Impaired humoral immunity to SARS-CoV-2 BNT162b2 vaccine in kidney transplant recipients and dialysis patients

Impaired humoral immunity to SARS-CoV-2 BNT162b2 vaccine in kidney transplant recipients and dialysis patients

  • June 15, 2021

Abstract

Patients with kidney failure are at increased risk for SARS-CoV-2 infection making effective vaccinations a critical need. It is not known how well mRNA vaccines induce B and plasma cell responses in dialysis patients (DP) or kidney transplant recipients (KTR) compared to healthy controls (HC). We studied humoral and B cell responses of 35 HC, 44 DP and 40 KTR. Markedly impaired anti-BNT162b2 responses were identified among KTR and DP compared to HC. In DP, the response was delayed (3-4 weeks after boost) and reduced with anti-S1 IgG and IgA positivity in 70.5% and 68.2%, respectively. In contrast, KTR did not develop IgG responses except one patient who had a prior unrecognized infection and developed anti-S1 IgG. The majority of antigen-specific B cells (RBD+) were identified in the plasmablast or post-switch memory B cell compartments in HC, whereas RBD+ B cells were enriched among pre-switch and naïve B cells from DP and KTR. The frequency and absolute number of antigen-specific circulating plasmablasts in the cohort correlated with the Ig response, a characteristic not reported for other vaccinations. In conclusion, these data indicated that immunosuppression resulted in impaired protective immunity after mRNA vaccination, including Ig induction with corresponding generation of plasmablasts and memory B cells. Thus, there is an urgent need to improve vaccination protocols in patients after kidney transplantation or on chronic dialysis.

INTRODUCTION

COVID-19 leads to a high morbidity and mortality especially among patients with kidney failure (1). Dialysis patients (DP) and kidney transplant recipients (KTR) are at increased risk of developing COVID-19 and experiencing a severe infection, due to exposure risk in the health care system, their co-morbidities, and their impaired immune function from kidney failure or immunosuppressive medications. For this vulnerable population, vaccination is of the utmost importance.

The mRNA SARS-CoV-2 vaccine BNT162b2 (BioNTech/Pfizer) has demonstrated efficacy in healthy individuals in a clinical study (2) and under real-world conditions (3). Recent data described a lower serological response to an mRNA vaccine in dialysis patients (4) and kidney transplant recipients (5), suggesting an overall diminished vaccine response. Whereas numerous studies have addressed the consequences of conventional vaccines on B and plasma cells (68) and corresponding Ig levels, nothing is known yet about the B lineage consequences in response to an mRNA vaccine among healthy controls and immunocompromised patients. The ongoing uremic state in kidney failure patients leads to an immune dysfunction on various levels of innate and adaptive immunity. Restoring kidney function by kidney transplantation does not fully restore cellular and adaptive immunity while immunosuppressive drugs impair protective immunity further. Thus, kidney failure patients (with or without kidney transplant) show an increased susceptibility for infection and viral-associated cancers (911).

Previous studies in kidney failure patients (with or without kidney transplant) report markedly diminished response to vaccinations. This has led to an adaption of vaccination protocols with either higher initial vaccine doses or more frequent booster doses (12, 13). If such adaptations of the protocol are required for the COVID-19 mRNA vaccines or if alternate adjuvanted vaccines are necessary is not yet known.

The induction of B cell memory by mRNA vaccines and the relation to humoral immune response is largely under-investigated, especially studies of immunocompromised cohorts. Upon natural acute SARS-CoV-2 infection, immunological memory (antibodies and memory B cells) is shown to last for at least 8 months (1416). In patients with chronic kidney disease, such data are largely lacking, although prolonged time of viral shedding with impaired virus clearance is reported and likely related to impaired cell-mediated immunity (17).

In this study, we compared the characteristics of the humoral and antigen-specific B cell immune response against the mRNA vaccine BNT162b2 between healthy controls and patients with kidney failure treated by maintenance hemodialysis or kidney transplantation. We found a diminished humoral response to BNT162b2, and a lack of proper B lineage memory formation including RBD-specific plasmablasts and post-switch memory B cells.

RESULTS

Cohorts and patient characteristics

For this study, we recruited 35 healthy controls (HC), 41 patients on maintenance hemodialysis, 4 peritoneal dialysis patients and 40 KTR. Hemodialysis and peritoneal dialysis (PD) patients did not significantly differ in age and vaccine response and were therefore grouped together. After written informed consent, serum and peripheral blood mononuclear cells (PBMCs) were collected before vaccination (baseline) and 7 ± 2 days after boost vaccination (second dose), respectively. Serological follow-up was available in DP and KTR patients 3-4 weeks after boost. Due to local vaccination guidelines, HC, who were mainly health care workers, were significantly younger than DP (p< 0.01). DP were significantly older than KTR. As known for patients with kidney failure (18), a majority of DP and KTR were male. The median time on dialysis was 5.5 years (IQR, 2.0, 9.0). Among KTR only one patient was transplanted less than one year ago and median time after transplantation was 5.0 years (IQR. 2.0, 10.0). KTR were on a uniform immunosuppressive regimen with mycophenolate mofetil (MMF) in 39/40, steroid in 37/40 and calcineurin inhibitor (CNI) in 37/40 patients. Demographics are summarized in Table 1. To identify previously SARS-CoV-2 infected individuals we measured anti-nucleocapsid protein (NCP) antibodies 7 ± 2 days after boost, which is not a component of BNT162b2. Therefore, positivity of NCP originated from natural infection. One HC, one DP and one KTR were identified anti-NCP positive (Figure S1).

Table 1 Patient characteristics.

Substantially impaired serological response upon mRNA vaccination with BNT162b2 in DP and even more pronounced in KTR patients

Antibody response to BNT162b2 was assessed in all individuals 7 ± 2 days after boost using the Euroimmun ELISA for the detection of IgG and IgA against the S1 domain of the SARS-CoV-2 spike. All HC seroconverted, were positive for both anti-S1 IgG and anti-S1 IgA (Fig. 1 A, B), and showed SARS-CoV-2 neutralization (Fig. 1C). Anti-S1 IgA and anti-S1 IgG titers were markedly diminished 7 ± 2 days after boost in DP patients compared to HC (Fig. 1A, B). In the S1 IgG assay, 31/44 (70.5%) of the DP were positive and 30/44 (68.2%) developed anti-S1 IgA antibodies.

Fig. 1

Humoral immune response was delayed in DP and markedly reduced in KTR. (A-C) Humoral immune response against SARS-CoV-2 was assessed by Euroimmune ELISA for (A) spike protein S1 IgG, (B) spike protein S1 IgA and (C) virus neutralization by a blocking ELISA in HC (n=34), DP (n=44) and KTR (n=40) 7 ± 2 days after 2nd vaccination with BNT162b2 in the total cohort. (D-F) Humoral immune response with each cohort divided according to age (>60 n=71 (HC n=13, DP n=35, KTR n=23) and <60 years n=47 (HC n=21, DP n=9, KTR n=17)) into two subgroups and the corresponding results are shown for (D) spike protein S1 IgG, (E) spike protein S1 IgA and (F) virus neutralization by a blocking ELISA. (G-I) Follow-up sera were collected from 37 DP and 26 KTR patients, respectively 3-4 weeks after 2nd vaccination and investigated for (G) spike protein S1 IgG, (H) spike protein S1 IgA a and (I) virus neutralization by a blocking ELISA . (A-I) Threshold of upper limit of normal is indicated as dotted lines. (A-F) Kruskal-Wallis with Dunn´s post-test. Previously infected individuals are indicated in red. (G-I) Two-way ANOVA with Šidák´s post-test. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

Of particular interest, anti-S1 IgG and anti-S1 IgA responses were substantially diminished in KTR compared to HC and DP, respectively. Only one out of 40 patients (2.5%) was positive for IgG (apparently after prior unrecognized infection) and 4 patients for IgA (10%). Virus neutralization was observed in 30/44 (68.2%) DP patients (Fig. 1C), while 0/40 KTR had inhibiting antiviral antibodies (Fig. 1C). Interestingly, the patient’s serum with IgG and prior infection did not achieve neutralizing effects. Previously infected individuals are indicated in red in (Fig. 1A-C). Their levels of antibody and neutralization was in the range of other individuals of the respective group.

To further address the effect of age in our cohort, we divided the group into individuals <60 years and >60 years of age. HC >60 years showed a lower anti-S1 IgG and IgA than HC <60 years, while their neutralization capacity was unchanged (Fig. 1D-F). DP and KTR did not show differences in anti-S1 IgG and IgA, but DP >60 exhibited a lower neutralization capacity compared to DP<60 years (Fig. 1D-F). DP and KTR <60 and >60 years of age showed an overall diminished anti-S1 IgG and IgA as well as neutralization capacity compared to HC<60 and >60 years of age, respectively (Fig. 1D-F). Anti-S1 IgG and IgA correlated with age in HC while this correlation was weak in DP and KTR (Figure S2).

HC showed no significant further increase of humoral response later than 28 days post initial vaccination with BNT162b2 (19). A delayed immune response might have explained the initial limited serologic response in immunocompromised individuals (DP and KTR) with mRNA vaccines. Therefore, we collected additional follow-up samples from KTR and DP 3-4 weeks after boost. Interestingly, anti-S1 IgG increased significantly in DP (Fig. 1G), while anti-S1 IgA and surrogate neutralization remained stable (Fig. 1H) during the additional observation. In contrast, KTR patients did not develop additional anti-S1 IgG, anti-S1 IgA and neutralizing antibodies until the second follow-up investigation 3-4 weeks after the boost (Fig. 1G-I). In summary, KTR showed a significantly reduced serological response including lack of further increases up to 3-4 weeks after BNT162b2 boost.

DP and KTR showed reduced B cells numbers but similar distribution among memory subsets

B cell lymphopenia is described for DP (20) and KTR (21) and might affect proper humoral immune responses. To initially address the frequency, distribution, and phenotype of peripheral blood B cells in DP, KTR compared to HC, we analyzed the distribution of B cell subsets at baseline (pre-vaccination) and 7 ± 2 days after boost (Fig. 2A). Of interest, the frequency of CD19+ B cells was significantly diminished only in KTR compared to DP at the assessment 7 ± 2 days after boost and compared to HC at baseline, while no differences were otherwise observed (Fig. 2B). However, substantial reductions in absolute B cell counts were identified between KTR patients and HC at baseline as well as HC versus the DP and KTR cohorts, 7 ± 2 days after boost, respectively (Fig. 2C).

Fig. 2

B cells were reduced in DP and KTR but show a similar distribution after 2nd BNT162b2 vaccination. (A) Representative pseudocolor plots of CD19+ B cell gating into plasmablasts and mature B cells, and representative pseudocolor plots of IgD/CD27 based classification. (B) Frequency of CD19+ B cells (gates shown in (A)) in HC, DP and KTR before vaccination (n=46: HD n=11, DP n=21 and KTR n=14) and 7 ± 2 days after 2nd vaccination (n=119: HD n=35, DP n=44 and KTR n=40) with BNT162b2. (C) Corresponding absolute numbers (per μl blood) measured by BD Trucount . Frequencies of plasmablasts and mature B cells according to CD27/IgD (gates shown in (A)) at (D) baseline (n=46: HD n=11, DP n=21 and KTR n=14) and (E) 7 ± 2 days after 2nd vaccination (n=119: HD n=35, DP n=44 and KTR n=40). (F) Representative pseudocolor plot of IgA and IgG expression in B cells from HC. (G) Distribution of surface immunoglobulin isotype expression among HC, DP and KTR 7 ± 2 days after 2nd vaccination (n=119: HD n=35, DP n=44 and KTR n=40). Two-way ANOVA with Šidák´s post-test. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

The frequency of plasmablasts among total CD19+ B cells did not differ between groups (Fig. 2D, E) at baseline and after boost. DP and KTR patients carried lower frequencies of pre-switch B cells, while KTR had an increased frequency of naïve B cells before vaccination but not after vaccination. Post-switch memory B cells were higher in DP before but not after vaccination. Double negative (DN, CD27-IgD-) B cells did not differ significantly among groups (Fig. 2D,E). Interestingly, immunoglobulin isotype distribution among B cell subsets was not different among study groups (Fig. 2F,G). In summary, KTR and DP showed a characteristic reduction of absolute B cells with certain differences in the pre-memory (naive and pre-switch) but no differences within B memory compartments.

Impaired induction of anti-BNT162b2 B cell and plasmablast responses in KTR and HD patients

In order to better understand the underlying B and plasma cell differentiation upon vaccine challenge, we developed a flow cytometric method to identify and quantify RBD-specific B cells in human peripheral blood. B cells (CD3−CD14−CD19+) able to bind simultaneously RBD-AF488 and RBD-AF647 were validated as antigen-specific (Fig. 3A). The specificity of RBD binding was further confirmed by blocking with unlabeled RBD prior to staining (Fig. 3A). We identified an RBD-specific clone (CDRH3: ARDYGGNANYFHY, CDRL3:QQYDNLPIT) in 3 different vaccines (HC) with highly identical amino acid sequence as reported before upon mRNA vaccinations (22). Subsequently RBD+ B cells were further analyzed according to their distribution among subsets and isotypes (gated as shown for general B cells in Fig. 2A,F.

Fig. 3

RBD-specific B cells were present in DP and KTR patients after BNT162b2 vaccination but populate different B cell subsets. (A) Representative dot plot of double positive cells RBD-specific B cells before and after blocking with unlabeled RBD are shown. (B) Frequencies and (C) absolute numbers of RBD+ cells among total CD19+ B cells measured before (n=59: HD n=10, DP n=23 and KTR n=26) and 7 ± 2 days after 2nd vaccination (n=119: HD n=35, DP n=44 and KTR n=40). (D) Frequencies of plasmablasts, naïve, pre-switch, post-switch and double negative B cells (bar) and immunoglobulin isotype distribution among subsets (cakes) (HD n=10, DP n=23 and KTR n=26). (E) Immunoglobulin isotype expression among total RBD+ cells in HC, DP and KTR and 7 ± 2 days after 2nd vaccination (HD n=35, DP n=44 and KTR n=40). (F) Two-dimensional t-SNE of all RBD+ cells in HC (n=21), DP (n=23) and KTR (n=34). Color code indicates expression of CD27 (upper panel), CD38 (middle panel) and IgG (lower panel). Previously infected individuals are marked red (E). (B-D) Two-way ANOVA with Šidák´s post-test. (E) Kruskal-Wallis with Dunn´s post-test. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

Overall, an increased frequency of RBD-specific B cells among CD19+ B cells was found 7 ± 2 days after boost compared to baseline for HC, DP and KTR (Fig. 3B). The absolute number of antigen-specific B cells was significantly increased in HC at 7 ± 2 days after boost only in contrast to DP and KTR patients (Fig. 3C).

Subsequent analyses addressed the distribution of the RBD-specific B cells among B cell subsets (gating as seen in Fig. 2A). Most notably, a large number of RBD+ B cells were found in the plasmablast compartment in HC, which was significantly lower in DP and KTR (Fig. 3D and Figure S3). The very limited antigen-specific B cells in KTR resided preferentially within the naïve and pre-switch compartment compared to HC (Fig. 3D and Figure S3). In contrast, antigen-specific B cells from HC were detected mainly within post-switch and double negative B cells belonging largely to the memory compartment (Fig. 3D). Consistent with impaired (not completely executed) B memory induction, the frequency of IgM RBD+ B cells (defined as IgG-IgA-) was more frequently detected in KTR and DP patients compared to HC, in whom antigen-specific IgG+ B cells dominated. The frequency of IgA+ RBD+ B cells was comparable across groups (Fig. 3E).

Two-dimension t-SNE plots clustering all RBD+ B cells according to expression patterns, analyzed with a color axis for CD27, CD38 and IgG, illustrated the notable differences between groups including the substantially reduced plasmablasts (CD27++, CD38++) and IgG expressing RBD+ B cells in the KTR cohort (Fig. 3F). In summary, KTR patients were not only characterized by a reduced overall number of antigen specific B cells, but also exhibited signatures of abnormal B cell memory formation.

Unique correlation of anti-BNT162b2 serological and B cell responses

Our earlier vaccination studies against tetanus, diphtheria and KLH (Keyhole Limpet Hemocyanin) do not reveal a typical relation between plasmablast/ B cell responses and the serologic Ig outcome (68) in contrast to such relation for polysaccharides, such as meningococcal and pneumococcal vaccine (23, 24). Therefore, we wondered how the anti-BNT162b2 humoral immune and B cell specific responses against an mRNA vaccine are interrelated. A correlation matrix including all groups and patients was carried out. As previously described (25, 26), the neutralization capacity strongly correlates with anti-S1 IgG as well as anti-S1 IgA (Fig. 4A). The frequency of total RBD+ cells did not correlate with anti-S1 IgG, IgA and neutralization capacity, respectively. The frequency and total number of RBD+ plasmablasts correlated with all parameters of humoral response (anti-S1 IgG, anti-S1 IgA and the neutralization capacity). Age and the total number of RBD+ B cells correlated in HC, while it did not in DP and KTR (Figure S2). Subsequent analyses addressed how non-responders with a negative neutralization test (<30%) differed from responders (>30%). Responders and non-responders were significantly different in the frequency and number of RBD+ plasmablasts and RBD+ pre-switch memory B cells as well as in the frequency of RBD+ naïve B cells (Fig. 4B). This data suggested clear interdependence of the distinct memory B and plasmablast compartments being a characteristic of this mRNA vaccine.

