International Journal of
Environmental Research
and Public Health
Article
Vaccination against SARS-CoV-2 in Haemodialysis Patients:
Spike’s Ab Response and the Influence of BMI and Age
Pedro Ponce 1 , Ricardo Peralta 2 , Carla Felix 2 , Carla Pinto 1 , Bruno Pinto 2 and João Fazendeiro Matos 2, *
Citation: Ponce, P.; Peralta, R.; Felix,
C.; Pinto, C.; Pinto, B.; Matos, J.F.
Vaccination against SARS-CoV-2 in
Haemodialysis Patients: Spike’s Ab
Response and the Influence of BMI
and Age. Int. J. Environ. Res. Public
Health 2022, 19, 10091. https://
doi.org/10.3390/ijerph191610091
Academic Editor: Paul B. Tchounwou
Received: 30 June 2022
Accepted: 12 August 2022
Published: 15 August 2022
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Int. J. Environ. Res. Public Health 2022, 19, 10091. https://doi.org/10.3390/ijerph191610091
1 Country Medical, NephroCare Portugal, Fresenius Medical Care Portugal, 1750-233 Lisboa, Portugal
2 Direção de Enfermagem, NephroCare Portugal, Fresenius Medical Care Portugal, 4470-573 Porto, Portugal
* Correspondence: jfazendeiro.matos@fmc-ag.com
Abstract: Patients with chronic kidney disease (CKD-5D) in dialysis have been associated with higher
rates of SARS-CoV-2 infection. Objective: To identify the CKD-5D patients’ immune system behavior
regarding the Pfizer-BioNTech (BNT162b2 mRNA) vaccine (Comirnaty©). This was a multicenter
study carried out in 38 dialysis units in NephroCare Portugal. Eligible patients from two cohorts—one
composed of completely vaccinated patients with Comirnaty© (vaccinated group) against a second
cohort of patients who recovered from SARS-CoV-2 infection (control group)—were selected through
representative sampling for each cohort. Humoral response was assessed at 3 (t0) and 6 months
(t1) after complete vaccination and, in the control group, 6 months after COVID-19 recovery. In the
vaccinated group, at t0, the median anti-Spike IgG level was 1120 AU/mL and, at t1, all participants’
antibody level decreased to a median of 455 AU/mL. In the control group, the median serum SARS-
CoV-2 antibodies level was 1836 AU/mL. In the vaccinated group, at t0, patients < 70 years presented
a significantly (p = 0.002) higher level of anti-Spike IgG titres. In contrast, older patients from the
control group presented a significantly (p = 0.038) higher IgG. No correlation was found between
age and anti-Spike IgG antibodies level in any of the studied groups. Patients with a higher body
mass index showed a greater immune response in both the vaccinated and control group, although
without significance. We concluded that, in the vaccinated group, elderly patients developed a lower
immune response than younger patients and the levels of anti-Spike IgG antibodies declined faster
between t0 and t1, while in the control group, the oldest and overweight patients developed the best
humoral response.
Keywords: SARS-CoV-2; COVID-19; vaccine; antibody; immunity; dialysis
1. Introduction
The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) has been associated with causing high incidence,
mortality, and fatality rates in people with chronic kidney disease in stage 5 (CKD-5D) [1–4]
in a regular dialysis program. According to the literature, this group of patients is five
to sixteen times more likely to be infected with SARS-CoV-2 and has nearly a 30 to 130%
higher risk of death than the general population [5]. Thus, prioritizing this particular group
of patients for vaccination was a common strategy in several countries, like Portugal [6].
Current vaccination programs include the Moderna (mRNA-1273), Pfizer-BioNTech
(BNT162b2 mRNA) Comirnaty©, Oxford/AstraZeneca (ChAdOx1 nCoV-19), and Johnson
& Johnson COVID-19 (Ad26.COV2.S) vaccines, which have all been shown to induce both
humoral and cellular immune responses [7–9] against the Spike protein of the SARS-CoV-2
virus, protecting individuals from the risk of subsequent infection. The vaccination regime
for the Comirnaty© vaccine (composed of two doses) showed a 95% induced protection
against COVID-19 in the general population. However, CKD-5D patients were not included
in the clinical trials, thus there are no data on the efficacy for this group of patients [10,11].
https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 10091 2 of 10

