Shang,2 Julie Parsonnet
Glenn M. Chertow ,1,4 Shuchi Anand ,1 Brigitte Schiller ,1,2 and Graham Abra1,2
CJASN 17: –, 2022. doi: https://doi.org/10.2215/CJN.00890122
Data indicate a diminished antibody response to severe
acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) vaccination among patients on dialysis (1–3).
Circulating antibody titers decline rapidly, regardless of
vaccine type; low circulating levels are linked with a
more than ten-fold higher risk for breakthrough infec-
tions (3). To determine whether a booster dose would
offer protection against SARS-CoV-2, we compared
antibody responses in early postvaccination periods
after completing the initial vaccine schedule versus
completing the booster dose schedule of a SARS-CoV-2
vaccine in a cohort of US patients on dialysis.
We partnered with a nonprofit dialysis provider
serving patients receiving maintenance dialysis in four
states. The dialysis provider implemented monthly test-
ing for SARS-CoV-2 receptor binding domain (RBD)
antibody levels among a majority of their patient popu-
lation from February through April 2021, and quarterly
thereafter. Starting in late September 2021, the dialysis
provider offered in-facility mRNA vaccine boosters to
patients dialyzing in their facilities. From 8229 patients
receiving dialysis and completing the initial recom-
mended vaccination schedule for the two mRNA or
Ad26.COV2.S vaccines, we identified 3041 and 2720
patients who had antibody results available within
14–60 days postinitial vaccination and postbooster,
respectively. In cases where more than one antibody
result was available, we used the maximum antibody
results within 14–60 days. We used multinomial
logistic regression to obtain the estimate margins of
response level. We collected antibody data through
November 10, 2021.
We quantified the antibody response using one of
two semiquantitative Siemens RBD IgG assays. On
the basis of our previous research (3), we categorized
the response as RBD IgG antibody index value ,10,
10–23, and .23. Index values of 10 and 23 correspond
to 218 and 506 binding antibody units per milliliter,
respectively, according to the World Health Organiza-
tion international standard. We have previously
shown that values ,10 and in the range of 10–23 were
associated with higher risks of breakthrough infection
(rate ratio, 11.6; 95% confidence interval [95% CI],
3.4 to 39.5 and rate ratio, 6.0; 95% CI, 1.5 to 23.6,
respectively).
www.cjasn.org Vol 17 July, 2022
Research Letter
,3,4
1
Department of
Clinical characteristics, including age, sex, diabetes Medicine (Nephrology),
Stanford University,
status, and vaccine type, were similar among patients Stanford, California
in both cohorts (i.e., patients completing the initial vacci- 2
Medical Clinical
nation schedule [n53041] and patients completing a Affairs, Satellite
booster dose [n52720]). A majority (66% and 70%, Healthcare, Satellite
Healthcare, San Jose,
respectively) of patients completed the initial vaccine California
series with the mRNA1273 vaccine. Nearly all patients 3
Department of
(97%) who received a booster received the BNT162b2 Medicine (Infectious
vaccine. The median time between initial vaccine series Diseases and
Geographic Medicine),
and booster vaccination was 189 days. Whereas 81% Stanford University,
(95% CI, 80% to 82%) of patients achieved an RBD IgG Stanford, California
index value .23 after initial vaccination (including 88% 4
Department of
and 76% who received the mRNA1273 and BNT162b2 Epidemiology and
Population Health,
vaccine, respectively), 97% (95% CI, 96% to 97%) did so Stanford University,
in 14-60 day period after the booster. Among patients Stanford, California
with data available from both time points (n51431), 130
patients had an RBD IgG index value ,10 after the ini- Correspondence:
tial vaccine series. Of these 130 patients, 106 (82%) Dr. Pablo Garcia, 777
developed an RBD IgG index value .23 after the Welch Road Suite DE,
Palo Alto, CA 94304.
booster vaccine. The antibody response to the initial Email: pgarciah@
vaccine series was inversely proportional to age; how- stanford.edu
ever, after a third dose of mRNA vaccine, older patients
achieved nearly as robust a response as younger
patients (Table 1).
In this cohort of patients on dialysis from four US
states, a majority of whom completed two doses of
mRNA1273 and thereafter received BNT162b2 as the
third dose, we observed a robust response to the
booster dose. In the immediate postbooster period,
.95% of patients achieved an antibody index value
associated with enhanced protection against SARS-
CoV-2 breakthrough infection (3). These data are con-
cordant with other studies from Europe and the
United States, although the duration between the ini-
tial series and booster dose was longer than that pub-
lished from European data (4,5). Response to the
BNT162b2 vaccine booster after either the mRNA1273
or BNT162b2 initial vaccine series supports the
so-called “mix and match” strategy, at least with
respect to the mRNA vaccines. We had too few
patients in the booster cohort who had initially
received the Ad26.CoV2.S vaccine to assess the
response to an mRNA booster in this group. We could
not assess cellular immune response, although recent
data indicate that humoral and cellular responses are
Copyright © 2022 by the American Society of Nephrology 1
 2 CJASN

Table 1. Prevalence of absent response among fully vaccinated individuals by vaccine type, age group, and overall between 14 and 60 days after completion of vaccine and booster

Completed Initial Schedule of Doses: Days 14 and 60, n53041 Completed Booster Dose: Days 14 and 60, n52720

