key: cord-0964978-yom7bok5 authors: Lindemann, Monika; Krawczyk, Adalbert; Dolff, Sebastian; Konik, Margarethe; Rohn, Hana; Platte, Maximillian; Thümmler, Laura; Schwarzkopf, Sina; Schipper, Leonie; Bormann, Maren; van de Sand, Lukas; Breyer, Marianne; Klump, Hannes; Knop, Dietmar; Lenz, Veronika; Temme, Christian; Dittmer, Ulf; Horn, Peter A.; Witzke, Oliver title: SARS‐CoV‐2‐specific humoral and cellular immunity in two renal transplants and two hemodialysis patients treated with convalescent plasma date: 2021-02-09 journal: J Med Virol DOI: 10.1002/jmv.26840 sha: b3f7258188c42db321d4d4eb1893254ccd97c5d0 doc_id: 964978 cord_uid: yom7bok5 When patients with chronic kidney disease are infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) they can face two specific problems: virus‐specific immune responses may be impaired and remdesivir, an antiviral drug described to shorten recovery, is contraindicated. Antiviral treatment with convalescent plasma (CP) could be an alternative treatment option. In this case report, we present two kidney transplant recipients and two hemodialysis patients who were infected with SARS‐CoV‐2 and received CP. Antibodies against the receptor‐binding domain in the S1 subunit of the SARS‐CoV‐2 spike protein were determined sequentially by immunoglobulin G (IgG) enzyme‐linked immunosorbent assay (ELISA) and neutralization assay and specific cellular responses by interferon‐gamma ELISpot. Before treatment, in both kidney transplant recipients and one hemodialysis patient antibodies were undetectable by ELISA (ratio < 1.1), corresponding to low neutralizing antibody titers (≤1:40). ELISpot responses in the four patients were either weak or absent. After CP treatment, we observed an increase of SARS‐CoV‐2‐specific antibodies (IgG ratio and neutralization titer) and of specific cellular responses. After intermittent clinical improvement, one kidney transplant recipient again developed typical symptoms on Day 12 after treatment and received a second cycle of CP treatment. Altogether, three patients clinically improved and could be discharged from the hospital. However, one 83‐year‐old multimorbid patient deceased. Our data suggest that the success of CP therapy may only be temporary in patients with chronic kidney disease; which requires close monitoring of viral load and antiviral immunity and possibly an adaptation of the treatment regimen. In patients with chronic kidney disease and infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) treatment can be complicated because their immune function is suppressed due to medication to prevent allograft rejection and/or the underlying kidney disease. Thereby, the formation of specific antibodies and of T-cell immunity is impaired; which can result in a prolonged persistence of SARS-CoV-2 (for up to 2 months 1 ). Furthermore, remdesivir, an antiviral nucleoside analog that shortened the time to recovery in adults hospitalized with coronavirus 2019 (COVID-19) disease, 2 is contraindicated in this special cohort. Antiviral treatment with convalescent plasma (CP) could be an alternative treatment option. Data on patients with chronic kidney disease infected with SARS-CoV-2 and receiving CP treatment are still limited. We are aware of only 14 described kidney transplant recipients who received CP. [3] [4] [5] [6] [7] Whereas clinical improvement after CP has been shown for all six kidney transplant recipients included in three studies, [3] [4] [5] in the fourth study 6 a mortality rate for solid organ recipients (including six with kidney allograft) in the range of recipients without CP treatment [8] [9] [10] was reported (23% 6 vs. 24%-32%, [8] [9] [10] respectively). In the fifth study describing HIV-infected kidney transplant recipients 7 one of the two patients died after having received CP treatment. However, the previous reports did not present data on the course of SARS-CoV-2-specific antibodies or cellular responses in the patients. It was the aim of the current study to follow-up up virusspecific humoral and cellular immunity in patients with chronic kidney disease who were infected with SARS-CoV-2 and received CP therapy. We functionally analyzed the antibodies (by neutralization assay) and measured specific cellular responses by the highly sensitive ELISpot method, using various protein antigens of SARS-CoV-2 as specific stimuli. Finally, in one transplant recipient who again developed typical COVID-19 symptoms after initial clinical improvement, we had the chance to modify the treatment regimen and to apply the second cycle of CP therapy. The current case report includes two renal transplant recipients and two hemodialysis patients (Table 1) (Table 2 ). Details on the donor selection criteria have been described recently. 