Shared and Data-Driven Decision-Making with Transplant Recipients About COVID-19 Vaccination Is Crucial.
Shared and Data-Driven Decision-Making with Transplant Recipients About COVID-19 Vaccination Is Crucial.
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与移植受者就 COVID-19 疫苗接种进行共享和数据驱动的决策至关重要。
DOI：
10.1002/lt.26418
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发表时间：
2022
期刊：
影响因子：
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通讯作者：
Werbel,WilliamA
中科院分区：
文献类型：
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作者：
Strauss,AlexandraT;Segev,DorryL;Werbel,WilliamA
我们赞赏这种强有力的患者视角，即在2019冠状病毒病（COVID-19）大流行期间，作为一名免疫抑制患者所固有的持续斗争和权衡。在这场大流行期间的生活充满挑战，特别是对于免疫功能低下的人来说，他们对疫苗接种没有产生抗体反应，因此对他们感染严重急性呼吸系统综合征冠状病毒2（SARS-CoV-2）的持续高风险感到沮丧和恐惧。事实上，抗代谢物，如霉酚酸酯（MMF），与肝移植受者中疫苗血清反应不良密切相关（1），这使其成为寻求改善疫苗免疫原性的潜在可改变风险因素。在接受心脏、肺和肾移植的患者中，霉酚酸酯剂量与疫苗接种的抗体应答之间存在强相关性。（2，3）根据我们的临床经验，在严重血细胞减少、胃肠道不适和严重感染综合征（包括COVID-19）期间，我们通常保持MMF。然而，与自身免疫性疾病患者不同，风湿病学会建议患者在血清反应改善的证据下保持MMF围接种期（4，5），考虑到排斥反应和同种免疫激活的理论风险，这不是移植患者的标准治疗。因此，我们正在临床试验环境中积极研究这种方法在抗体滴度阴性且移植团队认为同种免疫风险低的腹部移植受者中的安全性和免疫原性（NCT 05077254）。我们同意，在这个快速发展的环境中，患者和提供者之间关于检测、干预和风险承受能力的共同决策是关键。这些决定关系到病人在真实的世界中如何生活。对于移植受者来说，“呆在家里，避免所有的社会交往”的笼统声明可能是不可能的，他们中的许多人已经练习了近2年的版本。作为医生，我们有责任帮助患者根据机械理解和可用数据的组合做出明智的决定。我们强烈支持在决策过程中增加抗体数据;毕竟，抗体数据已经指导了第三剂疫苗的建议以及预防性和治疗性单克隆抗体的患者选择。现在是时候让移植协会的建议更加数据驱动和细致入微地制定个人接受者的风险评估，而不仅仅是普遍的社交距离和戴面具。我们赞扬作者提出了我们整个移植界应该仔细考虑的重要问题。
We appreciate this powerful patient perspective regarding the ongoing struggles and trade-offs inherent to being an immunosuppressed patient during the coronavirus disease 2019 (COVID-19) pandemic. Living during this pandemic has been challenging, particularly for immunocompromised persons who have not generated antibody response to vaccination and thus remain frustrated and frightened about their continued high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Indeed, antimetabolites, such as mycophenolate mofetil (MMF), are strongly associated with poor vaccine seroresponse in liver transplantation recipients,(1) which makes it a potentially modifiable risk factor in the search for improved vaccine immunogenicity. In patients undergoing heart, lung, and kidney transplantation, there is a strong association between MMF dose and antibody response to vaccination.(2, 3) In our clinical experience, we routinely hold MMF in the setting of significant cytopenia, gastrointestinal upset, and during severe infectious syndromes including COVID-19. However, unlike in patients with autoimmune disease where rheumatology societies advise patients to hold MMF perivaccination given evidence for improved seroresponse,(4, 5) this is not standard of care for transplantation patients given the theoretical risks of rejection and alloimmune activation. We are therefore actively studying safety and immunogenicity of this approach in the clinical trial setting for abdominal transplantation recipients with negative antibody titers and deemed low alloimmune risk by their transplantation teams (NCT05077254). We agree that shared decision making between patient and providers regarding testing, interventions, and risk tolerance is key amid this rapidly evolving environment. These decisions matter as to how patients live their lives in the real world. A blanket statement of “stay home and avoid all societal interaction” may just not be possible for transplantation recipients, many of whom have been practicing a version of this for nearly 2 years. As physicians, we have a responsibility to help patients make informed decisions based on a combination of mechanistic understanding and available data. We strongly support adding antibody data to the decision-making process; antibody data, after all, have already guided recommendations for third vaccine doses as well as patient selection for preventative and therapeutic monoclonal antibodies. It is time for transplantation society recommendations to be more data-driven and nuanced in framing individual recipient risk assessments beyond universal social distancing and mask-wearing. We commend the author on raising important concerns that our entire transplantation community should carefully consider.