Receptor Binding Receptor Binding

Characteristics Receptor Binding Receptor Binding Receptor Binding Receptor Binding
Domain IgG 5 Domain IgG 5
Domain IgG ,10 Domain IgG .23 Domain IgG ,10 Domain IgG .23
n 10–23 (95% n 10–23 (95%
(95% Confidence (95% Confidence (95% Confidence (95% Confidence
Confidence Confidence
Interval), n5377 Interval), n52462 Interval), n545 Interval), n52626
Interval), n5202 Interval), n549
Vaccine type
(initial dose)a
mRNA1273 1990 7 (5 to 8) 6 (5 to 7) 88 (86 to 89) 1902 1 (0.7 to 2) 2 (1 to 2) 97 (97 to 98)
BNT162b2 832 16 (13 to 18) 9 (7 to 11) 76 (73 to 78) 815 3 (2 to 4) 3 (1 to 4) 95 (93 to 96)
Ad26.COV2.S 219 60 (53 to 66) 4 (2 to 7) 36 (30 to 42) 3 NA NA NA
Age group, yrb
18–44 225 8 (5 to 11) 3 (0.8 to 5) 89 (86 to 93) 229 — — 98 (96 to 100)
45–64 892 8 (7 to 10) 6 (4 to 8) 86 (84 to 88) 1026 1 (0.4 to 2) 1.1 (0.4 to 2) 98 (97 to 100)
65–80 1316 14 (12 to 16) 7 (5 to 8) 79 (77 to 81) 1032 2 (1 to 3) 1.8 (1 to 3) 96 (95 to 98)
$80 608 19 (16 to 22) 9 (7 to 11) 73 (69 to 76) 433 3 (1 to 4) 4.3 (2 to 6) 93 (91 to 95)
Overallc 12 (11 to 14)d 7 (6 to 8)d 81 (80 to 82)d 2 (1 to 2)d 2 (1 to 2)d 97 (96 to 97)d

Data are percentage (95% confidence interval) obtained within 14–60 days after two doses of either the mRNA1273 or BNT162b2 vaccine and a single dose of the Ad26.COV2.S vaccine.
NA, not available; —, insufficient data.
a
Adjusted for age and sex.
b
Adjusted for sex.
c
Adjusted for age, sex, and vaccine type.
d
Overall results.
CJASN 17: –, July, 2022
concordant. Another limitation is the lack of data on prior
SARS-CoV-2 breakthrough infection.
In summary, nearly all patients requiring maintenance
dialysis who received a booster dose of mRNA vaccine
developed a robust antibody response 14–60 days after
vaccination. Perhaps most importantly, we found that a
third dose of mRNA vaccine was effective in providing
high levels of antibody among older patients who were not
uniformly protected after the initial vaccine series.
Disclosures
G. Abra reports employment with Satellite Healthcare, consul-
tancy agreements with Akebia, and serving in an advisory or leader-
ship role for Nephrology News & Issues. S. Anand serves as a medical
director at a Satellite Healthcare dialysis unit and reports consul-
tancy agreements with GLG Group, honoraria from St. Rose Hospi-
tal (continuous medical education activity), and serving in an advi-
sory or leadership role for CENCAM (unpaid) and i3C (International
Society of Nephrology; unpaid). G.M. Chertow reports consultancy
agreements with Akebia, Amgen, Ardelyx, AstraZeneca, Baxter,
Cricket, DiaMedica, Gilead, Miromatrix, Reata, Sanifit, Unicycive,
and Vertex; ownership interest in Ardelyx, CloudCath, Durect,
DxNow, Eliaz Therapeutics, Outset, Physiowave, and PuraCath;
research funding from the National Institute of Allergy and Infec-
tious Diseases and the National Institute of Diabetes and Digestive
(NIDDK) and Kidney Diseases; serving on the board of directors of
Satellite Healthcare, a nonprofit dialysis provider, and as coeditor of
Brenner & Rector’s The Kidney (Elsevier); and Data and Safety Moni-
toring Board service for Angion, Bayer, NIDDK, and ReCor. J. Par-
sonnet reports research funding from Gauss Surgical and serving in
an advisory or leadership role for Doctors for America and Scrubs
Addressing the Firearm Epidemic. B. Schiller reports employment
with Satellite Healthcare; consultancy agreements with CVS, Quanta,
and Rockwell Medical; ownership interest in Unicycive Therapeutics
Inc.; serving in an advisory or leadership role for the board of direc-
tors at Unicycive; and speakers bureau for AstraZeneca. T. Shang
and S. Sun report employment with Satellite Healthcare. All remain-
ing authors have nothing to disclose.
Funding
S. Anand was supported by National Institute of Diabetes and
Digestive and Kidney Diseases grant R01DK127138. G.M. Chertow
and M.E. Montez-Rath were supported by National Institute of
Diabetes and Digestive and Kidney Diseases grant K24DK085446.
COVID-19 Booster Response among Patients on Dialysis, Garcia et al. 3
Author Contributions
S. Anand, M.E. Montez-Rath, P. Garcia, J. Han, and J. Parsonnet
conceptualized the study; J. Han, T. Shang, and S. Sun were respon-
sible for data curation; S. Anand, P. Garcia, and J. Han were respon-
sible for investigation; J. Han was responsible for formal analysis;
S. Anand, S. Anand, P. Garcia, J. Han, and M.E. Montez-Rath were
responsible for methodology; G. Abra, S. Anand, B. Schiller,
T. Shang, and S. Sun were responsible for project administration;
G. Abra, S. Anand, B. Schiller, T. Shang, and S. Sun were responsible
for resources; M.E. Montez-Rath was responsible for validation;
G. Abra, S. Anand, S. Anand, M.E. Montez-Rath, J. Parsonnet, and
B. Schiller provided supervision; P. Garcia and J. Han wrote the
original draft; and G. Abra, S. Anand, S. Anand, J. Parsonnet, and
B. Schiller reviewed and edited the manuscript.
Data Sharing Statement
A limited dataset without PHI may be available upon review of
request and appropriate data sharing agreements.
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P.G., J.H., B.S., and G.A. contributed equally to this work.
Published online ahead of print. Publication date available at
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