Fig. 4

Correlation of anti-BNT162b2 serological and B cell responses. (A) Spearman´s correlation matrix showing the correlation of frequency of RBD+ cells in each B cell subset in the cohort. Corresponding correlations are represented by red (negative) or blue (positive) circles; size and intensity of color refer to the strength of correlation (HD n=35, DP n=44 and KTR n=40). Only correlations with p ≤ 0.05 are indicated. (B) Frequency (upper panel) and absolute numbers (lower panel) of RBD+ plasmablasts (PB), naïve B cells and post-switch B cells in non-responders (surrogate virus neutralization capacity ((NC) NC<30%, n=55) and responders (NC >30%, n=63). Each point represents a donor. Unpaired two-sided Mann-Whitney U test. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

Diminished T cell and plasmablast response in KTR

To further understand the lack of B cell memory induction, we sorted CD27++CD38++ plasmablasts, CD27+CD38var memory B cells and HLA-DR+CD38+ activated T cells of the peripheral blood as indicators of the ongoing immune response after vaccination (7, 27) and generated single cell transcriptomes combined with Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITE-seq) (28) for selected surface markers (Figure S4) 7 ± 2 days after boost vaccination. After removal of doublets, we analyzed a total of 10796 cells. According to their transcriptomes, these cells were categorized in 7 different clusters as shown by Uniform Manifold Approximation and Projection for Dimension Reduction (UMAP) (29) (Figure S4A, B). We focused on the most abundant clusters. Four of which belong to the T cell compartment, with the most abundant cluster 0 having represented activated CD8+HLADR+MS4A1+ T cells, followed by cluster 1 which represented different types of the CD4+ T cells, including e.g., FOXP3+CD25+ regulatory T cells (Figure S4C and S5). Cluster 2 contained different populations of CD8+ T cell expressing either CD45RA or CD45RO (Figure S4B,C) and finally cluster 5 represented a TCF7+CD27+GZMK+ T cells. Cluster 6 contained proliferating cells expressing MKI67 (Figure S4B-C). Memory B cells expressing high levels of MS4A1, HLA-DRA and CD27 were located in cluster 3. Cluster 4 represented plasmablasts expressing CD27, CD38, PRDM1 and IRF4 (Figure S4B-C). Of note, the protein expression of selected surface markers detected by CITE-seq supported the classification of the 7 main clusters (Figure S5). In the selected cohort of 4 KTR, 3 did not show a serological response to the vaccination (non-responder), while one individual had detectable anti-S1 IgG antibodies but also a previously undetected infection (responder). Accordingly, the 3 non-responders had reduced frequencies of cluster 4, 5 and 6 representing plasmablasts, TCF7+CD27+GZMK+ T cells and proliferating MKI67-expressing lymphocytes (Figure S4D, E). CD45RO+ follicular T helper like cells expressing either IL21 or PDCD1+ could only be detected in the CD4+ T cell compartment (Cluster 1) of the non-responder #3 and the responder (Figure S4F). Interestingly, the majority of memory B cells (cluster 3) of the responder expressed ITGAX (gene encoding for CD11c), while this subpopulation in cluster 3 was almost absent in the non-responders (Figure S4F).

DISCUSSION

SARS-CoV-2 mRNA vaccines are highly protective against COVID-19 (2, 30), while it is not yet clear how these vaccines induce and maintain B cell memory responses among immunocompromised patients. Available data show a durable humoral response and B cell response (31, 32) in healthy individuals and also elderly patients (2, 19). Moreover, mRNA vaccines are reported to induce germinal center (GC) responses in mice and are expected to result in lasting plasma cell responses (33). Here, we investigated the distribution of anti-BNT162b2 antigen-specific B cell responses among HC in comparison to DP and KTR as prototypes for differentially immunocompromised patients. An assay for the detection of RBD-specific B lineage cells has been developed with high specificity based on our prior experiences for the detection of antigen-specific B cells and plasmablasts (i.e., tetanus, KLH, pentraxin (8, 34)). Specificity was proven by appropriate blocking experiments and identification of an RBD-specific clone (CDRH3) among RBD++ B cells, which was found in 3 different vaccines (HC) with highly identical amino acid sequence immunized as reported very recently upon mRNA vaccinations (22). Of particular interest, seroconversion and the induction of neutralizing antibodies upon BNT1622b vaccination was very robust and similar in our cohort in HC as observed by prior studies (2). In these HC, we also found a typical formation of antigen-specific plasmablasts and post-switch memory B cells upon vaccination boost which was comparable to frequencies of tetanus-specific B cells after booster vaccination (35). Thus, the findings among HC provide a valid comparison with the two patient cohorts.

Among DP and KTR, we observed a markedly diminished generation of antigen-specific B cells, especially within major effector compartments of protective B cell immunity, namely plasmablasts and memory B cells. Consistently, lower IgG+ anti-RBD cells were found related to impaired induction of a vaccine response. This was accompanied by a low rate of seroconversion of DP on day 7 ± 2 that somewhat improved 3-4 weeks after vaccination, while this could not be compared to HC in our cohort due to a missing follow-up. In the KTR cohort, the rate of serological and cellular response was almost absent with only one patient who developed specific anti-S1 IgG but apparently based on a prior unrecognized infection and likely reflecting a further boost underlining the potential effectiveness of optimized vaccines or vaccination protocols. Interestingly, no KTR patient exhibited a positive neutralization at day 7± 2 after boost including the patient with positive IgG titers. At a further follow up 3-4 weeks after boost, no seroconversions were found in KTR. These data are in contrast to recently published data of Boyarsky et al. who described a seroconversion in 23/223 (10.35%) of KTR vaccinated with BNT162b2 already after the first dose (5). As a limitation of our study, we only have a limited sample size as well as a very uniform immunosuppressive regimen of KTR, which does not allow for a firm conclusion which immunosuppressant may cause the impaired immune response. For DP patients, seroconversion rates of about 90% after two doses have been described which is similar to the findings in our cohort (4, 36).

The large discrepancy of the serological response and impaired B cell response in our KTR cohort raises the question about which factors or mechanism are involved. Incorrect handling of the sensitive mRNA vaccine can be excluded since the same mRNA vaccine of the same lot induced a favorable response among DP patients. The major difference between KTR and DP/HC appeared to be the almost uniform immunosuppressive therapy with MMF, CNI and glucocorticoids among the KTR patients, although the individual impact of MMF, cyclosporine vs. tacrolimus and glucocorticoids needs to be further delineated. CNI and MMF directly inhibit activation and proliferation of CD4+ T cells, Tfh cells and B cells (3741). In this regard, single cell transcriptomes and CITE-seq analyses identified substantial differences between the vaccine responder and three non-responders within the KTR cohort. Namely plasmablasts, TCF7+CD27+GZMK+ T cells and proliferating MKI67-expressing lymphocytes were increased in the responders suggesting that these three subsets are key drivers of a successful BNT162b2 response.

Three individuals with likely prior asymptomatic virus exposure (each in HC, DP and KTR cohorts) were identified by preexisting antibodies against viral NC. Interestingly, they did not show notable differences in vaccine response compared to their cohorts, with the exception of one seroconversion in the KTR. A number of recent studies report that a first vaccination in previously infected individuals acts as a boost that leads to higher antibody levels than individuals vaccinated twice with an mRNA vaccine. It further does not change isotype distribution among memory B cells (32, 42, 43). After a natural COVID-19 infection the numbers of RBD-specific memory B cells of healthy individuals are similar to those of patients who recovered from natural COVID-19 infection, while levels of anti-S1 and anti-RBD IgG are significantly higher in vaccinated individuals (44). Interestingly, the clonality of IGLV genes among RBD+ is very comparable between natural infection and the mRNA vaccination (44). At the moment it is not known whether the magnitude of antibody levels or the presence or magnitude of a T cell response, or both, correlate with the protection against symptomatic COVID-19. However, after natural COVID-19 infection the presence of anti-spike antibodies protects from recurrent infection, while a previous infection without detectable antibodies does not (45). Initial observational data from Israel indicate that CKD as well as immunosuppression have a negative impact on vaccine efficacy (46), which indicates that impaired B cell memory also results in diminished protection.

Interestingly, we found a unique relationship between plasmablast response and Ig titers which is not seen in tetanus and KLH vaccination (68) and is only described for polysaccharide and protein-polysaccharide conjugate vaccinations (47). Polysaccharide vaccines in contrast to mRNA vaccines induce certain serological responses following vaccination in KTR (48) which possibly relates to T independent responses. In this context, our single cell analysis confirmed a diminished plasmablast induction in the non-responders (KTR) but importantly also lack of proper CD4 and CD8 T cell activation. In the responder, classical signs of vaccine response with simultaneous B and T cell activation occurred but insufficient to induce neutralizing antibody titers. KTR have to be considered as a patient group who remains vulnerable to SARS-CoV-2 infection, even if vaccinated with the currently established BNT162b2 vaccination scheme.

In summary, we described a diminished humoral response to BNT162b2 as well as lack of appropriate memory formation including RBD-specific plasmablasts and post-switch memory B cells in DP and KTR. DP were able to further mature their antibody response in contrast to KTR. As such, optimized vaccination strategies especially for KTR patients are needed to achieve adequate antiviral protection.

MATERIALS AND METHODS

Study design

The study was designed to investigate the sero-response (anti-S1 IgA, anti-S1 IgG levels and neutralization test) and B cell memory formation in DP and KTR after vaccination with BNT162b2. HC, KTR and DP were vaccinated with BNT162b2 21 days apart. Baseline blood was drawn to identify previously infected individual (NCP ELISA, anti-S1 IgA, anti-S1 IgG levels) and access baseline B cell phenotype of HC, DP and KTR (flow-cytometry). To investigate the plasmablast response peripheral blood samples were obtained 7 ± 2 days after boost vaccination. B cell subtypes as well antigen-specific B cells were analyzed by flow-cytometry. Seroresponse was investigated 7 ± 2 days (HC, DP, KTR) and 3-4 weeks after the second dose (DP, KTR).

Study participants

Peripheral blood samples (EDTA anti-coagulated or serum-tubes, BD Vacutainersystem, BD Diagnostics, Franklin Lakes, NJ, USA) from 35 healthy controls, 40 hemodialysis patients, 4 peritoneal dialysis patients and 40 kidney transplant recipients were collected at 7 ± 2 days after the second dose of SARS-CoV-2 BNT162b2 vaccination. Individuals of KTR and DP are in part also represented in published manuscripts (serological response only) (49, 50). Material before vaccination was available for 19 healthy controls, 21 hemodialysis patients, 2 peritoneal dialysis patients, and 28 kidney transplant recipients, while a follow up after 3-4 weeks after boost is available for currently for 26 KTR and 37 DP. Donor information is summarized in Table 1. All participants gave written informed consent according to the approval of the ethics committee at the Charité University Hospital Berlin (EA2/010/21, EA4/188/20), the ethics committee of Saxony-Anhalt (EA7/21) and the ethics committee of the University of Greifswald (BB019/21).