With the establishment and progression of chronic kidney disease, it has been con-
firmed that patients with this infirmity have a pro-inflammatory condition that leads to
an immune system disorder. So, this chronic condition makes patients more susceptible
to infections, as well as to virus-associated cancer, and causes them to respond poorly
to the standard vaccination protocols, as previously observed with hepatitis B [12] and
influenza vaccinations [13], which revealed lower rates of antibody seroconversion and
reduced durability. Moreover, in dialysis patients, CD8+ T cells are diminished in both
number and function. Because both arms of the immune system are usually impaired, this
could explain the increased susceptibility of these patients to viral and bacterial infections
and their poor vaccination responses [14].
It is of critical importance to identify the behavior of the CKD-5D patients’ immune
system regarding the Comirnaty© vaccine in order to anticipate future risks and to provide
sufficient information to plan the future strategies to combat COVID-19 in this population.
The objective of this study is to evaluate the immune response of CKD-5D patients to
the Comirnaty® vaccine after a period of 3 and 6 months after completing the vaccination
regime, and compare it with that of non-vaccinated patients infected with SARS-CoV-2.

2. Materials and Methods

2.1. Participants’ Inclusion
Enrolled patients were selected from 38 NephroCare Portugal (Fresenius Medical
Care Portugal) dialysis units into two cohorts: one composed of completely vaccinated
patients with Comirnaty® (vaccinated group) against a second cohort of patients who
recovered from COVID-19 (control group), confirmed by the RT-PCR laboratory technique.
The inclusion criteria were patients who completed vaccination in our dialysis clinic
network until 20 February 2021 (vaccination is considered completed 7 days after the
second immunization), and patients who had an infection in the sixth (±1) month prior
to blood sample collection. Regarding vaccinated patients, only data from patients with
valid outcomes in both blood sample periods was considered. Out of the 3672 eligible
patients, we created three age subgroups according to the following criteria: <60 years; 60
to 70 years; and >70 years old. Three subgroups were also created for the body mass index
(BMI) variable according to the quartiles.

2.2. Sample Collection

Through a randomization process, a representative sample for each group was ob-
tained with a 95% confidence interval and 5% of sample error, a process conducted ac-
cording to Bartlett JE, et al. [15]. In order to achieve representativeness for the vaccinated
population, a sample of 385 patients was considered, including 10% to accommodate
dropouts during the 6 months of follow-up. The same procedures were followed to calcu-
late the representative sample (205) of the control group.

2.3. Anti-Spike IgG Level Quantification

For this purpose, with regard to the vaccinated group, we performed blood sampling
in order to quantify the specific Spike antibody IgG (titre of s-Ab) of the vaccine-induced
immune responses in two different moments, after 90 and 180 days (±15 days) of complet-
ing the vaccination, and with regard to the control group, we performed blood sampling
in order to quantify the specific Spike antibody IgG (titre of s-Ab) of the SARS-CoV-2
response to COVID-19 after 180 days (±15 days) of a positive test for SARS-CoV-2. As
previously suggested, the threshold for seroconversion was 50 arbitrary units per millilitre
(AU/mL) [16].
A total of mL of blood was collected in the dialysis unit immediately at the begin-
ning of treatment when scheduled. Immunogenicity was assessed by chemiluminescence
immunoassay (CLIA) to quantify IgG antibodies Anti-SARS-CoV-2 IgG Spike.

Int. J. Environ. Res. Public Health 2022, 19, 10091
previously suggested, the threshold for seroconversion was 50 arbitrary units per mi
tre (AU/mL) [16].
A total of mL of blood was collected in the dialysis unit immediately at the beginn
of treatment when scheduled. Immunogenicity was assessed by chemiluminescence
3 of 10
munoassay (CLIA) to quantify IgG antibodies Anti-SARS-CoV-2 IgG Spike.

