CHAPTER 76: Vaccinations

INTRODUCTION

Infectious diseases are a major cause of morbidity and mortality in end-stage renal disease, dialysis, and kidney transplant patients. Impaired humoral and cellular immunity in these patients is attributable not only to kidney disease itself but also to immunosuppressive agents. Active immunization is an effective way to protect transplant candidates and recipients against certain infectious agents. Patients should be immunized against common infections such as pneumococci and influenza as soon as chronic kidney disease is diagnosed.^1–14 Furthermore, infections can contribute to rejection of the transplanted organ and to the subsequent development of certain types of cancers. Following transplantation, the risk for infectious diseases increases and the serologic response to vaccination decreases due to immunosuppressive agents. Historically, vaccination of adult dialysis and renal transplanted patients has been underutilized. For this reason, efforts should be made to vaccinate patients early in the course of kidney disease.

PRINCIPLES

• Protection upon vaccination results from the complex interaction of humoral and cellular components of the immune system.^15,16

• Humoral responses to vaccines are significantly reduced after solid organ transplantation by immunosuppressive agents, organ type, organ function, and age.¹⁰

• High variability of the antibody response was observed for all vaccines, possibly due to multiple factors (varying seasonal composition of the influenza vaccine, different vaccination schedules and doses, different immunosuppressive agents, presence of viral coinfections, etc.).

• However, despite reduced humoral response and low antibodies titers, vaccine-specific cellular immunity can be present.¹⁵

• Inactivated vaccines are safe in the posttransplant patient receiving immunosuppressive therapy. Live vaccines are generally contraindicated in adult immunosuppressed patients. Ideally, transplant surgery should not be performed 1–2 months after immunization with a live vaccine.

• However, based on recent data, vaccination with live-attenuated vaccines (varicella zoster virus [VZV], measles-mumps-rubella [MMR]) should be considered when the risk of exposure is high.¹⁰

• Guidelines and recommendations for vaccination of solid organ transplantation recipients are poorly supported by evidence and are largely extrapolated from what is known in the immune competent population.¹⁵

• If possible, transplant patients should receive all age-appropriate and risk-specific vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention prior to transplantation.^17–20

• As important as the immunization of the transplant recipients is the immunization of close household contacts and health care workers who will care for the immune-suppressed patient. Updating the vaccination of household contacts and health care workers will minimize the transplant patient’s exposure to certain viral and bacterial agents. It is safe to immunize close contacts of transplant patients with live viruses (VZV) except for the typhoid, smallpox, and oral polio vaccines.

• Monitoring antibody titers 1 or 2 months after vaccination series can be useful to check for seroconversion.

Pretransplantation

Timing of vaccination appears to be of paramount importance because serologic response to vaccinations is decreased in patients with chronic kidney disease. Patients with solid organ transplants receiving ...