Sample processing and isolation of peripheral blood mononuclear cells (PBMCs) and staining

Serum tubes were centrifuged at 3000rpm for 10 min to separate plasma. Serum was stored at -20C for antibody analysis. PBMCs were prepared by density gradient centrifugation using Ficoll-Paque PLUS (GE Healthcare Bio-Sciences, Chicago, IL, USA). For staining 1-3 × 106 cells were suspended in 50 μl of PBS/0.5% BSA/EDTA and 10 μl Brilliant Buffer (BD Horizon, San Jose, CA, USA. Cells were stained for 15 min on ice and washed afterwards with PBS Dulbecco containing 1% FCS (fetal calf serum, Biowest, Nuaillé, France) (810 xg, 8 min, 4°C). Flow cytometric analysis was performed as indicated in the Figs. 14.

Flow cytometry

All flow cytometry analyses were performed using a BD FACS Fortessa (BD Biosciences, Franklin Lakes, NJ, USA). To ensure comparable mean fluorescence intensities (MFIs) over time of the analyses, Cytometer Setup and Tracking beads (CST beads, BD Biosciences, Franklin Lakes, NJ, USA) and Rainbow Calibration Particles (BD Biosciences, Franklin Lakes, NJ, USA) were used. For flow cytometric analysis, the following fluorochrome-labeled antibodies were used: BUV737 anti-CD11c (BD, clone B-ly6, 1:50), BUV395 anti-CD14 (BD, clone M5E2, 1:50), BUV395 anti-CD3 (BD, clone UCHT1, 1:50), BV786 anti-CD27 (BD, clone L128, 1:50), BV711 anti-CD19 (BD, clone SJ25C1,1:25), BV605 anti-CD24 (BD, clone ML5, 1:50), BV510 anti-CD10 (BD, clone HI10A, 1:20), BV421 anti-CXCR5 (BD, clone RF8B2, 1:20), PE-Cy7 anti-CD95 (ThermoFischer, Waltham, MA, USA clone APO-1/Fas, 1:100), PE-CF594 anti-IgD (Biolegend, San Diego, CA, USA, clone IA6-2, 1:5000), APC-Cy7 anti-CD38 (Biolegend, clone HIT2, 1:1000), PE-Cy7 anti-IgG (BD, clone G18-145, 1:1000), anti-IgA-Biotin (BD, clone G20-359, 1:50), BV650 anti-IgM (BD, clone MHM-88, 1:50), FITC anti-HLA-DR (Biolegend, clone L234, 1:25), PE anti-CD21 (BD, clone B-ly4, 1:25), APC anti-CD22 (BD, clone S-HCL-1, 1:25). Siglec-1 (CD169, 1:25) expression analysis on CD14+ monocytes was performed at baseline and at the follow-up time-point as previously described (11). Number of absolute B cells was measured with Trucount (BD) and samples were processed according to the manufacturer’s instruction.

Staining of antigen-specific B cells

To identify RBD-specific B cells, recombinant purified RBD (DAGC149, Creative Diagnostics, New York, USA) was labeled with either AF647 or AF488. Double positive cells were considered as antigen-specific (Fig. 3). Antigens were labeled at the German Rheumatism Research Centre (DRFZ), Berlin with NHS esters conjugation for AF647 and AF488. A blocking experiment using unlabeled RBD in 100-fold concentration was used to ensure specificity of the staining (Fig. 3A). The number of recorded antigen-specific events ranged from 0-422 events. To ensure the specificity of our RBD-specific flow cytometric staining, we labeled memory B cells with fluorescently the two RBD and isolated them cytometrically. The isolated B cells were analyzed for their transcriptome and B cell receptor sequence using DropSeq (10X genomics). We were able to intercept and examine 168 cells from 8 vaccinated individuals 7 days after secondary immunization. This population of RBD-specific memory B cells was found to employ VDJ gene rearrangements using preferentially certain IgHV segments (IGHV3-30, IGHV3-53 and IGH3-23) and IGKV genes (IGKV1-39, IGKV1-33, IGKV1-9, and IGLV3-21) after mRNA inoculation, as described in Wang et al. (22). Most importantly, we even identified an RBD-specific clone (CDRH3: ARDYGGNANYFHY, CDRL3:QQYDNLPIT), which was found in 3 different vaccinees with highly identical amino acid sequence immunized as reported very recently upon Biontech or Moderna vaccinations (22).

Enzyme-linked immunosorbent assay (Euroimmun)

The Euroimmun anti-SARS-CoV-2 assay is a classical enzyme-linked immunosorbent assay (ELISA) for the detection of IgG to the S1 domain of the SARS-CoV-2 spike (S) protein, IgA to the S1 domain of the SARS-CoV-2 spike protein, and IgG to the SARS-CoV-2 NCP protein. The assay was performed according to the manufacturer´s instructions and as described previously (25, 26).

Surrogate SARS-CoV-2 neutralization test (GenScript)

This blocking ELISA qualitatively detects anti-SARS-CoV-2 antibodies suppressing the interaction between the receptor binding domain (RBD) of the viral spike glycoprotein (S) and the angiotensin-converting enzyme 2 (ACE2) protein on the surface of cells. The assay was performed according to the manufacturer´s instructions and as described previously (25, 26).

Single Cell RNA sequencing

Peripheral blood Cells were enriched from peripheral blood using StraightFrom Whole Blood CD19, CD3 and CD138 MicroBeads (Miltenyi Biotec) according to manufacturer’s instructions. Afterwards cell were stained, incubated with TotalSeq oligomer-conjugated hashtag antibodies ((TotalSeq-C anti-human Hashtag antibody 1 to 4) and sorted with a MA900 Multi-Application Cell Sorter (Sony Biotechnology).

Sorted populations were identified as plasmablasts (DAPI-CD3-CD14-CD16-CD38++CD27++), memory B cells (DAPI-CD3-CD14-CD16-CD38varCD27+) and activated T cells (DAPI-CD3+CD14-CD16-CD38+HLA-DR+). The three sorted populations were pooled in equal proportions and further processed for single cell RNA sequencing. Single Cell RNA-library preparation and sequencing, single-cell transcriptome sequencing as well as well as data analysis and statistics has been performed as previously described (51). All details can additionally be found in the supplementary materials.

Data Analysis and Statistics

All details can be found in the supplementary materials.

Acknowledgments: The authors are grateful to Dr. Michael Moesenthin, Dr. Peter Bartsch (both Dialysezentrum Burg), Dr. Ralf Kühn, Dr. Dennis Heutling (both Dialyse Tangermünde), Dr. Petra Pfand-Neumann (Nierenzentrum Köthen) and Dr. Jörg-Detlev Lippert (MVZ Diaverum, Neubrandenburg) for patient recruitment as well as Dr. Petra Glander and Pia Hambach for biobanking of samples. Funding: ES was funded by the Federal Ministry of Education and Research (BMBF) grant BCOVIT, 01KI20161. ES received a grant by the Berlin Institute of Health with the Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health. MFM received a Starting Grant-Multi-Omics Characterization of SARS-CoV-2 infection, Project 6 ”Identifying immunological targets in Covid-19” from the Berlin Institute of Health. HS is receives funding by the Ministry for Science, Research and Arts of Baden-Württemberg, Germany. ALS is funded by a scholarship of the German Society of Rheumatology. AS and KK receive funding by the Sonnenfeldstiftung Berlin, Germany. TD is grantholder oft the Deutsche Forschungsgemeinschaft grants KO 2270/7 1, KO-2270/4-1 (KK); Do491/7-5, 10-2, 11-1, Transregio 130 TP24. MFM receives funding of the State of Berlin and the “European Regional Development Fund” with the grant ERDF 2014–2020, EFRE 1.8/11. AR is funded though the Deutsche Forschungsgemeinschaft (DFG) through the TRR130-P16 and TRR241 B03 grants. MFM is part of the Leibniz Association (Leibniz Collaborative Excellence, TargArt). HRA holds a scholarship of the COLCIENCIAS scholarship No. 727, 2015. AS and KK receive funding by a grant of the Chiesi GmbH. Author contributions: HRA, ES, ACL, ALS and TD developed the concept of the study. KB, FH, MC, UW, AS and ES collected patient’s samples. FSZ, ALS, HRA, HS, BJ, KL, GMG, MFG, MFM, AP, YC obtained the data. HR, ES, ALS, MFG, MFM and ACL, PD, FH analyzed the data. TD, ES, AS ALS and HR developed the theoretical framework. ACL, KK, KUE, GB, KB, AR and TD supervised the work. All authors developed, read, and approved the current manuscript. Competing interests: Authors declare that they have no competing interests. Data and materials availability: All data are available in the main text or the supplementary materials. Data from transcriptome sequencing and immune profiling in GEO under the accession GSE176442. This work is licensed under a Creative Commons Attribution 4.0 International (CC BY 4.0) license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/. This license does not apply to figures/photos/artwork or other content included in the article that is credited to a third party; obtain authorization from the rights holder before using such material.

Extra COVID-19 vaccine may help protect transplant patients

Extra COVID-19 vaccine may help protect transplant patients

  • June 14, 2021

A small study offers the first hint that an extra dose of COVID-19 vaccine might give some organ transplant recipients a boost in protection.

Even as most vaccinated people celebrate a return to near normalcy, millions who take immune-suppressing medicines because of transplants, cancer or other disorders remain in limbo — uncertain as to how protected they are against the coronavirus. It’s simply harder for vaccines to rev up a weak immune system.