2.4. Measure of Body Mass Index

2.4. Measure of Body Mass Index
Body mass index was obtained by bioimpedance spectroscopy measurements of
Body mass index was obtained by bioimpedance spectroscopy measurements of the
body composition with the BCM(R) (Body Composition Monitor—Fresenius Med
body composition with the BCM(R) (Body Composition Monitor—Fresenius Medical Care)
Care) and was defined as the dry weight (kg) divided by height in square meters.
and was defined as the dry weight (kg) divided by height in square meters.

2.5. Statistical2.5. Statistical Analysis

Analysis
Categorial
Categorial variables variables
were reportedwere reported asand
as frequencies frequencies and percentages.
percentages. Continuous
Continuous vari-
ables were reported as median and interquartile range (IQR). For paired samples andsamples
iables were reported as median and interquartile range (IQR). For paired
when the of
when the assumption assumption
normalityof wasnormality was not
not verified, the verified,
Wilcoxonthe Wilcoxon
test test
was used. was
For theused. For
comparison of different groups (vaccinated versus infected patients),
comparison of different groups (vaccinated versus infected patients), the Mann–Whitney the Mann–Whit
U testwhen
U test was used, was appropriate.
used, when appropriate. The results
The results were were significant
considered consideredwhen
significant
they when t
had a p < 0.05. All of the statistical analyses were performed using
had a p < 0.05. All of the statistical analyses were performed using SPSS (version 23; IBM, SPSS (version 23; I
Armonk,
Armonk, NY, USA). NY, USA).

3. Results 3. Results
This observational,
This observational, prospective,
prospective, and multicentre and multicentre
study studyofhad
had a cohort 4609a patients
cohort of
on4609 pati
haemodialysison(HD)
haemodialysis
distributed(HD)
in 38 distributed in 38
clinics. A total clinics.
of 3672 wereA scheduled
total of 3672
forwere scheduled for
vaccination
cinationbetween
against SARS-CoV-2 against SARS-CoV-2 between2021.
January and February JanuaryFromandthatFebruary 2021.
group, 385 From that group,
participants
participants
with no evidence with no
of previous evidence
exposure toofSARS-CoV-2
previous exposure to SARS-CoV-2
were randomized to thewere randomize
study
the study
(vaccinated group) (vaccinated
(Figure group)
1). A total (Figure
of 695 1).positive
tested A total offor695 tested positive
SARS-CoV-2 for SARS-CoV-
in RT-PCR
RT-PCR laboratory
laboratory technique tests fromtechnique
Decembertests 2020from December2021,
to February 2020 205
to February
of whom2021, were205 of wh
were
enrolled for the enrolled
“control for the “control group”.
group”.

Figure
Figure 1. Patient flow1.diagram
Patient flow
showsdiagram shows
enrollment, enrollment, randomization,
randomization, and follow-upand follow-up
of study of study patie
patients.

Eighty-six participants were lost during

Eighty-six participants were the
lostfollow-up
during thefor the reasons
follow-up for described
the reasonsindescribe
Figure 1. In the vaccinated
Figure 1. In thegroup, five participants
vaccinated were excluded
group, five participants owing
were to later
excluded infection
owing to later infec
by SARS-CoV-2; even so, only one had dyspnoea, diabetic decompensation,
by SARS-CoV-2; even so, only one had dyspnoea, diabetic decompensation, and was and
hospitalized for 6 days. The remaining four patients did not present symptoms and were
only identified after performing routine tests. Therefore, none of those patients developed
severe symptoms requiring intensive care admission or died.
The median age was 68 years old (range (19–95), IQR = 57–79) with mostly males
(n = 297, 58.90%), and the control group was older (p = 0.042) (Table 1).
Int. J. Environ. Res. Public Health 2022, 19, 10091 4 of 10

Table 1. Patient baseline characteristics of the vaccinated group and the COVID-19-recovered group.

