Kidney Transplant Recipients Develop Nasal Mucosal Antibodies to SARS-CoV-2 With ACE2-Inhibiting Activity Following mRNA Vaccination

BACKGROUND: Less than 60% of kidney transplant recipients (KTRs) become IgG seropositive for the viral spike (S) antigen following two COVID-19 vaccine doses, with a third dose increasing these numbers further. Mucosal antibodies play a critical role in protection against SARS-CoV-2 (re)infection; however, the presence and functionality of these antibodies after vaccination have not been well-studied in high-risk groups with reduced vaccine immunogenicity.

METHODS: We assessed the concentration of ancestral S-specific antibodies in the nasal mucosa and in serum as well as their capacity to neutralize binding of the receptor-binding domain (RBD) to the ACE2 receptor in KTRs after two, three, and/or four vaccinations, compared with an age-matched control group after two vaccine doses.

RESULTS: KTRs showed an increase in nasal and serum S-specific IgG and S-specific IgA geometric mean concentrations (GMCs) as well as ACE2 binding inhibition at 28 days after both two-dose and additional vaccinations compared to baseline, although postvaccination GMCs remained lower than in the control group. We observed a high correlation between nasal and serum antibody levels (r S > 0.63) and ACE2 inhibiting capacity (r S > 0.65). Furthermore, nasal S-specific IgG, and to a lesser extent IgA, was correlated with nasal ACE2 binding inhibition (r S > 0.64 and 0.5).

CONCLUSIONS: KTRs develop nasal mucosal antibodies, which are able to inhibit binding to ACE2 after COVID-19 vaccination, but at a lower concentration than controls. Mucosal sampling provides an accessible and minimally invasive addition to measuring serum antibodies for monitoring the response to vaccination at a population level.