12 To assess SARS-CoV-2-specific humoral immunity, IgG antibodies in donor and patient sera were determined by a CE marked anti-SARS-CoV-2 IgG semi-quantitative enzyme-linked immunosorbent assay (ELISA; Euroimmun), according to the manufacturer's instructions. The ELISA plates were coated with recombinant SARS-CoV-2 spike (S) 1 protein (receptor binding domain). Serum samples were analyzed automatically at a 1:100 dilution, using the Immunomat™ (Virion\ Serion). Results are given as a ratio (patient sample/control sample). An antibody ratio of ≥1.1 was considered positive, of ≥0. 8 To assess SARS-CoV-2-specific cellular immunity, we performed ELISpot assays, using peptide pools of the S1/S2 protein, the S1 protein, and the membrane (M) protein (PepTivator®, Miltenyi Biotec) and an S1 protein antigen of SARS-CoV-2 (Sino Biological). The peptide pools consist mainly of 15-mer sequences with 11 amino acids overlap. We tested 250,000 peripheral blood mononuclear cells per cell culture and measured interferon-gamma (IFN-γ) production after 19 h, as published recently in detail. 12 In both kidney recipients and one hemodialysis patient with undetectable SARS-CoV-2-specific IgG (ratio < 1.1) and low neutralizing antibody titers ( ≤ 1:40; RTX01, RTX02, and HD01; Table 1 ) we observed an increase of antibody titers ( Figure 1A-C) . Figure 1D ). However, SARS-CoV-2-specific antibodies in the CP F I G U R E 1 Course of specific humoral and cellular immunity in four patients with chronic kidney disease infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and receiving convalescent plasma treatment. Antibodies were determined by an S1 specific immunoglobulin G (IgG) enzyme-linked immunosorbent assay (Euroimmun) and by cell-culture based neutralization assay (NT titer). Cellular responses were analyzed by an interferon-gamma (IFN-γ) ELISpot assay, using peptide pools of the S1/S2, S1, and M protein and an S1 protein antigen as specific stimuli (depicted as S1/S2, S1, M, and S ELI). We here present data on two kidney transplant recipients (RTX01, RTX02) and two patients on hemodialysis (HD01, HD02) and compared their immune responses with those of the corresponding donors of convalescent plasma (CP; shaded area). SARS-CoV-2-specific antibody data (IgG ratio and NT titer) are given on the left Y-axis and ELISpot data on the right one. donor of the fourth patient were lower than in the patient (ratio: 3.39, neutralizing titer: 1:320). Cellular immunity could be followed-up by IFN-γ ELISpot, using four different SARS-CoV-2-specific antigens (peptide pools of the S1/S2, S1, and M protein and an S1 protein antigen). Before CP treatment, one patient was negative to the ELISpot (HD02) and three showed weak responses (RTX01, RTX02, and HD01). Three patients could be followed-up after CP treatment. In these three patients, IFN-γ production to the ELISpot intermittently increased, reaching a maximum at Days 6-14 after CP therapy. Our data show an increase of specific humoral and cellular immunity in two kidney transplant recipients and two hemodialysis patients with ELISpot data, we observed a maximum of IFN-γ responses shortly after completion of the CP cycle. Of note, cellular immunity is regarded as important for recovery from SARS-CoV-2 infection 16 and appears as short-lived in the current cohort. As CP therapy is a form of passive immunization, an increase in cellular responses is not expected at first glance. After an initial increase, IFN-γ production decreased again, which could reflect the fact that proinflammatory immune responses shifted to anti-inflammatory responses. 17 It has already been shown that there was a reduction in proinflammatory cytokines like IL-6 and an increase in anti-inflammatory cytokines after CP was administered. [18] [19] [20] Moreover, chronic kidney disease suppressed T-cell function, which could impede long-term protection against reinfection. 3, 21 Three out of four patients with chronic kidney disease showed clinical improvement; which is in the range of previous reports. [3] [4] [5] [6] However, due to the low patient number, it was beyond the aim of our study to answer the question of CP therapy was effective. This answer can only be given by large randomized clinical studies such as the Randomized Evaluation of COVID-19 Therapy (RECOVERY) trial 22 ; which is currently underway. In conclusion, our data suggest that despite an increase of SARS-CoV-2-specific immunity the success of CP therapy may only be temporary in patients with chronic kidney disease. Thus, short-term treatment control (monitoring of viral load and antiviral immunity) appears mandatory for this patient group. If necessary, the treatment regimen has to be adapted. 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The study was approved by the local ethics committee (20-