The study published Monday tracked just 30 transplant patients, but it’s an important step toward learning if booster doses could help.

Of the 24 patients who appeared to have no protection after the routine two COVID-19 vaccinations, eight developed virus-fighting antibodies after an extra shot, researchers from Johns Hopkins University reported in Annals of Internal Medicine. And six others who’d had only minimal antibodies got a big boost from the third dose.

“It’s very encouraging,” said Dr. Dorry Segev, a Hopkins transplant surgeon who helped lead the research. “Just because you’re fully negative after two doses doesn’t mean that there’s no hope.”

Working with the National Institutes of Health, Segev’s team hopes to begin a more rigorous test of a third vaccination in 200 transplant recipients this summer.

Immune-suppressing drugs prevent rejection of transplant patients’ new organs but leave them extremely vulnerable to the coronavirus. Transplant patients were excluded from initial testing of COVID-19 vaccines, but doctors urge that they get vaccinated in hopes of at least some protection.

There is some benefit. The Hopkins team tested more than 650 transplant recipients and found that about 54% harbored virus-fighting antibodies after receiving two doses of the Pfizer-BioNTech or Moderna vaccines — although generally fewer than in otherwise healthy vaccinated people.

Protection against COVID-19 is also a concern for those with autoimmune disorders. One study of patients with rheumatoid arthritis, lupus and other autoimmune disorders found that 85% developed antibodies, said Dr. Alfred Kim of Washington University in St. Louis. But those who used certain immune-suppressing drugs produced dramatically lower levels, a cause for concern.

“We tell our patients to act like the vaccine is not going to work as well as it does for their family and friends,” said Kim, who would like to test a third dose in autoimmune patients. “This is very frustrating news to them.”

Guidelines issued in France recommend a third COVID-19 shot for certain severely immune-suppressed people, including transplant recipients, Segev noted.

Doctors sometimes give extra doses of other vaccines, such as the hepatitis B shot, to people with weak immune systems.

The U.S. hasn’t authorized extra COVID-19 vaccinations. But around the country, immune-compromised patients are seeking third doses on their own; those are the people Hopkins sought to test.

In San Francisco, Gillian Ladd agreed to blood tests before and after receiving an extra dose. The transplant recipient of a kidney and pancreas, Ladd, 48, was terrified to leave her house after learning she had no measurable COVID-19 antibodies, despite two Pfizer shots.

With the additional dose, she said, “I had gotten what I needed in order to survive,” but she’s sticking with masks and other precautions.

“I am being as careful as I possibly can while acknowledging that I’m coming back into the world of the living,” she said.

Additional research is needed to tell if a third dose really helps, who are the best candidates and if different brands of vaccine offer different benefits — plus whether the extra immune stimulation could increase the risk of organ rejection.

Segev notes that in addition to antibodies, vaccinations normally spur protections such as T-cells that can fend off severe illness. He and other research groups are testing whether immune-compromised patients get that benefit.

But for now, said Washington University’s Kim, “the best way to protect these people is for others to get vaccinated.”

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Local hospital explains revolutionary CAR T-cell immunotherapy for cancer patients

  • June 13, 2021

SAN ANTONIO – There’s a breakthrough therapy for treating patients with blood cancer called CAR T-cell immunotherapy.

Dr. Paul Shaughnessy, medical director of the Adult Blood and Marrow STEM Cell Transplant Program at Methodist Hospital explains the therapy and how exactly it works.


How does it differ from other forms of cancer therapy?

“This immune therapy is much more directed, as much more specific to attack just the cancer cell and direct our immune system to fight cancer and our immune systems recognize and fight cancer all the time,” said Shaughnessy. “But this gives that extra boost to our immune cells to recognize this cancer that’s growing in the body unchecked and can really direct the immune system to fight cancer even more powerfully than chemotherapy.”


CAR T-cell immunotherapy

CAR T-cell immunotherapy is a new therapy that programs a patient’s immune system to recognize and fight cancer. The immune system is responsible for ridding the body of abnormal cells that are foreign (like cancer) or infected.

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T-lymphocytes (T-cells) are a type of cell responsible for killing abnormal cells. During the CAR T-cell treatment process, T-cells are drawn from a patient’s blood and genetically modified to recognize the patient’s cancer cells when reinfused.

Here’s how it works:

  • First, a patient’s white blood cells are collected through a process called apheresis.

  • Then, the T-cells are isolated from other blood cells.

  • T-cells are then modified in a special facility to program them to recognize the cancer cells, which can be thought of as “fighter” T-cells.

  • Lastly, the new “fighter” T-cells are re-infused into the patient to target and kill cancer.


Doris Franke, former educator and patient shared her experience receiving CAR T-cell immunotherapy after qualifying for the therapy after two unsuccessful cancer therapies.

“It meant the world to me gave me an opportunity to have a longer period of remission so that I can enjoy my family, my grandchildren, this beautiful world, all kinds of activities that I’m so grateful that I was chosen to be part of this trial,” said Franke. “It was like a miracle. After I received the treatment, I had a reaction when I was in the hospital for several weeks, I came out of that and I just started getting better. After that, I felt good. I gained back my energy.”

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Infection Organ Damage Concept

Many COVID-19 Patients Produce Immune Responses Attacking Their Body’s Own Tissues and Organs

  • June 13, 2021

Infection Organ Damage Concept

A University of Birmingham-led study funded by the UK Coronavirus Immunology Consortium has found that many patients with COVID-19 produce immune responses against their body’s own tissues or organs.

COVID-19 has been associated with a variety of unexpected symptoms, both at the time of infection and for many months afterward.  It is not fully understood what causes these symptoms, but one of the possibilities is that COVID-19 is triggering an autoimmune process where the immune system is misdirected to attack itself.

The study, published on June 3, 2021, in the journal Clinical & Experimental Immunology, investigated the frequency and types of common autoantibodies produced in 84 individuals who either had severe COVID-19 at the time of testing or in the recovery period following both severe COVID-19 and those with milder disease that did not need to attend hospital. These results were compared to a control group of 32 patients who were in intensive care for another reason other than COVID-19.

An autoantibody is an antibody (a type of protein) produced by the immune system that is directed against one or more of the individual’s own proteins and can cause autoimmune diseases. Infection can, in some circumstances, lead to autoimmune disease.  Early data suggest that SARS-CoV-2 infection can trigger long-term autoimmune complications and there are reports of SARS-CoV-2 infection being associated with a number of autoimmune disorders including Guillain-Barre Syndrome.

Supported by UK Research and Innovation (UKRI) and the National Institute for Health Research (NIHR), the study found higher numbers of autoantibodies in the COVID-19 patients than the control group and that these antibodies lasted up to six months.

Non-COVID patients displayed a diverse pattern of autoantibodies; in contrast, the COVID-19 groups had a more restricted panel of autoantibodies including skin, skeletal muscle, and cardiac antibodies.  

The authors also find that those with more severe COVID-19 were more likely to have an autoantibody in their blood.

First author Professor Alex Richter, of the University of Birmingham, explained: “The antibodies we identified are similar to those that cause a number of skin, muscle and heart autoimmune diseases. 

“We don’t yet know whether these autoantibodies are definitely causing symptoms in patients and whether this is a common phenomenon after lots of infections or just following COVID-19. These questions will be addressed in the next part of our study.”

Senior author Professor David Wraith, of the University of Birmingham, adds:  “In this detailed study of a range of different tissues, we showed for the first time that COVID-19 infection is linked to production of selective autoantibodies. More work is needed to define whether these antibodies contribute to the long-term consequences of SARS-CoV-2 infection and hence could be targeted for treatment.”

Professor Paul Moss, Principal Investigator of the UK Coronavirus Immunology Consortium and Professor of Haematology at the University of Birmingham added: “This is an interesting study that reveals new insights into a potential autoimmune component to the effects of COVID-19. Research like this has been made possible by the huge collaborative efforts made by those that are a part of the UK Coronavirus Immunology Consortium. This study is another important step towards delivering real improvements in prevention, diagnosis, and treatment of COVID-19 to patients.”

The study participants were separated into four cohorts:

  • Group one: 32 individuals sampled during their stay in intensive care for reasons other than COVID-19.  41% of individuals had autoantibodies. In this group, there were many different causes of their illness (over half was pneumonia) and autoantibodies were found against nearly all of the different autoantigens examined, indicating a more random distribution.
  • Group two: 25 individuals who were sampled during their stay in intensive care following a diagnosis of severe COVID-19. 60% had autoantibodies.  Of those who tested positive for autoantibodies, 41% had epidermal (skin) antibodies, while 17% had skeletal antibodies.
  • Group three: 35 individuals who had been admitted to intensive care with COVID-19, survived and were sampled three to six months later during routine outpatient follow up.  77% of individuals had autoantibodies.  Of those who tested positive for autoantibodies, 19% had epidermal (skin) antibodies, 19% had skeletal antibodies, 28% had cardiac muscle antibodies; and 31% had smooth muscle antibodies.
  • Group four: 24 healthcare workers sampled one to three months after mild to moderate COVID-19 that did not require hospitalisation. 54% of individuals had autoantibodies.  In those who tested positive for autoantibodies, it was against only four autoantigens: 25% had epidermal (skin) antibodies; 17% had smooth muscle antibodies; 8% had anti-neutrophil cytoplasm (ANCA) antibodies that target a type of human white blood cells; and 4% had gastric parietal antibodies which are associated with autoimmune gastritis and anemia.

Reference: “Establishing the prevalence of common tissue-specific autoantibodies following SARS CoV-2 infection” by Alex G. Richter, Adrian M. Shields, Abid Karim, David Birch, Sian E. Faustini, Lora Steadman, Kerensa Ward, Timothy Plant, Gary Reynolds, Tonny Veenith, Adam F. Cunningham, Mark T. Drayson and David C. Wraith, 3 June 2021, Clinical & Experimental Immunology.
DOI: 10.1111/cei.13623

The University of Birmingham is ranked amongst the world’s top 100 institutions, and its work brings people from across the world to Birmingham, including researchers and teachers and more than 6,500 international students from nearly 150 countries.

The UK Coronavirus Immunology Consortium brings together 20 UK immunology centers of excellence to research how the immune system interacts with SARS-CoV-2 to help us improve patient care and develop better diagnostics, treatments, and vaccines against COVID-19. It is jointly funded by UK Research and Innovation (UKRI) and National Institute for Health Research (NIHR) and supported by the British Society for Immunology.

The National Institute for Health Research (NIHR) is the nation’s largest funder of health and care research. The NIHR:

  • Funds, supports, and delivers high-quality research that benefits the NHS, public health, and social care
  • Engages and involves patients, carers, and the public in order to improve the reach, quality, and impact of research
  • Attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future
  • Invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services
  • Partners with other public funders, charities, and industry to maximize the value of research to patients and the economy

The NIHR was established in 2006 to improve the health and wealth of the nation through research, and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR supports applied health research for the direct and primary benefit of people in low- and middle-income countries, using UK aid from the UK government

Therapeutic Diets for COVID Patients

Therapeutic Diets for COVID Patients

  • June 12, 2021

Dr. Vasanta Kohli
Optimum Nutrition and Healthy balanced diets is an important Therapy for treating COVID patients. A well balanced diet provides stronger immune system and reduce the risk of chronic illness and infectious diseases.
Including the right kind of foods, in the right amounts is important for our health and also to boost immune system that makes the body strong to fight the disease.
A low carb, high protein diet is recommended and include vegetables and fruits which are rich in Vitamin-C and other essential Anti-Oxidants. Include a combination of different foods like whole grains and complex carbohydrates to provide the required energy for the body. Avoid refined Flour like Maida and use only multigrain flour, avoid taking too refined and polished rice, provide calories and carbohydrates through complex carbs. Avoid refined sugar and sugary drinks and glucose, as the virus survive and grow on the sugar and glucose. During high fever and illness, patient may not be able to eat our customary chapattis and Rice, hence provide semisolid, liquid diet in the form of thin Kichadi, Dhaliya, Porridge, Custard Jelly, Soups etc. Try to avoid sweets and sugar as for as possible.
Patient needs good amount of protein to maintain the tissues and strength of the body. 1 to 1.5 gm protein per Kg body weight has to be given. The required amount of protein can be provided by including eggs, cheese or paneer, milk, chicken, fish, meat etc. for non-vegetarians and by including different type of pulses and beans, milk, cheese, paneer in vegetarian diets.
The preparation method has to be modified as per the condition of the patient – if the patient can take normal consistency food, prepare the food in the conventional way, otherwise modify to boiled or scrambled egg, soups, pureed form as per the patient’s ability to consume food.
Plenty of vegetables may be included in the diet for example in each major meal include one softly cooked vegetable – vegetables can be given in the form of blenderized soup also. This will provide required vitamins and minerals.
To get required amount of Vitamin-C and other anti-oxidants, fruits like melons, apple, orange or any other seasonal and locally grown fruit should be included – WHO recommends consuming a minimum of 400 gms i.e. 5 portions of fruits and vegetables per day.
If the patient is unable to take fruits due to indigestion or distention of the stomach, fruits juices, electrolytes and coconut water may be given. Avoid soft drinks and other sugar syrup drinks.
Certain seeds and nuts like sunflower seeds, flaxseed, pumpkins seeds, melon seeds, almonds, walnut, cashew nuts are excellent source of protein and vitamin-E. Certain foods like mushroom, tomato, bell pepper and green vegetables like spinach, broccoli are also good options to build immunity in the body against infections. Nutritional supplements rich in omega 3 & 6 fatty acids are also good to build up immunity. Some natural immunity supplements include ginger, amla and turmeric which are common in our Indian dishes and snacks. There are several herbs that help in boosting immunity like Garlic, basil leaves and black cumin. It is advisable to take nutritional supplements like Vitamin-C to enhance immunity and as a powerful antioxidant and protects against damage induced by oxidative stress.
Vitamin-D has a mild protective effect against respiratory track infections- Zinc is vital component of WBC which fights infections. Zinc deficiency often makes one more susceptible to flue and common cold and other viral infections.
Turmeric and Garlic: The bright yellow spice Turmeric contains a compound called Curcumin which boost immune function. Garlic has a powerful anti-inflammatory and anti-viral properties which enhance body immunity. Turmeric milk or golden milk cab be given to the parents. Garlic roasted and boiled in the milk also can be given to the patient.
Drink 8 to 10 glass of luke warm water every day – can consume lemon tea, fruit juices, vegetable soups, tea etc. to maintain the hydration. Avoid sweetened fruit juices, syrups and other sugary drinks.
Consume moderate amounts of fat and oil. Avoid fried and processed food. Eat less salt and sugar. When cooking and preparing food, limit the amount of salt and high sodium condiments like sauces. Limit the salt intake to less than 5 gm which is equivalent to 1 teaspoon. Avoid foods, snacks that are high in salt and sugar.
Most COVID patients experience loss of smell and taste or difficulty in swallowing. It is important to eat semi-solid, soft or liquid diet at small intervals. Add chutney and pudina, anardana, dry mango powder to boost the taste buds. Avoid vegetable salads, as it may interfere with digestion and can cause stomach distention.
Eating a healthy diet, being physically active, managing stress and getting enough sleep may support the maintenance of health in both children and adults and can be our first line of antiviral defence. Strict hygienic and food safety measures while handling the food must be taken along with social distancing and quarantine protocols recommended by WHO.
Each a variety of home-made foods, including whole grains, lentils, pulses, legumes, fresh fruits and vegetable nuts and seeds and some food from animal sources for non-vegetarians. Probiotics like Yogurt, Yakult and fermented food are good sources to rejuvenate the composition of gut bacteria, which is important for nutrient absorption by the body.
Integrating healthy habits that composes the whole body – mild exercises, meditation and prayers, eating well, getting enough sleep, reduce stress shall able to cope up the infection and help the patient to come out successfully during the pandemic period.
Crash dieting may be discouraged as it affects the general immunity of the body. Maintain the ideal body weight by taking a balanced diet with all the optimum nutrients.
(The author is former HOD, Dietetics & Therapeutics, SKIMS, Srinagar & GMC, Jammu – Presently at BEE ENN General Hospital, Jammu.)

Non-altered birth cord cells boost survival of critically ill COVID-19 patients

Non-altered birth cord cells boost survival of critically ill COVID-19 patients

  • June 8, 2021

IMAGE

IMAGE: Ismail Hadisoebroto Dilogo, professor of medicine at Cipto Mangunkusumo Central Hospital-Universitas Indonesia, corresponding author of the study.
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Credit: AlphaMed Press

Durham, NC – Critically ill COVID-19 patients treated with non-altered stem cells from umbilical cord connective tissue were more than twice as likely to survive as those who did not have the treatment, according to a study published today in STEM CELLS Translational Medicine.

The clinical trial, carried out at four hospitals in Jakarta, Indonesia, also showed that administering the treatment to COVID-19 patients with an added chronic health condition such as diabetes, hypertension or kidney disease increased their survival more than fourfold.

All 40 patients who took part in the double-blind, controlled, randomized study were adults in intensive care who had been intubated due to COVID-19-induced pneumonia. Half were given intravenous infusions containing umbilical mesenchymal stromal cells, or stem cells derived from the connective tissue of a human birth cord, and half were given infusions without them.

The survival rate of those receiving the stem cells was 2.5 times higher and climbed even more – 4.5 times – in the COVID-19 patients who had other chronic health conditions, said Ismail Hadisoebroto Dilogo, professor of medicine at Cipto Mangunkusumo Central Hospital-Universitas Indonesia and research team member.

The stem cell infusion also was found to be safe and well-tolerated with no life-threatening complications or acute allergic reactions in seven days of post-infusion monitoring, he said.

Previous clinical trials have shown that treating COVID-19 pneumonia patients with stem cells from umbilical cord connective tissue may help them survive and recover more quickly, but the Indonesian study is the first to treat intubated, critically ill COVID-19 pneumonia patients with a naive, or non-genetically manipulated, form of the stem cells.

“Unlike other studies, our trial used stem cells obtained through explants from actual umbilical cord tissue and we did not manipulate them to exclude ACE2, a cellular protein thought to be an entry point for COVID-19,” Dilogo said.

Some research suggests that one of the main causes of acute respiratory distress in COVID-19 patients is “cytokine storm,” a condition in which infection prompts the body’s immune system to flood the bloodstream with inflammatory proteins.

“The exact cause of cytokine storm is still unknown, but our study indicates that the presence of non-manipulated umbilical cord stromal stem cells improves patient survival by modulating the immune system toward an anti-inflammatory immune state,” Dilogo said.

Since there is no cure for COVID-19, supportive care has been the only help available for patients who are critically ill with the virus.

“Although our study focused on a small number of patients, we think this experimental treatment could potentially lead to an effective adjuvant therapy for COVID-19 patients in intensive care who do not respond to conventional supportive treatment,” he said.

