The general health care of patients with end-stage renal disease (ESRD) is often provided by nephrologists. A principal feature of such care is the implementation of preventive measures, including immunizations. (See "The nephrologist as primary care physician in patients with end-stage renal disease".)
Patients with ESRD have a reduced response to vaccination because of the general suppression of the immune system associated with uremia. Compared with vaccination in patients without ESRD, for example, dialysis patients have a lower antibody titer and an inability to maintain adequate antibody titers over time [1,2]. The relatively low antibody response to a vaccine also appears to correlate with the degree of renal failure, but not with the specific mode of dialysis . It appears that disturbances in T lymphocytes and antigen-presenting cells may be responsible for the altered acquired immunity in ESRD patients, but additional studies are required [4-6].
Little information exists concerning the effects of dialysis adequacy on the antibody response to vaccination. There is, however, indirect evidence that increasing dialysis may be associated with an enhanced response. In a study of 32 nutritionally-replete peritoneal dialysis patients immunized with the hepatitis B vaccine, the initial weekly Kt/V was 2.37 and 2.01 in converters and nonconverters, respectively .
Despite the evidence of decreased efficacy, current recommendations are to vaccinate patients with ESRD [1,8,9]. Immunization recommendations in the United States are developed by the Advisory Committee on Immunization Practices (ACIP) of Centers for Disease Control and Prevention (CDC) and are presented in the figures (figure 1 and figure 2). A review of vaccination strategies in patients with ESRD is presented here. The discussion will center upon the vaccines of most importance for the dialysis population. These include hepatitis B virus (HBV), tetanus, pneumococcal, influenza, and varicella-zoster virus (VZV) vaccines.
HEPATITIS B VIRUS VACCINE
Controversy exists concerning the overall effectiveness, including the cost/benefit ratio, of hepatitis B virus (HBV) vaccination in patients with end-stage renal disease (ESRD). The primary arguments against routine HBV vaccination in this patient population are based upon the following observations: