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Immunizations in patients with end-stage renal disease

INTRODUCTION

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 [3]. 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 [7].

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 ESRD. The primary arguments against routine HBV vaccination in this patient population are based upon the following observations:

           

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Literature review current through: Jun 2014. | This topic last updated: Jun 13, 2014.
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References
Top
  1. Rodby RA, Trenholme GM. Vaccination of the dialysis patient. Semin Dial 1991; 4:102.
  2. Dinits-Pensy M, Forrest GN, Cross AS, Hise MK. The use of vaccines in adult patients with renal disease. Am J Kidney Dis 2005; 46:997.
  3. Kausz A, Pahari D. The value of vaccination in chronic kidney disease. Semin Dial 2004; 17:9.
  4. Eleftheriadis T, Antoniadi G, Liakopoulos V, et al. Disturbances of acquired immunity in hemodialysis patients. Semin Dial 2007; 20:440.
  5. Litjens NH, Huisman M, van den Dorpel M, Betjes MG. Impaired immune responses and antigen-specific memory CD4+ T cells in hemodialysis patients. J Am Soc Nephrol 2008; 19:1483.
  6. Agrawal S, Gollapudi P, Elahimehr R, et al. Effects of end-stage renal disease and haemodialysis on dendritic cell subsets and basal and LPS-stimulated cytokine production. Nephrol Dial Transplant 2010; 25:737.
  7. Dacko C, Holley JL. The influence of nutritional status, dialysis adequacy, and residual renal function on the response to hepatitis B vaccination in peritoneal dialysis patients. Adv Perit Dial 1996; 12:315.
  8. Schwebke J, Mujais S. Vaccination in hemodialysis patients. Int J Artif Organs 1989; 12:481.
  9. Kausz AT, Gilbertson DT. Overview of vaccination in chronic kidney disease. Adv Chronic Kidney Dis 2006; 13:209.
  10. Stevens CE, Alter HJ, Taylor PE, et al. Hepatitis B vaccine in patients receiving hemodialysis. Immunogenicity and efficacy. N Engl J Med 1984; 311:496.
  11. Buti M, Viladomiu L, Jardi R, et al. Long-term immunogenicity and efficacy of hepatitis B vaccine in hemodialysis patients. Am J Nephrol 1992; 12:144.
  12. Seaworth B, Drucker J, Starling J, et al. Hepatitis B vaccines in patients with chronic renal failure before dialysis. J Infect Dis 1988; 157:332.
  13. Dukes CS, Street AC, Starling JF, Hamilton JD. Hepatitis B vaccination and booster in predialysis patients: a 4-year analysis. Vaccine 1993; 11:1229.
  14. DaRoza G, Loewen A, Djurdjev O, et al. Stage of chronic kidney disease predicts seroconversion after hepatitis B immunization: earlier is better. Am J Kidney Dis 2003; 42:1184.
  15. Finelli L, Miller JT, Tokars JI, et al. National surveillance of dialysis-associated diseases in the United States, 2002. Semin Dial 2005; 18:52.
  16. Moyer LA, Alter MJ, Favero MS. Hemodialysis-associated hepatitis B: Revised recommendations for serologic screening. Semin Dial 1990; 3:201.
  17. Edey M, Barraclough K, Johnson DW. Review article: Hepatitis B and dialysis. Nephrology (Carlton) 2010; 15:137.
  18. Miller ER, Alter MJ, Tokars JI. Protective effect of hepatitis B vaccine in chronic hemodialysis patients. Am J Kidney Dis 1999; 33:356.
  19. Favero MS, Alter MJ. The reemergence of hepatitis B virus infection in hemodialysis centers. Semin Dial 1996; 9:373.
