Kidney transplantation and patients who decline SARS‐CoV‐2 vaccination: an ethical framework

Abstract

The COVID‐19 pandemic has had a major impact on kidney transplantation and on patients with end‐stage kidney disease. Transplantation activity has been substantially reduced, and kidney transplant recipients have suffered increased mortality. The introduction of vaccines against SARS‐CoV‐2 has offered considerable hope that it may be possible to protect patients from the risks associated with SARS‐CoV‐2 infection, and that more patients may once again have access to kidney transplantation.

Early humoral immune response to two doses of severe acute respiratory syndrome coronavirus 2 vaccine in a diverse group of solid organ transplant candidates and recipients

“…39 In a survey of patients from randomly-selected dialysis units in the United States, 20-29% of hemodialysis patients were vaccine hesitant due to fear of side effects. 40 With such hesitancy, and consideration of a person's autonomy, 41,42 mandating vaccination may not be appropriate but education regarding the risks of vaccine avoidance and the low rate of side effects from the COVID-19 vaccines should be an ongoing requirement for healthcare and, especially, transplant programs.…”

Ethical Issues in Kidney Transplant and Donation During COVID-19 Pandemic

“…46 A detailed ethical framework to argue for or against mandating vaccination in kidney patients prior to activation or reactivation on transplant waiting list has previously been published (Table 3). 47,48 One of the arguments against mandating vaccination is the uncertain vaccine efficacy, especially in transplant candidates or transplant recipients on immunosuppression. 47 On the other hand, this is exactly the reason to strongly recommend for vaccination before and not after kidney transplantation, in order to ensure the optimal protection.…”

“…47,48 One of the arguments against mandating vaccination is the uncertain vaccine efficacy, especially in transplant candidates or transplant recipients on immunosuppression. 47 On the other hand, this is exactly the reason to strongly recommend for vaccination before and not after kidney transplantation, in order to ensure the optimal protection. Registry data have suggested reduced mortality risk from Covid-19 infection for vaccinated kidney transplant recipients when compared to unvaccinated patients.…”

COVID-19 Vaccine Refusal and Organ Transplantation

“…Vaccine status can be considered "one component of clinical risk" that determines expected graft and patient survival over time. [7] Candidates whose expected outcomes meet the minimum CMS requirement threshold should be waitlisted, even if they fail to maximize their odds for the best clinical outcome. While these candidates are making bad choices and they should be strongly counselled to get vaccinated, penalizing them is inconsistent with our fiduciary obligation of beneficence.…”

“…Directive counseling can take many forms: educational programs provided in virtual group pre-transplant sessions and/or written educational materials that address vaccine concerns for candidates and families, a peer educator program of vaccine advocates, and tailored conversations as part of outpatient appointments. [7] Our responsibility does not end if they initially refuse. A vaccine refusal at one timepoint does not take the conversation off the table because recent data show increasing vaccination among previously hesitant individuals.…”