Vaccinated Group COVID-19-Recovered

p-Value
(n = 321) Group (n = 183)
Demographics
Age (years), median (IQR) 67 [56–78] 70 [59–80] p = 0.042
BMI (Kg/m2 ), median (IQR) 24.8 [22–28.20] 24.8 [21.50–29.30] p = 0.646
Dialysis vintage (months),
62 [27.50–116] 57 [30–101] p = 0.942
median (IQR)
Male, n (%) 190 (59.20) 107 (58.50)
Vascular access
AVF n (%) 245 (66.0) 126 (33.9)
AVG n (%) 30 (60) 20 (40)
CVC n (%) 46 (55.42) 37 (44.58)
Causes of ESRD (n, %)
Diabetic nephropaty 49 (37.12) 83 (62.88)
Hypertension/vascular
27 (41.54) 38 (58.46)
disease
Polycystic kidney disease 13 (37.14) 22 (62.86)
Glomerulonephritis 22 (27.50) 58 (72.50)
Chronic pyelonephritis 19 (44.19) 24 (55.81)
Other causes 53 (36.31) 96 (64.43)
Note: % presented are related to the frequencies evaluated within the respective class of the vaccinated and
recovered group. For continuous variables, we present the median and the interquartile range (IQR). Mann–
Whitney U test to compare the groups in which the variables were continuous. Abbreviations: AVF, arteriovenous
fistula; AVG, arteriovenous graft; CVC, central venous catheter; BMI, body mass index.

3.1. Humoral Response of Vaccinated Patients after 3 and 6 Months

The mean interval between the end of completion of the vaccination program with
the Comirnaty© vaccine and the first blood sampling was 3.63 ± 0.06 (range, 3.03–3.87)
months (t0). Overall, at t0, the median anti-Spike IgG level was 1120 (IQR = 493–2805)
AU/mL. Eight patients (2.49%) were weak responders with a median of 32 (range 11–50)
AU/mL. No non-responders were observed. Among those eight, four (50%) were diabetics,
older, and heavier (median 76, IQR = 62–85 years and BMI 27.95, IQR = 25.8–32.70 Kg/m2 ,
respectively) than the respective overall group; however, they had been on haemodialysis
for a shorter period of time. The second blood sampling was performed at a mean of
6.64 ± 0.10 (range 6.53–7.10) months (t1). All participants decreased their antibody level to
a median of 455 (IQR = 189–967) AU/mL and the weak responders increased to 21 (6.54%).
The differentiating factor present in these participants was again the dialysis vintage, but in
this case, these patients were on dialysis for a longer time when compared with the others.

3.2. Humoral Response of COVID-19-Recovered Patients (Control Group)

In the 183 patients recovered from COVID-19 (control group), the mean time from
COVID-19 diagnosis to baseline blood sampling was 5.18 ± 0.94 (range = 4.4–9.23) months.
Median serum SARS-CoV-2 antibodies level was 1836 (IQR = 749–5168) AU/mL. Out
of those patients, four (2.18%) were weak responders with a median of 34 (range 21–50)
AU/mL. Notably, these patients are younger, but have been on HD for much longer (median
57, IQR = 48–74 years and vintage dialysis 262, IQR = 149–314 months, respectively) than
the others.

3.3. Anti-Spike Antibody Response between Groups

After 6 months of complete vaccination (t1), median anti-Spike IgG antibodies were
significantly lower, at 455 (IQR = 189–967) AU/mL, when compared with t0 (median 1120
(IQR = 493–2805) AU/mL) (Wilcoxom = −15.597; p < 0.001). However, comparing the
vaccinated group at t0 with the control group (recovered from COVID-19), the humoral
response was significantly higher in the control group (Mann–Whitney = 13391; p < 0.001),
with a median concentration of 1836 (IQR = 749–5168) AU/mL even after 5.18 months of
seroconversion (Table 2).
Int. J. Environ. Res. Public Health 2022, 19, 10091 5 of 10

Table 2. Comparison of humoral immunity status between the two groups: vaccinated at 3(t0) and 6
(t1) months and COVID-19 recovered (control group).

