key: cord-1048272-zx6ibv48
authors: Duengelhoef, Paul; Hartl, Johannes; Rüther, Darius; Steinmann, Silja; Brehm, Thomas T.; Weltzsch, Jan Philipp; Glaser, Fabian; Schaub, G. M.; Sterneck, Martina; Sebode, Marcial; Weiler‐Normann, Christina; Addo, Marylyn M.; Lütgehetmann, Marc; Haag, Friedrich; Schramm, Christoph; Schulze zur Wiesch, Julian; Lohse, Ansgar W.
title: SARS‐CoV‐2 vaccination response in patients with autoimmune hepatitis and autoimmune cholestatic liver disease
date: 2022-03-15
journal: United European Gastroenterol J
DOI: 10.1002/ueg2.12218
sha: 201d3f2572d13147b3000b0580fca1ccba86528e
doc_id: 1048272
cord_uid: zx6ibv48

BACKGROUND/AIMS: In this observational study, we explored the humoral and cellular immune response to SARS‐CoV‐2 vaccination in patients with autoimmune hepatitis (AIH) and patients with cholestatic autoimmune liver disease (primary sclerosing cholangitis [PSC] and primary biliary cholangitis [PBC]). METHODS: Anti‐SARS‐CoV‐2 antibody titers were determined using the DiaSorin LIAISON and Roche immunoassays in 103 AIH, 64 PSC, and 61 PBC patients and 95 healthy controls >14 days after the second COVID‐19 vaccination. The spike‐specific T‐cell response was assessed using an activation‐induced marker assay (AIM) in a subset of individuals. RESULTS: Previous SARS‐CoV‐2 infection was frequently detected in AIH but not in PBC/PSC (10/112 (9%), versus 4/144 (2.7%), p = 0.03). In the remaining patients, seroconversion was measurable in 97% of AIH and 99% of PBC/PSC patients, respectively. However, in 13/94 AIH patients antibody levels were lower than in any healthy control, which contributed to lower antibody levels of the total AIH cohort when compared to PBC/PSC or controls (641 vs. 1020 vs. 1200 BAU/ml, respectively). Notably, antibody levels were comparably low in AIH patients with (n = 85) and without immunosuppression (n = 9). Also, antibody titers significantly declined within 7 months after the second vaccination. In the AIM assay of 20 AIH patients, a spike‐specific T‐cell response was undetectable in 45% despite a positive serology, while 87% (13/15) of the PBC/PSC demonstrated a spike‐specific T‐cell response. CONCLUSION: Patients with AIH show an increased SARS‐CoV‐2 infection rate as well as an impaired B‐ and T‐cell response to SARS‐CoV‐2 vaccine compared to PBC and PSC patients, even in the absence of immunosuppression. Thus, antibody responses to vaccination in AIH patients need to be monitored and early booster immunizations considered in low responders.

The severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) vaccine-induced immune response of different cohorts with liver disease including cirrhotic patients and liver transplant recipients has recently been published. 1 It demonstrated lower spikespecific antibody levels after the second SARS-CoV-2 vaccination in transplant patients but equally high antibody levels in cirrhotic patients compared to HC. In contrast, the spike-specific T-cell response was reduced in both patient groups. Another study revealed that patients with various autoimmune diseases and immunosuppression like rheumatic arthritis were also less likely to reach seroconversion after SARS-CoV-2 vaccination. 2 However, the vaccination response in patients with autoimmune liver diseases has not been studied comprehensively so far, nor have risk factors for an inadequate vaccination response been explored in this vulnerable cohort.

This prospective observational study compared the humoral and T-cellular immune response to SARS-CoV-2 vaccination in a large cohort of patients with AIH and cholestatic autoimmune liver disease (PBC and PSC). Also, predictors of low response to vaccination were explored in this cohort. AstraZeneca). Clinical data were obtained from the patients' electronic medical records. In addition, previous data from 95 control subjects matched by age, vaccination regimen, and time since second vaccination were included. 3 In all participants, the immune response was determined >2 weeks after the second vaccination. The study was approved by the local Ethics Committee of Hamburg, Germany (Reg. numbers PV7103, PV7298, EV5332) and the Paul Ehrlich Institute, the German Federal Institute for Vaccines and Biomedicines (Reg. number NIS508). All participants signed written informed consent.