  20. Rangel MC, Coronado VG, Euler GL, Strikas RA. Vaccine recommendations for patients on chronic dialysis. The Advisory Committee on Immunization Practices and the American Academy of Pediatrics. Semin Dial 2000; 13:101.
  21. Bond TC, Patel PR, Krisher J, et al. Association of standing-order policies with vaccination rates in dialysis clinics: a US-based cross-sectional study. Am J Kidney Dis 2009; 54:86.
  22. Marangi AL, Giordano R, Montanaro A, et al. Hepatitis B virus infection in chronic uremia: long-term follow-up of a two-step integrated protocol of vaccination. Am J Kidney Dis 1994; 23:537.
  23. Donati D, Gastaldi L. Controlled trial of thymopentin in hemodialysis patients who fail to respond to hepatitis B vaccination. Nephron 1988; 50:133.
  24. Propst T, Propst A, Lhotta K, et al. Reinforced intradermal hepatitis B vaccination in hemodialysis patients is superior in antibody response to intramuscular or subcutaneous vaccination. Am J Kidney Dis 1998; 32:1041.
  25. Evans TG, Schiff M, Graves B, et al. The safety and efficacy of GM-CSF as an adjuvant in hepatitis B vaccination of chronic hemodialysis patients who have failed primary vaccination. Clin Nephrol 2000; 54:138.
  26. Charest AF, McDougall J, Goldstein MB. A randomized comparison of intradermal and intramuscular vaccination against hepatitis B virus in incident chronic hemodialysis patients. Am J Kidney Dis 2000; 36:976.
  27. Fabrizi F, Lunghi G, Poordad FF, Martin P. Novel perspectives on hepatitis B vaccine in dialysis population. Int J Artif Organs 2002; 25:174.
  28. Pérez-García R, Pérez-García A, Verbeelen D, et al. AM3 (Inmunoferón) as an adjuvant to hepatitis B vaccination in hemodialysis patients. Kidney Int 2002; 61:1845.
  29. Verkade MA, van de Wetering J, Klepper M, et al. Peripheral blood dendritic cells and GM-CSF as an adjuvant for hepatitis B vaccination in hemodialysis patients. Kidney Int 2004; 66:614.
  30. Chau KF, Cheng YL, Tsang DN, et al. Efficacy and side effects of intradermal hepatitis B vaccination in CAPD patients: a comparison with the intramuscular vaccination. Am J Kidney Dis 2004; 43:910.
  31. Barraclough KA, Wiggins KJ, Hawley CM, et al. Intradermal versus intramuscular hepatitis B vaccination in hemodialysis patients: a prospective open-label randomized controlled trial in nonresponders to primary vaccination. Am J Kidney Dis 2009; 54:95.
  32. Kong NC, Beran J, Kee SA, et al. A new adjuvant improves the immune response to hepatitis B vaccine in hemodialysis patients. Kidney Int 2008; 73:856.
  33. Unger JK, Peters H. Hepatitis B in chronic kidney disease: moving toward effective prevention. Kidney Int 2008; 73:799.
  34. Surquin M, Tielemans CL, Kulcsár I, et al. Rapid, enhanced, and persistent protection of patients with renal insufficiency by AS02(V)-adjuvanted hepatitis B vaccine. Kidney Int 2010; 77:247.
  35. Alavian SM, Tabatabaei SV. Effects of oral levamisole as an adjuvant to hepatitis B vaccine in adults with end-stage renal disease: a meta-analysis of controlled clinical trials. Clin Ther 2010; 32:1.
  36. Tung J, Carlisle E, Smieja M, et al. A randomized clinical trial of immunization with combined hepatitis A and B versus hepatitis B alone for hepatitis B seroprotection in hemodialysis patients. Am J Kidney Dis 2010; 56:713.
  37. Janzen L, Minuk GY, Fast M, Bernstein KN. Vaccine-induced hepatitis B surface antigen positivity in adult hemodialysis patients: incidental and surveillance data. J Am Soc Nephrol 1996; 7:1228.
  38. Charest AF, Grand'Maison A, McDougall J, Goldstein MB. Evolution of naturally acquired hepatitis B immunity in the long-term hemodialysis population. Am J Kidney Dis 2003; 42:1193.
