Review

Vaccination for Patients Receiving Dialysis

Ramin Sam, Laura Rankin, Ifeoma Ulasi, Luc Frantzen, Dorothea Nitsch, David Henner,
Donald Molony, John Wagner, Jing Chen, Sanjay Kumar Agarwal, Andrew Howard,
Ralph Atkinson, Daniel Landry, Stephen O. Pastan, and Kamyar Kalantar-Zadeh

Vaccinating patients receiving dialysis may prevent morbidity and mortality in this vulnerable population. Complete author and article
The National Forum of End-Stage Renal Disease Networks (the Forum) published a revised vaccination information provided before
references.
toolkit in 2021 to update evidence and recommendations on vaccination for patients receiving dialysis.
Significant changes in the last 10 years include more data supporting the use of a high-dose influenza Correspondence to R. Sam
vaccine, the introduction of the Heplisav-B vaccine for hepatitis B, and changes in pneumococcal vac- ([email protected])
cines, including the approval of the PCV15 and PCV20 to replace the PCV13 and PPSV23 vaccines. Kidney Med. 6(3):100775.
Additional key items include the introduction of vaccines against severe acute respiratory syndrome Published online December
coronavirus 2, the virus that causes coronavirus disease 2019 (COVID-19), and a new vaccine to prevent 9, 2023.
respiratory syncytial virus disease. Historically, influenza and pneumococcal vaccinations were routinely doi: 10.1016/
administered by dialysis facilities, and because of possible risks of hematogenous spread of hepatitis B, j.xkme.2023.100775
dialysis providers often have detailed hepatitis B vaccine protocols. In March 2021, COVID-19 vaccines
were made available for dialysis facilities to administer, although with the end of the public health
emergency, vaccine policies by dialysis facilities against COVID-19 remains uncertain. The respiratory
syncytial virus vaccine was authorized in 2023, and how dialysis facilities will approach this vaccine also
remains uncertain. This review summarizes the Forum’s vaccination toolkit and discusses the role of the
dialysis facility in vaccinating patients to reduce the risk of severe infections.

© 2023 The Authors. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is an open access article
under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

V accinating patients receiving maintenance dialysis is

crucial to reducing morbidity and mortality in this
vulnerable population. Specifically, patients receiving
The advisory committee on immunization practices
(ACIP), recently updated in 2022, has stressed the
importance of 2 vaccines (hep B and pneumonia) that are
dialysis are more vulnerable to complications from an recommended for patients receiving dialysis.2 The Forum
infection because of the high prevalence of immune of End-Stage Renal Disease (ESRD) Networks also pub-
compromise. Additionally, patients receiving dialysis, lished a vaccination toolkit online.3 The common vaccines
particularly those being treated with in-center hemo- for influenza, pneumococcal pneumonia, and hepatitis B
dialysis, are a mandatory congregate population, are summarized in Table 1.
meaning that they cannot isolate when ill and there-
fore increase the risk of transmission of an infection to Pneumococcal Vaccination
others.
In 1983, a 23-valent polysaccharide vaccine (PPSV23,
Ideally, vaccination should be given in the dialysis
Pneumovax 23) was licensed to minimize the risk of
units because patients receiving dialysis spend a lot of
pneumococcal infections. Until recently, it was recom-
time commuting to the dialysis center and dialyzing
mended that most adults over 65 years receive 1 dose.
there, frequently feeling unable to keep many other
In 2011, a second pneumococcal vaccine became
medical appointments. Hence, administering the vac-
widely available to further minimize the risk of pneumo-
cines during dialysis will improve adherence. Surpris-
coccal disease. Polysaccharide conjugate vaccine 13
ingly, there are little data on the effectiveness of
(PCV13 or Prevnar 13) is a conjugate vaccine that covers
increasing adherence by vaccinating patients in the
most of the pneumococcal serotypes that cause this inva-
dialysis clinic. To the best of our knowledge, only 1
sive disease. