Background: The coronavirus disease 2019 (COVID-19) vaccine is not readily available in many countries where dosing interval is spaced more than ideal. Patients with chronic kidney disease, especially those on maintenance hemodialysis, have a tendency for a reduced immune response. This study was undertaken to demonstrate the distinct humoral immune response to the viral vector COVID-19 vaccine in patients with kidney failure receiving maintenance hemodialysis. Methods: The study was carried out with two cohorts: 1) patients receiving maintenance hemodialysis and 2) healthcare workers from the same dialysis center as controls, each group with 72 subjects. Participants received a dose of Covishield ChAdOx1 nCoV-19 coronavirus vaccine. The humoral immunological response was determined using electrochemiluminescence immunoassay which quantitatively measures antibodies to the severe acute respiratory syndrome coronavirus 2 spike protein receptor-binding domain.Results: All study subjects in the control group developed a humoral response (antibody titer of ≥0.8 U/mL), while only 64 of 72 in the dialysis group (88.9%) were responders. Age (ρ = -0.234, p = 0.04) and sodium level (ρ = 0.237, p = 0.04) correlated with low antibody titer in bivariate analysis. In multivariate analysis, only age (odds ratio, 1.10; 95% confidence interval, 1.01-1.22; p = 0.045) was associated with nonresponders. Conclusion: Our study demonstrated a weak antibody response of hemodialysis patients to the viral vector COVID-19 vaccine. Older age was associated with nonresponders. Evaluation of both humoral and cellular immunity after the second vaccine dose and serial antibody titers can help determine the need for booster shots.

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Summary:The broad spectrum of activity of ciprofloxacin makes it an ideal drug for the prophylaxis of bacterial infections in patients undergoing high-dose chemotherapy (HDC) with autologous stem cell rescue. We present two cases of ciprofloxacin-associated acute renal failure (ARF) in patients undergoing HDC. Maintaining a high index of suspicion for this complication will allow a prompt diagnosis, with discontinuation of the drug usually resulting in a reversal of renal failure. Renal biopsy usually reveals changes compatible with interstitial nephritis, but is not always possible in these patients due to severe thrombocytopenia following HDC. A brief course of steroid therapy may be beneficial although the role of glucocorticoids is difficult to ascertain in the absence of data regarding its efficiency in this clinical setting. Keywords: ciprofloxacin; nephrotoxicity; high-dose chemotherapy; stem cell transplantation Prophylactic antibiotics following high-dose chemotherapy (HDC) have become routine, decreasing febrile episodes and greatly reducing the mortality from bacterial infections, primarily gram-negative sepsis. 1 The use of prophylactic oral ciprofloxacin has greatly facilitated the outpatient management of patients undergoing HDC. We report two cases of ciproloxacin-associated nephrotoxicity in patients undergoing HDC. Case reports Case 1A 53-year-old man with breast cancer was treated with HDC (cyclophosphamide 6000 mg/m 2 , etoposide 1500 mg/m 2 and carboplatin 1200 mg/m 2 ). Prophylactic oral ciprofloxacin 750 mg and rifampin 300 mg twice daily, and acyclovir 400 mg three times a day were started on the day of stem cell reinfusion. On day 8 he developed febrile neutropenia and was hospitalized. Vancomycin 30 mg/kg/day and ceftriaxone 2 g/day intravenously were added and ciprofloxacin was continued. Rifampin was stopped. All cultures were negative. Clinically, the patient was not septic, hypovolemic or dehydrated and had good urine output. On admission his creatinine was 1.5 mg/dl, and increased to 4.8 mg/dl the following day. Urinalysis revealed few white blood cells and no eosinophils. Renal ultrasound showed neither obstruction nor hydroephrosis. Ciprofloxacininduced nephritis was diagnosed; all antibiotics were discontinued, and intravenous solumedrol 120 mg/day was started. The creatinine peaked the following day to 6.0 mg/dl, and returned to normal on the third day. Case 2A 56-year-old woman with multiple myeloma underwent HDC with melphalan 140 mg/m 2 . Prophylactic oral ciprofloxacin 750 mg and rifampin 300 twice daily were begun on the day of stem cell reinfusion. Her creatinine was 0.6 mg/dl. On day 9 she developed a fever and was begun on intravenous vancomycin 30 mg/kg/day and ceftriaxone 2 g/day, with continuation of ciprofloxacin. Rifampin was discontinued. All cultures were negative. The following day the creatinine rose to 3.3 mg/dl and she developed oliguria without hypotension or hypovolemia. She had received only one dose of vancomycin and ceftriaxone. Urinalysis showed few whit...

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