Vaccinated Vaccinated COVID-19

Variables p-Value
Group t0 Group t1 Recovered Group
Anti-Spike IgG (AU/mL)
1120 [493–2805] 455 [189–967] <0.001 a
median (IQR)
Anti-Spike IgG (AU/mL)
1120 [493–2805] 1836 [749–5168] <0.001 b
median (IQR)
Anti-Spike IgG (AU/mL)
455 [189–967] 1836 [749–5168] <0.001 c
median (IQR)
Note: For continuous variables, we present the median and the interquartile range (IQR). Wilcoxon test to compare
two paired groups was used for the vaccinated at the third and sixth months. Mann–Whitney U test to compare
the groups in which the variables were continuous. a Wilcoxom = −15.597, p < 0.001; b Mann–Whitney = 22562,
p < 0.001; c Mann–Whitney = 13391; p < 0.001. Abbreviations: AU/mL, arbitrary units per millilitre.

In the vaccinated group at t0, humoral response in older patients (>70 years) was
lower, at 874 (IQR = 351–2053) AU/mL, when compared with younger patients (≤60 years).
However, in the control group, the immune response was the opposite. In this group,
patients with >70 years had a better response (2096 (IQR = 890–9849) AU/mL) than in the
remaining age subgroups (Table 3).

Table 3. Comparison of humoral immunity status in the three age and body mass index subgroups.

COVID-19 Recovered
Anti-Spike IgG Anti-Spike IgG
Variables Anti-Spike IgG
(AU/mL) 3rd Month (AU/mL) 6th Month
(Au/mL) 6th Month
Age Groups
≤60 years, median (IQR) 1495 [686–3232] 554 [304–1224] 1769 [283–3394]
61–70 years, median (IQR) 1122 [482–2834] 416 [189–836] 1821 [990–4563]
>70 years, median (IQR) 874 [351–2053] 363 [128–852] 2096 [890–9849]
Body mass index
<23 Kg/m2 , median (IQR) 898 [342–2577] 363 [147–836] 1831 [794–6545]
23–28 Kg/m2 , median (IQR) 1155 [544–2838] 493 [227–986] 1791 [515–3822]
>28 Kg/m2 , median (IQR) 1229 [609–2853] 460 [196–1136] 2485 [818–5117]
Note: Three subgroups were created for age of ≤60, 61–70, and >70 years and for body mass index (BMI) of <23,
23–28, and >28 Kg/m2 . We present the median and the interquartile range (IQR). Patients with BMI > 28 developed
higher anti-Spike IgG levels in both vaccinated and control groups (median of 1229, IQR = 748–5168 AU/mL
versus median of 2485, IQR = 818–5117 AU/mL). In the subgroup of vaccinated patients older than 70 years, fewer
antibodies were observed when compared with the other subgroups. In contrast, in the control group, patients
with more than 70 had better immune response (median of 2096, IQR = 890–9849 AU/mL). AU/mL, arbitrary
units per millilitre.

To assess the response of elderly HD patients, they were partitioned into two age
subgroups, at <70 and ≥70 years. In the vaccinated group at t0, the patients with <70
years presented a significantly (p = 0.002) higher level of anti-Spike IgG titres (median
1380, IQR = 641–3021 AU/mL) than the older ones (Table 4). In contrast, the patients with
≥70 years from the control group presented a significantly (p = 0.038) higher IgG when
compared with the <70 years subgroup (median of 2096, IQR = 882–9872 AU/mL versus
median of 1807, IQR = 598–3945). However, we found no correlation between age and
anti-Spike IgG antibodies level in any of the studied groups.
We stratified the BMI into three subgroups according to quartiles, <23, 23–28, and
>28 Kg/m2 . Therefore, we decided to determine the median anti-Spike IgG in each pa-
tient group (vaccinated and control group). The subgroup with >28 kg/m2 showed a
higher humoral response, particularly in the control group, with a median concentration of
2485 [IQR = 818–5117] AU/mL (Table 3).
The weight variable was also partitioned into two subgroups, <30 and ≥30 kg/m2 . It
was observed that, in both groups, in the vaccinated group (t0, t1) and in the control group,
overweight patients had higher levels of anti-Spike IgG antibodies than in the <30 kg/m2
subgroup (Table 4), but without statistical significance (p = 0.975, p = 0.889, and p = 0.689,
respectively). Similarly to the weight variable, we also did not find a correlation between
Int. J. Environ. Res. Public Health 2022, 19, 10091 6 of 10

BMI and the anti-Spike IgG antibodies levels. More details are available in Supplementary
Tables S1–S3.

Table 4. Comparison of humoral immunity status in the age and body mass index subgroups.

Anti-Spike IgG COVID-19

Anti-Spike IgG
Variables p-Value 6th Month p-Value Recovered p-Value
3rd Month (AU/mL)
(AU/mL) (AU/mL)
Age Groups
<70 years, (n) median (IQR) (190) 1380 (641–3021) 712 (285–1774) (95) 1807 (598–3945)
≥70 years, (n) median (IQR) (131) 838 (345–2053) 0.002 684 (231–1949) 0.003 (88) 2096 (882–9872) 0.038
Body mass index
<30 Kg/m2 , (n) median (IQR) (268) 1083 (493–2813) 451 (196–981) 144–1817 (760–5330)
≥30 Kg/m2 , (n) median (IQR) (53) 1210 (459–2607) 0.975 469 (166–835) 0.889 39–2621 (711–5166) 0.689
Note: Two subgroups were created for ages of <70 and ≥70 years and for body mass index (BMI) <30 and
≥30 Kg/m2 . We present the median and the interquartile range (IQR). In the comparison between the subgroups,
we used the Mann–Whitney U test. Abbreviations: AU/mL, arbitrary units per millilitre.

When we crossed these two factors, age with BMI, we found that older and heavier
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 7 of 10
patients developed higher antibodies levels in the control group (Figure 2). More details
are available in Supplementary Tables S4–S6.

Figure
Figure 2. Graphic
2. Graphic representation of anti-spike
representation anti-spikeIgG
IgGantibodies level
antibodies between
level weight
between and body
weight and mass
body mass
index
index (BMI)
(BMI) variablesininthe
variables thevaccinated
vaccinated and
andcontrol
controlgroup. (A)(A)
group. In the vaccinated
In the group,
vaccinated a greater
group, a greater
variation of the humoral response was observed in the youngest and among the three
variation of the humoral response was observed in the youngest and among the three sub-groups sub-groups
of the BMI variable. (B) There was a high humoral response in older (>70 years) and heavier (BMI >
of the BMI variable. (B) There was a high humoral response in older (>70 years) and heavier
28 kg/m2) patients in the control group.
(BMI > 28 kg/m2 ) patients in the control group.
4. Discussion
4. Discussion
In the present study, we describe the kinetics of humoral response after Comirnaty®
In the present
vaccination study,with
in patients we describe the kinetics
CKD-5D after 3 and 6 of humoral
months response
compared withafter Comirnaty®
the control
vaccination in patients
group (patients with from
recovered CKD-5D after 3 and
COVID-19). 6 months
To the best of ourcompared
knowledge,withthis
theiscontrol
the firstgroup
study comparing humoral response in patients under a regular haemodialysis program,
(patients recovered from COVID-19). To the best of our knowledge, this is the first study
with the above
comparing humoralcharacteristics.
response in patients under a regular haemodialysis program, with the
Our results showed that, after 3 months (109 days) of the second Comirnaty© vaccine
above characteristics.
dose
Our(complete vaccination),
results showed that, aafter
large3majority
months (97.51%) of patients
(109 days) with CKD-5D
of the second Comirnaty©maintainvaccine
positivity for anti-Spike IgG, which was not observed in non-responders.
dose (complete vaccination), a large majority (97.51%) of patients with CKD-5D maintain This finding is
similar to previous published data in which, 36 days after the second immunization
positivity for anti-Spike IgG, which was not observed in non-responders. This finding is dose,
93.4% of the HD patients were seropositive with a median level of 1599 AU/mL [17].
similar to previous published data in which, 36 days after the second immunization dose,
However, the results reveal that this group had a 59.38% decline in antibody level in
93.4% of the HD patients were seropositive with a median level of 1599 AU/mL [17].
just 90 days of interval between t0 and t1, decreasing its protection degree. These results
However, the results reveal that this group had a 59.38% decline in antibody level in
are in line with other studies in which participants also lost titre levels three months after
justvaccination
90 days of[18]interval
and, inbetween t0 and
another study t1, decreasing
enrolling its protection
41 HD patients, degree. These
it was concluded that theresults
are seroconversion
in line with other studies infrom
rate decreases which98%participants
at 1 month toalso
65.80%lostattitre levelsafter
6 months threethemonths
second after
dose [19]. A study conducted by Labriola et al. [20] also noted an identical decline (median
of 65.6%) in all SARS-CoV-2-positive patients from 30 days after seroconversion through
the following 3 months. This reduction may be associated with the uremic condition in
patients undergoing hemodialysis and, therefore, plays an adverse role in the develop-
ment of adaptive immune responses [14,21]. This factor also seems to contribute to the
Int. J. Environ. Res. Public Health 2022, 19, 10091 7 of 10

