Chronic Kidney disease is considered to be an immunosuppressed state. The CKD patients are at higher risk of infection and also the severity of infections is much more in CKD patients than their healthy counterparts.
Which Vaccines are commonly recommended for CKD patients:
1. Pneumococcal Vaccine:
Inj. Prevenar-13 0.5 ml intramuscular one dose followed by 2 months later Inj. Pneumovax-23 0.5 ml intramuscular
Pneumovax-23 is repeated every 5 years thereafter.
If somebody has received Inj.Pneumovax-23 one dose, and never received Prevenar -13, then Inj. Prevenar-13 is given 1 year after the Pneumovax-23 dose, and then every 5 years Pneumovax -23 is repeated.
2. Influenza Vaccine:
Inj.Influvac is inactivated Influnza vaccine given once every year before the viral fever/Influenza season begins.
3. Hepatitis B vaccine:
Inj.SHANVAC-B 2ml intramuscular(1 ml in each arm) given as 0-1-2-6 month schedule. For those on dialysis the Anti-HBs Antibody level is tested every year and if the level fall below 10 then the schedule is repeated.
Pneumococcal Vaccines: Why, When and How?
| AGE STANDARDIZED RATES | India | UK | US |
| DEATHS/1Lakh | 113 | 25 | 11 |
| DALY/1Lakh | 1772 | 119 | 77 |
As compared to other developed countries the risk of deaths and disability adjusted life years per 1 lakh population, due to lung infections is more in Indians, due to various reasons:
All cause Mortality in CKD patients is significantly higher than those with normal kidney function and a major reason for this mortality is related to infections.
| eGFR | Risk |
| 89-60 | 16% |
| 59-45 | 37% |
| 44-15 | 64% |
The risk of infection-related hospitalization progressively increases as the kidney function(eGFR) decreases.( Am J Kidney Dis. 2012;59(3):356. Epub 2011 Sep 9)
Any infections, particularly Pneumonia/Urinary tract infection, are more than twice as common in CKD patients as compared to those with normal kidney function.
In a dialysis unit on an average 27.9% of patients get pneumonia in a year.
The deaths due to Pneumonia are 13.6% in hospitalized patients and 36.5% among those admitted to ICU.
The effect of an episode of pneumonia is comparable to getting a heart attack, with comparable death rates even 1 year after the event.
Deaths at one year after a heart attack are 5% to 8.2% whereas the death rate at 1 year after pneumonia is 7.2%.
Patients with pneumonia had an excess rate of death even up to 10 years after pneumonia, indicating the long term ill effects of pneumonia and hence the need to prevent it by all means.
Recommendation:
Hence it is recommended that all CKD patients especially those at CKD stage3 or above, be vaccinated against Pneumococcal pneumonia.
30% of the pneumonia are due to pneumococcus bacteria, and they can cause invasive disease hence Pneumococcal vaccines are recommended.
Hepatitis B Vaccine:
Hepatitis B virus infection occurs by contact with infected blood or body fluids, and cross infection in dialysis units due to exposure of blood to contaminated materials or due to transfusion of infected blood or blood products is a known risk. Hepatitis B infection may lead to a chronic carrier state, it remains undetected or without any symptoms often for decades, but when the virus reactivates, it can lead to chronic active hepatitis, liver failure, and Liver cancers. Thus Hepatitis B vaccination is a must for all those at increased risk of exposure to blood or blood products.
As the CKD stage advances the response to the vaccine is suboptimal. Only 70% of CKD individuals respond to the first schedule of 4 doses of vaccine. So it’s advisable to check for the response by checking for Anti-HBs antibody level. The titer should by above 100, if it’s 10-100 it is acceptable, if below 10 then the schedule should be repeated.
The immunity may fade with time, hence Anti-HBs antibody levels are monitored annually and if levels fall below 10 the vaccine schedule is repeated.