The vaccine-specific humoral immune response was quantitatively determined by the DiaSorin LIAISON XL anti-SARS-CoV-2 TrimericS IgG ChemiLuminescent ImmunoAssay (sensitivity 99.4%, specificity 99.8%, cut-off 33.8 BAU/mL 4 ), further denoted as anti-S Trimer, and the Roche Elecsys anti-SARS-CoV-2 S Ig ElectroChemiLuminescent ImmunoAssay (sensitivity 93.9%, specificity 99.6%, cut-off 0.8 U/mL 5 

In Nevertheless, antibody titers were significantly lower in comparison to HC when measured by the Trimer assay (p = 0.001; Figure 1a) and tended to be lower when the RBD assay was used (p = 0.08; Figure S2A ). Although the difference in median antibody levels between the total cohort of AIH patients and controls was moderately pronounced, it is noteworthy that in a subgroup of 13 (14%) AIH patients, antibody levels were lower than the lowest antibody titer measured in any healthy control (Figure 1a , Figure S2A ). The characteristics of this subgroup of AIH patients are shown in Table S2 . No individual risk factor for impaired antibody response could be detected in this subgroup.

Irrespective of the assay used, antibody titers in AIH were significantly lower when compared to patients with cholestatic liver diseases ( Figure 1b , Figure S2B ). Therefore, we next explored whether this difference might be related to the distribution of potential risk factors for an impaired vaccination response. Patients with AIH did not differ with regard to age, sex, time since second vaccination, diabetes,

Age (mean years, SD) 52 (17) 60 (17) 11%, p = 0.16). Hence, the potential impact of these factors on antibody levels was further explored.

Albeit most AIH patients require long-term immunosuppressive treatment, 7 nine (10%) AIH patients were in biochemical remission and had been off immunosuppressive therapy for at least 6 months.

Interestingly, AIH patients without immunosuppression had comparably low antibody levels as those under immunosuppression ( Figure 2a , Figure S3A ), as well as lower antibody titers than HC (p = 0.050). Of note, no difference between AIH patients with and without immunosuppression was observed concerning age, time since second vaccination, or any other baseline characteristic (Table 2) (Table S3) .

Hence, no extrinsic factor which might have contributed to the lower antibody levels among AIH patients could be identified.

When patients with cholestatic liver disease (PBC or PSC) were analyzed separately, PBC patients had lower antibody titers than patients with PSC ( Figure S4 ) despite less frequent immunosuppressive treatment (12 vs. 38%). However, it must be noted that PBC patients had a longer time interval after the second vaccination (85 vs. 73 days (mean)) and were significantly older (61 vs. 44 years (mean)) with consecutively lower glomerular filtration rate (81 vs.

100 ml/min (median)) than patients with PSC (Table S2 ).

The predictive degree of immunity to SARS-CoV-2 based on antibody levels has not been determined yet. Herein, we defined the cut-off for a "borderline response" at 100 BAU/mL (and 100 AU/mL) in line with previous reports and randomized trials. 1,8-10 Also, the cut-off level of 100 BAU/ml represents the lowest antibody level measured in any healthy control in this study. Furthermore, an additional cut-off for a "low" positive response was set at the 25% percentile of antibody levels from HC in the respective assay (i.e. 552 BAU/mL (anti-S Trimer) and 646 AU/mL (anti-RBD)).

Both endpoints, "borderline" and "low" response occurred more frequently in patients with AIH than in patients with autoimmune cholestatic liver disease ("borderline response": 11% vs. 3%, p = 0.028; "low response": 46% vs. 30%, p = 0.18; Table 1 ; Figure 3 ).

In the total cohort of patients with autoimmune liver diseases, an independent effect on both endpoints, "borderline response" as well as "low response", was demonstrated for only two parameters that is the use of steroids and time after second vaccination ( Table 3 , Table S3 and S4).

Thus, the impact of time after second vaccination was further investigated. The time interval varied between 2 weeks and 7 months and was not different between study groups (Table 1) . During this period, a decrease of antibody titers was observed in all study groups independently of the antibody assay applied (Figure 4 , Figure S5 ). Although no other factor was independently linked with borderline response in the small subset of patients with antibody levels <100 BAU/ml, age, sex, diabetes, and hypertension indicated some impact on "low response" consistently in both assays but this failed to reach significance in the multivariate analysis (Table 3,   Table S4 ).

Heterologous vaccination was associated with increased antibody levels, but only in the Trimer assay ( 

In addition to antibody-titers, the spike-specific T-cell response was assessed by the upregulation of the activation-induced markers (activation-induced marker assay (AIM)) CD154 and CD137 in 20 AIH patients, 15 patients with cholestatic liver disease (13 PBC, 2 PSC), and 7 controls to examine the spike specific T-cell response.

Almost every second AIH patient (9/20, 45%) did not show a specific CD4+ T-cell response upon stimulation, while this was the case in only 2/15 (13.3%) patients with cholestatic liver disease (both PBC) and none of the controls (Figure 5a) . Moreover, frequencies of spike-specific CD4 + and CD8 + T cells tended to be lower in AIH patients as compared to HC (p = 0.14, and p = 0.05, respectively), whereby in line with previous results, frequencies of spike specific CD8 + T cells were lower than respective frequencies of CD4 + T cells ( Figure S6 ). 11, 12 In the total cohort of patients with autoimmune liver diseases, a low humoral response (<552 BAU/ml) was linked with lower frequencies of spike-specific CD4 + T-cells and lower T-cell response upon stimulation ( Figure S7 ). However, the overall correlation 

This observational study is the first report that comprehensively and prospectively assessed the humoral and cellular immune response in patients with AIH following the second anti-SARS-CoV-2 vaccination.

Moreover, the vaccination response was compared to age-and sexmatched study groups of patients with cholestatic autoimmune liver disease (PBC/PSC) and HC. 3 Almost all AIH patients (97%) achieved a seroconversion.

Nevertheless, a subgroup of about 15% of patients with AIH showed a considerably reduced humoral immune response, which resulted in moderately reduced antibody levels of the total AIH cohort when compared to healthy individuals or patients with cholestatic liver diseases. Also, in contrast to some previous reports 11 but in accordance with more recent publications, 12 

F I G U R E 5 T cell response after second SARs-CoV-2 vaccination in patients with autoimmune hepatitis (AIH), patients with cholestatic autoimmune liver disease (primary biliary cholangitis/primary sclerosing cholangitis) and healthy controls (HC) (a) Responder rates within patient groups according to CD4 + (left) and CD8 + (right) T cell. Stimulation index (SI) was calculated by dividing the percentages of CD154 + CD4 + T cells or rather either CD154 + or CD137 + CD8 + Tcells in the stimulated sample by the respective unstimulated value. A SI of >2 was interpreted as a positive reaction. SI below 1 were set to 1 (b) Stimulation indices (SI) compared to the humoral response (c) Correlation of percentages of CD154 + CD4 + T cells to antibody levels (anti-S Trimer). Dotted horizontal line indicates cut-off value for an adequate T cell response; dotted vertical lines indicate cut-off values for no, "borderline", or "low response" (<33,8 BAU/mL, <100 BAU/mL, <552 BAU/mL) the sample size may have been too small, to detect more subtle pronounced effects, which is clearly a limitation of this study. Especially the small sample size in the subgroups including AIH patients without immunosuppression (n = 9), patients with the lowest antibodies (n = 13) and infection rates among AIH patients and PBC/PSC (n = 11) limits the significance of the results. Furthermore, not standardizing timepoints of blood collection after second vaccination is a main methodological limitation of this study. Although time since second vaccination was equally distributed between study groups, the time interval varied considerably, and therefore, might have introduced bias. In addition, this study is limited by the restricted number of patients in whom the T-cell response was explored. In addition, we did not look for the functionality of the T cells (e.g. via cytokine staining),

hence the full T cell response and level of protection in our cohort is still unknown. Finally, it has to be pointed out that the level of circu- 

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The authors wish to thank all study participants and contributing departments of the UKE for their active participation in the study.Open access funding enabled and organized by Projekt DEAL.

All authors declare that they have no known competing financial, professional, or personal conflicts that could have appeared to influence the work reported in this paper.

Individual participant data will not be shared.

https://orcid.org/0000-0002-4037-9938Darius Rüther https://orcid.org/0000-0003-3783-380X