vaccination [18] and, in another study enrolling 41 HD patients, it was concluded that the
seroconversion rate decreases from 98% at 1 month to 65.80% at 6 months after the second
dose [19]. A study conducted by Labriola et al. [20] also noted an identical decline (median
of 65.6%) in all SARS-CoV-2-positive patients from 30 days after seroconversion through
the following 3 months. This reduction may be associated with the uremic condition in
patients undergoing hemodialysis and, therefore, plays an adverse role in the development
of adaptive immune responses [14,21]. This factor also seems to contribute to the lower
humoral response reported in recent studies [16,21,22], which showed that HD patients
develop impaired humoral responses after vaccine dose when compared with the general
population. Despite this significant reduction, we observed that 93.46% of patients after
180 days were still considered positive, which was not observed in any participants with
seroconversion to negative.
The maintenance of antibodies from patients in the control group was significantly
higher than that of those in the vaccinated group (t0 and t1), even after a median of 158 days.
On the other hand, the response rate was also higher (97.82%) in the control group.
The findings on the partitioning of participants by age revealed that the immune response
was lower in the oldest vaccinated group (≥70 years), when compared with age-matched
participants in the control group. Previous studies have also concluded that age was an
important factor in the humoral response following the Comirnaty© vaccine [16,22–24]. Age
is another factor that may explain, at least in part, the lower humoral response in patients on
dialysis. In opposition, our results showed that SARS-CoV-2 infection induces a significantly
stronger immune response, particularly in older patients. We did not find an explanation for
these findings, but in our interpretation, it may be attributable to the high severity of COVID-19
and, consequently, to the higher immune response in patients with multiple comorbidities.
Thus, elderly patients presented a more severe COVID-19 clinical setup, with an increased risk
of developing dyspnoea or pneumonia and mortality in HD patients that was 19.6% higher as
compared with the non-elderly group [25]. Some studies have shown that HD patients have a
robust and sustained antibody response when they have recovered from severe COVID-19,
and these levels can be maintained over time [26,27].
It was observed that heavier patients that were considered obese (BMI ≥ 30 Kg/m2 )
showed a greater immune response in both the vaccinated and control group; however, we
did not find any significant relation between BMI and antibody response. Our study is in
line with recent publication describing that the BMI was not considered a factor associated
with the antibody titre in the haemodialysis patients [21].
Despite the importance of vaccination, owing to the emergence of new variants and
because of the vulnerability of this population, hygienic measures remain an indispensable
cornerstone in the prevention of SARS-CoV-2 infections in dialysis units.
This study has several limitations. We acknowledge that our study only evaluated
the immune response of the anti-Spike IgG antibodies, and it did not measure T cell
response, which would help us to better understand the observed immune response.
We did not identify patients with immunosuppressive therapy that could influence the
immune response. Although the findings of previous studies regarding this factor were
non-conclusive, it was observed that the lower respondents after the second dose had a
history of immunosuppression [28,29], but, on the other hand, there are also studies that
cannot find any suggestion that immunosuppression weakens this response [26]. In one
study conducted by Bonelli, Michael et al. [30], they observed that B-cell-depleting therapy
with rituximab affects the humoral immune response to SARS-CoV-2 vaccination and,
furthermore, they also noticed a T-cell-mediated immune response even in B-cell-depleted
patients. However, other studies suggested that immunosuppression therapy in kidney
transplant patients is a strong inhibitor of humoral response [21,31].