Dilogo’s research team launched the clinical trial last year after the COVID-19 occupancy rate in Jakarta’s intensive care units climbed to 80 percent and the mortality rate of critically ill COVID-19 pneumonia patients in the ICUs reached 87 percent.

“This study, which assessed the potential therapeutic effect of human umbilical-cord mesenchymal stem cells on critically-ill COVID-19 patients, provides promising results that could inform a potential treatment to increase survival rates,” said Anthony Atala, M.D., Editor-in-Chief of STEM CELLS Translational Medicine and Director of the Wake Forest Institute for Regenerative Medicine. “Having additional potential therapies, such as MSCs, could be highly beneficial for these patients.”

###

The full article, “Umbilical Cord Mesenchymal Stromal Cells as Critical COVID-19 Adjuvant Therapy: A Randomized Controlled Trial” can be accessed at https://stemcellsjournals.onlinelibrary.wiley.com/doi/abs/10.1002/sctm.21-0046.

About STEM CELLS Translational Medicine: STEM CELLS Translational Medicine (SCTM), co-published by AlphaMed Press and Wiley, is a monthly peer-reviewed publication dedicated to significantly advancing the clinical utilization of stem cell molecular and cellular biology. By bridging stem cell research and clinical trials, SCTM will help move applications of these critical investigations closer to accepted best practices. SCTM is the official journal partner of Regenerative Medicine Foundation.

About AlphaMed Press: Established in 1983, AlphaMed Press with offices in Durham, NC, San Francisco, CA, and Belfast, Northern Ireland, publishes two other internationally renowned peer-reviewed journals: STEM CELLS® (http://www.StemCells.com), celebrating its 39th year, is the world’s first journal devoted to this fast paced field of research. The Oncologist® (http://www.TheOncologist.com), also a monthly peer-reviewed publication, entering its 26th year, is devoted to community and hospital-based oncologists and physicians entrusted with cancer patient care. All three journals are premier periodicals with globally recognized editorial boards dedicated to advancing knowledge and education in their focused disciplines.

About Wiley: Wiley, a global company, helps people and organizations develop the skills and knowledge they need to succeed. Our online scientific, technical, medical and scholarly journals, combined with our digital learning, assessment and certification solutions, help universities, learned societies, businesses, governments and individuals increase the academic and professional impact of their work. For more than 200 years, we have delivered consistent performance to our stakeholders. The company’s website can be accessed at http://www.wiley.com.

About Regenerative Medicine Foundation (RMF): The non-profit Regenerative Medicine Foundation fosters strategic collaborations to accelerate the development of regenerative medicine to improve health and deliver cures. RMF pursues its mission by producing its flagship World Stem Cell Summit, honouring leaders through the Stem Cell and Regenerative Medicine Action Awards, and promoting educational initiatives.

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Antibody treatment reactivates the immune defense in patients with advanced-stage cancer

Antibody treatment reactivates the immune defense in patients with advanced-stage cancer

  • June 3, 2021

Researchers at the University of Turku, Finland, showed that the antibody treatment reactivates the immune defense in patients with advanced-stage cancer. The treatment alters the function of the body’s phagocytes and facilitates extensive activation of the immune system.

The immune defense is the body’s own defense system equipped to combat cancer. However, cancer learns to hide from immune attacks and harnesses this system to promote its own growth. Therefore, it would be beneficial to be able to return the immune defense back to restricting the advancement of cancer.

Macrophages, a type of white blood cell, are central in the fight against cancer. Cancer educates macrophages to subdue the defense system and renders many treatments targeting the immune system ineffective.

Academy Research Fellow Maija Hollmén’s research group has searched for means of altering the activity of macrophages in order to direct the immune defense to attack cancer. The antibody bexmarilimab, developed based on this research and in collaboration with Faron Pharmaceuticals, is currently undergoing clinical trials in patients. Hollmén’s group has studied the changes occurring in the defense systems of patients with cancer following antibody treatment.

“In the majority of patients, the antibody treatment activated killer T cells, which are the body’s strike force against cancer. Additionally, the antibody treatment successfully lowered the suppressive potential of macrophage precursors travelling in the blood circulation. The patients also showed increases in certain mediators of inflammation and types of white blood cell in the blood,” describes Hollmén.

The activation of the killer T cells is a very promising demonstration of the antibody’s capability to boost the defense system against cancer. The treated patients had very advanced and poorly treatable cancers, which highlights the significance of the results.”


Jenna Rannikko, Doctoral Candidate

Bexmarilimab may benefit patients for whom current treatment options are ineffective

The research also yielded new information on the mode of action of bexmarilimab. The antibody binds the molecule Clever-1 present on macrophages and alters its function.

Clever-1 transports material needless to the body inside macrophages to be degraded. Objects disposed in this manner are swept under the rug, in a manner of speaking. This kind of concealment is beneficial for the body’s natural balance and helps to avoid stirring the immune defense unnecessarily.

“However, cells originating from cancer should be detected. When the antibody is used to block Clever-1 from performing its cleaning job, it facilitates the activation of cells of the immune defense. This in part leads to the waking up of the T cells in patients,” describes Doctoral Candidate Miro Viitala.

There is demand for treatments that boost the activity of the immune defense since the current options on the market only help some patients.

“Bexmarilimab’s mode of action is different from the drug treatments against cancer currently on the market. Therefore, it can be beneficial for patients for whom current treatment options are ineffective,” concludes Postdoctoral Researcher Reetta Virtakoivu.

Maija Hollmén’s research group is part of the InFLAMES Flagship which is a joint initiative of University of Turku and Åbo Akademi University. The goal of the Flagship is to integrate immunological and immunology-related research activities to develop and exploit new diagnostic and therapeutic tools.

Source:

Journal reference:

Virtakoivu, R., et al. (2021) Systemic blockade of Clever-1 elicits lymphocyte activation alongside checkpoint molecule downregulation in patients with solid tumors: Results from a phase I/II clinical trial. Clinical Cancer Research. doi.org/10.1158/1078-0432.CCR-20-4862.

Pfizer-BioNTech Booster Vaccine Significantly Improves Immune Responses in Patients With Cancer

Pfizer-BioNTech Booster Vaccine Significantly Improves Immune Responses in Patients With Cancer

  • May 26, 2021

Patients from the United Kingdom (U.K.) who had an active diagnosis of cancer experienced significantly improved immune responses to the Pfizer-BioNTech COVID-19 vaccine after receiving the booster shot 21 days after the first dose, according to data from a recently published observational study.

The results, according to the study authors, indicate the importance of prioritizing patients with cancer for receipt of an early second dose of the vaccine.

“In patients with cancer, one dose of the Pfizer-BioNTech vaccine yields poor efficacy,” they wrote. “Immunogenicity increased significantly in patients with solid cancer within two weeks of a vaccine boost at day 21 after the first dose.”

Of note, the U.K. government in 2020 announced that the general population should receive the second doses of the COVID-19 vaccine approximately 12 weeks after receiving the first dose. This recommendation is a departure from the three to four-week window suggested by the vaccine manufacturers — which the United States follows.

This data comes after the same group of researchers previously reported that after a SARS-CoV-2 infection, some patients with cancer (especially those with B-cell malignancies) showed a delayed or negligible development of antibodies, abnormally low activity in the immune system and prolonged virus shedding compared to those not diagnosed with cancer. Moreover, previous research has shown that older and immunocompromised patients — including those with cancer — experience minimal benefits from vaccines.

As a result, the authors sought to evaluate the effectiveness and safety profiles of vaccines against SARS-CoV-2 (the virus that causes COVID-19) in patients with cancer — specifically, with Pfizer-BioNTech.

A total of 134 patients with solid cancer and hematological cancer from three hospitals in the U.K. (Guy’s & St Thomas’ NHS Trust, King’s College Hospital and Princess Royal University Hospital) participated in the study. There were also 34 healthy individuals (controls) for comparison. Blood samples were collected before patients were vaccinated, and then three weeks after and five weeks after their first vaccination. A COVID-19 nasal swab test was also completed every 10 days or in cases of symptoms of COVID-19.

The 92 patients with solid cancer enrolled on the study received their anticancer treatments either within 15 days before (38 patients) or after (50 patients) their first dose COVID-19 vaccination.

By the end of the study, 736 blood samples had been processed to assess effectiveness of the Pfizer-BioNTech COVID-19 vaccine in patients with cancer, as well as virus neutralization and T-cell responses. The study authors noted that any samples obtained after March 19, 2021 are still being processed.

“The (Pfizer-BioNTech) vaccine was generally well tolerated in patients with cancer, even in those on immunotherapy who might have been anticipated to make exaggerated, inflammatory immune responses,” they wrote. “However, by three weeks following single-dose (30 microgram) vaccination, immunogenicity was low.”

Specifically, immunogenicity (the immune system’s response to the vaccine) was 38% in patients with solid cancer and 18% in those with hematological cancer and did not improve in the following two weeks. However, after receiving a booster shot on day 21, the response substantially improved in patients with solid cancer.

Almost all of the healthy controls (94%) in the study had antibodies (or considered responders to the vaccine) at approximately 21 days after the first vaccination, compared to 38% of patients with solid cancer and 18% of those with a hematologic cancer.

The authors noted that there were not enough patients with hematological cancer who received a booster shot to truly assess the impact of receiving the second dose on day 21 in those patients.

Fifty-four percent of the patients with cancer reported no side effects after receiving the first dose. After the second dose, no side effects were reported in 71% of patients with cancer. Compared with the healthy controls, 38% of which reported no side effects after the first dose and 31% after the second. The most reported side effect among patients with cancer (35%) and the healthy controls (48%) was pain at the injection site seven days following the first dose. There were no vaccine-related deaths.