  39. Tsouchnikas I, Dounousi E, Xanthopoulou K, et al. Loss of hepatitis B immunity in hemodialysis patients acquired either naturally or after vaccination. Clin Nephrol 2007; 68:228.
  40. Ahuja TS, Kumar S, Mansoury H, et al. Hepatitis B vaccination in human immunodeficiency virus-infected adults receiving hemodialysis. Kidney Int 2005; 67:1136.
  41. Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the management of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2005; 40:1559.
  42. Girndt M, Pietsch M, Köhler H. Tetanus immunization and its association to hepatitis B vaccination in patients with chronic renal failure. Am J Kidney Dis 1995; 26:454.
  43. Fuchshuber A, Kühnemund O, Keuth B, et al. Pneumococcal vaccine in children and young adults with chronic renal disease. Nephrol Dial Transplant 1996; 11:468.
  44. Bond TC, Spaulding AC, Krisher J, McClellan W. Mortality of dialysis patients according to influenza and pneumococcal vaccination status. Am J Kidney Dis 2012; 60:959.
  45. McGrath LJ, Kshirsagar AV. Influenza and pneumococcal vaccination in dialysis patients: merely a shot in the arm? Am J Kidney Dis 2012; 60:890.
  46. Lefebure AF, Verpooten GA, Couttenye MM, De Broe ME. Immunogenicity of a recombinant DNA hepatitis B vaccine in renal transplant patients. Vaccine 1993; 11:397.
  47. United States Renal Data System: US Department of Public Health and Human Services, Public Health Services, National Institutes of Health, Bethesda, 2006.
  48. Ortbals DW, Marks ES, Liebhaber H. Influenza immunization in patients with chronic renal disease. JAMA 1978; 239:2562.
  49. Jordan MC, Rousseau WE, Tegtmeier GE, et al. Immunogenicity of inactivated influenza virus vaccine in chronic renal failure. Ann Intern Med 1973; 79:790.
  50. Scharpé J, Peetermans WE, Vanwalleghem J, et al. Immunogenicity of a standard trivalent influenza vaccine in patients on long-term hemodialysis: an open-label trial. Am J Kidney Dis 2009; 54:77.
  51. Crespo M, Collado S, Mir M, et al. Efficacy of influenza A H1N1/2009 vaccine in hemodialysis and kidney transplant patients. Clin J Am Soc Nephrol 2011; 6:2208.
  52. Gilbertson DT, Unruh M, McBean AM, et al. Influenza vaccine delivery and effectiveness in end-stage renal disease. Kidney Int 2003; 63:738.
  53. McGrath LJ, Kshirsagar AV, Cole SR, et al. Influenza vaccine effectiveness in patients on hemodialysis: an analysis of a natural experiment. Arch Intern Med 2012; 172:548.
  54. Temiz G, Kasifoglu N, Kiris A, et al. Immune response after a single vaccination against 2009 influenza A H1N1 in hemodialysis patients. Ren Fail 2010; 32:716.
  55. Fehr T, Bossart W, Wahl C, Binswanger U. Disseminated varicella infection in adult renal allograft recipients: four cases and a review of the literature. Transplantation 2002; 73:608.
  56. Shinefield H, Black S, Fattom A, et al. Use of a Staphylococcus aureus conjugate vaccine in patients receiving hemodialysis. N Engl J Med 2002; 346:491.
  57. www.nabi.com/pipeline/clinicaltrials.php#1 (Accessed on April 07, 2007).
  58. Nabi discontinues StephVax after confirmatory phase III trial fails. Pharmaceutical Approvals Monthly 2005; 10:7.
  59. Schaffer AC, Lee JC. Staphylococcal vaccines and immunotherapies. Infect Dis Clin North Am 2009; 23:153.
  60. Tanisaro T, Tantawichien T, Tiranathanagul K, et al. Neutralizing antibody response after intradermal rabies vaccination in hemodialysis patients. Vaccine 2010; 28:2385.