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|Year : 2016 | Volume
| Issue : 7 | Page : 15-18
Guidelines for vaccination in patients with chronic kidney disease
|Date of Web Publication||27-Apr-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Guidelines for vaccination in patients with chronic kidney disease. Indian J Nephrol 2016;26, Suppl S1:15-8
By virtue of their immunosuppressive state, chronic kidney disease (CKD) patients are at risk for many infections, some of which are vaccine preventable. Knowledge of vaccination is imperative to treat CKD patients effectively.  [Table 12] summarizes the vaccine schedule for CKD patients. ,,,,,,
|Table 12: Recommendations for all vaccines in chronic kidney disease patients |
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Discussed in this section are special issues related to vaccination in subjects with CKD.
| Hepatitis B Vaccine || |
Hepatitis B vaccination is recommended for all CKD patients. ,,,, Patients with uremia who were vaccinated before they required dialysis have higher seroprotection rates and antibody titers. The response to vaccination is also better in children. 
Dosage and schedule
Higher vaccine dosages or an increased number of doses are recommended for subjects with CKD (eGFR <30 ml/min).
If an adult patient begins the vaccine series with a standard dose before beginning hemodialysis treatment, then moves to hemodialysis treatment before completing the series, completing the series using the higher dose is recommended for hemodialysis patients. No specific recommendations have been made for higher doses for pediatric hemodialysis patients. If a lower than recommended vaccine dose is administered to adults or children, the dose should be repeated.
- Patients should receive four doses of hepatitis B vaccine as early in the course of disease as possible
- Recombinant hepatitis B vaccine is recommended
- Use special formulations of vaccine (40 mcg/ml) or two 1 ml 20 mcg doses given at one site. Dose schedule should be 0, 1, 2, and 6 months
- Vaccine should be given intramuscular in deltoid regions
- Assess antibody titer to hep B surface antigen (anti-HBs). First titer should be done 1-2 months after the primary course is completed and annually thereafter
- Booster dose should be given if anti-HBs titer falls below 10 mU/ml
- Revaccination with full doses is recommended for persons who do not develop protective antibody titer after primary course.
The prevalence and incidence of the hepatitis B infections are high, at about 7.6% and 3.2%, respectively among dialysis patients in India.  Vaccine provides effective protection against the infection. Vaccination in early stages of CKD has better seroconversion rate than late vaccination.
There is no difference in seroconversion rate in recombinant and plasma-derived vaccine but recombinant vaccine is preferred due to fear of disease communication with plasma.
Double dose (40 mcg) and four doses give better seroprotection rate (73-92%) compared to 45-67% with conventional 3 dose schedule.
Deltoid region is preferred to ensure intramuscular administration. Intradermal administration has no advantage over intramuscular administration.
Antibody titer falls with time in patients on dialysis, necessitating annual monitoring.
Vaccine has been shown to be safe for patients on dialysis with only minor local reactions including pain, redness, or swelling at the vaccination site.
An increase in anti-HBs response with coadministration of zinc, erythropoietin, or immunomodulators such as alpha and gamma interferon, thymopentine, interleukin-2, and granulocyte macrophage colony stimulating factor have been reported. Such approaches should be reserved for patients in whom it is difficult to achieve seroconversion with at least two courses of the vaccine.
| Pneumococcal Vaccine || |
The recommendations for administering pneumococcal conjugate vaccine-13 (PCV13) and valent pneumococcal polysaccharide vaccine 23 (PPSV23) in patients with CKD are shown in [Table 13]. ,,,,, CKD patients over the age of 19 should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later. Subsequent doses of PPSV23 should follow current PPSV23 recommendations for adults at high risk. Specifically, the second PPSV23 dose is recommended 5 years after the first PPSV23 dose for persons aged 19-64 years.
|Table 13: Recommendation for administering PCV13 and PPSV23 vaccines for patients with chronic kidney disease |
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The burden of pneumococcal infections in CKD patients is high, the cost of pneumococcal vaccination is low as compared with the global health costs in this population, and there are no data indicating potential disadvantages. Thus, pneumococcal vaccination should be administered to all patients with CKD as early in the disease as possible.  The ACIP schedule recommends a PCV13 prime vaccination followed by a PPV23 vaccination as mentioned in [Table 13].