The results of the trial were consistent with the low vaccine efficacy reported for patients with cancer receiving seasonal vaccines, the authors highlighted.

“(This trial implies) that single-dose (Pfizer-BioNTech) vaccination leaves most patients with cancer wholly or partially immunologically unprotected,” the authors concluded. “This finding is of particular concern given our and others’ observations that immunocompromised patients have a higher incidence of harboring persistent SARS-CoV-2 infections, possibly providing an important reservoir for the emergence of novel viral variants.”

The authors wrote that the data could be used to reassess the present U.K. policy of a 12-week Pfizer-BioNTech vaccine dosing interval in patients with cancer, as well as other high-risk groups. Additional studies that examine the immune system response after more, repeated boosting of immunocompromised patients are recommended. This population, specifically, should also continue to observe COVID-19-associated measures like physical distancing and masking, even after vaccination, according to the authors.

Before this data was published, the U.K. government noted in February the possibility of low vaccine responses in immunosuppressed patients and recommended those individuals schedule their second booster dose earlier than the 12-week window between doses.

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Freiburg researchers receive ERC funding to develop and test immunostimulatory drug candidates

Groundbreaking study optimizes patient’s own immune system to fight tumors

  • May 15, 2021

A groundbreaking study led by engineering and medical researchers at the University of Minnesota Twin Cities shows how engineered immune cells used in new cancer therapies can overcome physical barriers to allow a patient’s own immune system to fight tumors. The research could improve cancer therapies in the future for millions of people worldwide.

The research is published in Nature Communications, a peer-reviewed, open access, scientific journal published by Nature Research.

Instead of using chemicals or radiation, immunotherapy is a type of cancer treatment that helps the patient’s immune system fight cancer. T cells are a type of white blood cell that are of key importance to the immune system. Cytotoxic T cells are like soldiers who search out and destroy the targeted invader cells.

While there has been success in using immunotherapy for some types of cancer in the blood or blood-producing organs, a T cell’s job is much more difficult in solid tumors.

The tumor is sort of like an obstacle course, and the T cell has to run the gauntlet to reach the cancer cells. These T cells get into tumors, but they just can’t move around well, and they can’t go where they need to go before they run out of gas and are exhausted.”


Paolo Provenzano, senior author of the study and biomedical engineering associate professor in the University of Minnesota College of Science and Engineering

In this first-of-its-kind study, the researchers are working to engineer the T cells and develop engineering design criteria to mechanically optimize the cells or make them more “fit” to overcome the barriers. If these immune cells can recognize and get to the cancer cells, then they can destroy the tumor.

In a fibrous mass of a tumor, the stiffness of the tumor causes immune cells to slow down about two-fold–almost like they are running in quicksand.

“This study is our first publication where we have identified some structural and signaling elements where we can tune these T cells to make them more effective cancer fighters,” said Provenzano, a researcher in the University of Minnesota Masonic Cancer Center. “Every ‘obstacle course’ within a tumor is slightly different, but there are some similarities. After engineering these immune cells, we found that they moved through the tumor almost twice as fast no matter what obstacles were in their way.”

To engineer cytotoxic T cells, the authors used advanced gene editing technologies (also called genome editing) to change the DNA of the T cells so they are better able to overcome the tumor’s barriers. The ultimate goal is to slow down the cancer cells and speed up the engineered immune cells. The researchers are working to create cells that are good at overcoming different kinds of barriers. When these cells are mixed together, the goal is for groups of immune cells to overcome all the different types of barriers to reach the cancer cells.

Provenzano said the next steps are to continue studying the mechanical properties of the cells to better understand how the immune cells and cancer cells interact. The researchers are currently studying engineered immune cells in rodents and in the future are planning clinical trials in humans.

While initial research has been focused on pancreatic cancer, Provenzano said the techniques they are developing could be used on many types of cancers.

“Using a cell engineering approach to fight cancer is a relatively new field,” Provenzano said. “It allows for a very personalized approach with applications for a wide array of cancers. We feel we are expanding a new line of research to look at how our own bodies can fight cancer. This could have a big impact in the future.”

In addition to Provenzano, the study’s authors included current and former University of Minnesota Department of Biomedical Engineering researchers Erdem D. Tabdanov (co-author), Nelson J. Rodríguez-Merced (co-author), Vikram V. Puram, Mackenzie K. Callaway, and Ethan A. Ensminger; University of Minnesota Masonic Cancer Center and Medical School Department of Pediatrics researchers Emily J. Pomeroy, Kenta Yamamoto, Walker S. Lahr, Beau R. Webber, Branden S. Moriarity; National Institute of Biomedical Imaging and Bioengineering researcher Alexander X. Cartagena-Rivera; and National Heart, Lung, and Blood Institute researcher Alexander S. Zhovmer, who is now at the Center for Biologic Evaluation and Research.

The research was funded primarily by the National Institutes of Health (NIH) and University of Minnesota Physical Sciences in Oncology Center, which receives funding from NIH’s National Cancer Institute. Additional funding was provided by the American Cancer Society and the Randy Shaver Research and Community Fund. The University of Minnesota Imaging Center provided additional staff expertise. Some of the researchers also are part of the University of Minnesota Center for Genome Engineering and the University’s Institute for Engineering in Medicine.

Source:

Journal reference:

Tabdanov, E.D., et al. (2021) Engineering T cells to enhance 3D migration through structurally and mechanically complex tumor microenvironments. Nature Communications. doi.org/10.1038/s41467-021-22985-5.

A Nutritional Boost for Mesothelioma Patients

A Nutritional Boost for Mesothelioma Patients

  • May 4, 2021
Health & Wellness

Our fact-checking process begins with a thorough review of all sources to ensure they are high quality. Then we cross-check the facts with original medical or scientific reports published by those sources, or we validate the facts with reputable news organizations, medical and scientific experts and other health experts. Each page includes all sources for full transparency.

Spring is here, and that means an abundance of fresh fruits and greens will be filling your farmers markets and grocery stores. Depending on where you live, you may even be able to pick your own. 

Fruits and vegetables come in a variety of colors, and each color provides our bodies with a different antioxidant as well as a variety of vitamins, minerals and fiber.

For patients with mesothelioma, getting a good intake of plant foods is vital for a healthy immune system. It can be a challenge, though, especially when appetite is low due to stress, treatment or general fatigue. 

Smoothies are a quick and easy way to get nutrition into our bodies because they can be sipped slowly and don’t need to be chewed. It is a good idea to pair fruits and greens with a protein such as milk, yogurt or nuts so you get a drink that adds calories in addition to all those nutrients. 

The following recipes will provide some ideas, but you can use any fruit you have available. Frozen fruit is great because it blends into a perfectly cold smoothie. It also lasts much longer than fresh fruit, so you don’t have to rush to use it all.

Blueberry smoothies in glasses with berries

Blueberries give this Blueberry Blast smoothie an antioxidant boost.

Blueberry Blast Smoothie

This recipe is perfect for blueberry season. If you are lucky enough to pick your own you can freeze the extra to use in drinks such as this one.


Ingredients

  • 2 cups frozen unsweetened blueberries (do not thaw)

  • 1/2 cup orange juice
    (calcium-fortified preferred)

  • 3/4 cup vanilla yogurt

  • 1/2 medium frozen banana

  • 1/2 teaspoon pure vanilla extract


Directions

  • Place blueberries, orange juice, yogurt, banana and vanilla into blender.

  • Cover securely and blend for 30 to 35 seconds or until thick and smooth. For thinner smoothies, add more juice; for thicker smoothies, add more frozen fruit.

  • Pour into two glasses and serve immediately.

Recipe: American Institute for Cancer Research

Green smoothie with strawberries and kiwi

Spinach brings extra nutritional value to this smoothie with berries.

Berries and Spinach Smoothie

This smoothie incorporates spinach, which sounds unusual, but you don’t taste the greens and it gives your beverage a wonderful pop of color.

Experiment with different fruits if you don’t have all these handy, and try adding spices such as cinnamon, nutmeg or ginger for an extra antioxidant boost.


Ingredients

  • 2 cups frozen unsweetened strawberries

  • 1/2 cup blueberries

  • 1 banana cut into chunks

  • 1/2 kiwi, sliced

  • 2 cups fresh spinach

  • 1/2 cup ice cubes

  • 1 cup milk (of your choice)

  • 1/2 cup 100% apple juice


Directions

  • Combine strawberries, blueberries, banana, kiwi, spinach, ice cubes, milk and apple juice in blender.

  • Blend until smooth.

  • Serve in a cup (serves four).

Recipe: Academy of Nutrition and Dietetics

Strawberry blueberry smoothie in a glass with chia seeds

Try adding seeds or spices to a smoothie for additional health benefits.

Smoothies are easy to make and you won’t go wrong blending any combination of fruits, greens and proteins. 

For nutritious twists, try adding some of the following foods:

  • Flaxseeds (1 teaspoon to start)

  • Hemp seeds

  • Chia seeds

  • Kale

  • Cinnamon, nutmeg or other spice blends
    such as pumpkin spice/apple spice

For additional protein, try the following:

  • 1 scoop of your favorite protein powder

  • 1/4 cup Greek yogurt

  • 1 tablespoon peanut butter

To make sure the calories are high, try to use full-fat milk, yogurt or coconut milk. If you need your smoothies a little sweeter, use natural sugars such as maple syrup, honey or even a few pitted dates, which will blend smoothly in a high-powered blender.

Try these recipes and your own today and find the perfect springtime smoothie for you!

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