5. Conclusions
Elderly patients on HD after the Comirnaty© vaccine developed a lower immune
response than younger patients. Simultaneously, the levels of anti-Spike IgG antibodies
Int. J. Environ. Res. Public Health 2022, 19, 10091 8 of 10

declined faster between the third and sixth month. Moreover, heavier patients showed
a greater immune response in both the vaccinated and control group, although without
significance. Based on these findings, personalized immunization schedules of the elderly
population may be needed to be considered for boosting to sustain immune protection.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10.339

0/ijerph191610091/s1, Supplementary Table S1: Anti-Spike IgG, according to age and BMI in the vaccinated
group at t0; Supplementary Table S2: Anti-Spike IgG, according to age and BMI in the vaccinated group
at t1; Supplementary Table S3: Anti-Spike IgG, according to age and BMI in the SARS-CoV-2-recovered
(control) group; Supplementary Table S4: Comparison of humoral immunity status, according to age and
BMI subgroups in the vaccinated group at t0; Supplementary Table S5: Comparison of humoral immunity
status, according to age and BMI subgroups in the vaccinated group at t1; Supplementary Table S6:
Comparison of humoral immunity status, according to age and BMI subgroups in the SARS-CoV-2-
recovered (control) group.
Author Contributions: Conceived and designed the manuscript—P.P., J.F.M., R.P., B.P. and C.F. Data
analysis—R.P., B.P. and J.F.M. All authors critically revised. Supervision and final responsibility—P.P.
and J.F.M. All authors have read and agreed to the published version of the manuscript.
Funding: This clinical study benefited from Fresenius Medical Care. The funding had no role in
study design, data collection and analysis, or decision to publish.
Institutional Review Board Statement: The analysis was conducted in accordance with the declara-
tion of Helsinki. The analysis was conducted to inform a continuous quality improvement program
of health care practice. The Institutional Review Board of FMC-Nephrocare Portugal has confirmed
that the study adheres to ethical standards and approved the study protocol.
Informed Consent Statement: This study was reviewed and approved by the Ethical Committee of
Fresenius Medical Care, Portugal, n◦ 008/2021, in compliance with the 1975 Declaration of Helsinki,
as revised in 2013, and follows the international and national guidelines for health data protection.
All participants provided their written informed consent to participate in the study.
Data Availability Statement: The datasets used and/or analysed during the current study are
personal health information obtained during provision of healthcare services and cannot be shared to
protect their confidentiality in compliance with GDPR regulation.
Acknowledgments: Owing to the professionalism and resilience demonstrated along the last 2
years, which was determinant for the minimization of the pandemic effects among dialysis patients,
the authors would like to publicly express their acknowledgement to all of the dialysis clinics
professionals of the NephroCare Portugal dialysis clinics network.
Conflicts of Interest: All authors declare that the funders had no role in the design of the study; in
the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision
to publish the results.

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