Influenza vaccine should be given annually before the beginning of the influenza season for persons 6 months of age or older on dialysis.  Household contacts and health care workers should also be vaccinated annually to decrease the transmission to high-risk CKD patients.
The vaccine dose is 0.25 ml by intramuscular route for those between the ages of 6 and 35 months, and 0.5 ml thereafter. To those <9 years of age, 2 doses of influenza vaccine are administered at least 1 month apart and at 9-12 years, one dose of split virus vaccine should be given. After the age of 12 years, one dose of whole or split virus vaccine should be given.
Dialysis patients are at increased risk of influenza-related mortality. Four-fold increase in serum antibody titer against influenza antigens have been observed in 50% of dialysis patients compared to 40% healthy controls, and no systemic reactions have been reported following influenza vaccination in dialysis patients.
Recommendations regarding other routine vaccines
Live attenuated vaccines
Live vaccines are contraindicated in immunocompromised patients due to risk of vaccine-induced infections. Even though the limited number of studies in CKD patients has not shown any adverse reactions, these vaccines should be avoided, with the exception of varicella and MMR vaccines. 
Children 1 year of age or older should receive 1 dose of subcutaneous varicella vaccine as recommended for healthy children of 13 years of age and younger who do not had chicken pox previously. Adolescents and adults should receive 2 doses of 0.5 ml subcutaneously, with second injection at least 4 weeks after the first. MMR vaccine should be given to all children including those on dialysis between 12 and 15 months of age with a booster dose between 4 and 6 years of age.
There is high risk of complications and death associated with chicken pox infection in adulthood. About 85% of children on dialysis develop protective antibody levels within 6 months following single dose of vaccine. Varicella vaccine has been reported to be safe for children on dialysis.
Seroconversion rate following MMR vaccine for all 3 antigens is approximately 30%, for mumps alone 50%, and for measles and rubella combined 80%. Patients on dialysis should be tested for seroconversion.
Use of inactivated vaccines and toxoids in chronic kidney disease
All inactivated vaccine and toxoids are safe and effective when used in dialysis patients and should be administered to children and adults on chronic dialysis using the same doses and schedules recommended for immunocompetent persons. 
Haemophilus influenzae Type B conjugate vaccine (HiB) HiB vaccine is safe and should be given to children beginning at 2 months to 5 years of age using same dosage and schedule used for healthy children and adults. A study of children on chronic ambulatory peritoneal disease (CAPD) has shown seroconversion rate of 90%.
Children on dialysis should receive diphtheria and tetanus toxoids and pertussis vaccine as recommended for healthy children. The vaccine is well tolerated by dialysis patients. The persistence of immunity in patients on dialysis is comparable to that among healthy persons.
Hepatitis A vaccine is highly immunogenic in children, adolescents, and adults, with up to 100% of recipients develop protective level of antibodies > 20 mU/ml persisting for up 48 months. CKD patients at increased risk of infections such as travelers to countries to intermediate or high endemicity of infection, children 2 years of age and older living in areas rate of hepatitis A are at least twice the national average, drug users, men who have sex with men, persons with CLD or clotting disorders and persons working with nonprimates should receive the vaccine as recommended for normal adults.
Staphylococcus aureus vaccine
Patients on dialysis are at high-risk of S. aureus infection.  ESRD patients had an impaired immunological response to S. aureus vaccination, in comparison to that of the healthy controls, and showed 50% reduction of IgG levels 6 months after a 25-μg vaccination with a monovalent conjugated S. aureus type 5 capsular polysaccharide.  In another study, a single injection of a bivalent conjugate vaccine containing S. aureus type 5 and 8 capsular polysaccharide 25 μg of each capsular polysaccharide also showed only partial and short-lived protection in ESRD patients. The study was declared as failure study as the decrease in vaccine efficacy occurred after 40 weeks. 
To prolong the efficacy of the vaccine, a higher dose of the same vaccine (100 μg of each capsular polysaccharide) was tested in ESRD patients in comparison to placebo. The vaccine was efficient and well tolerated in comparison to placebo during the study period. However, the incidence of S. aureus bacteremias was not statistically different from placebo after 50 weeks.  With limited data on S. aureus vaccination in these patients, this vaccine is presently not recommended. It appears that there is need of multicomponent vaccines incorporating several surface proteins, toxoids, and surface polysaccharides to overcome multiple and redundant virulence factors of staph aureus. 
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[Table 12], [Table 13]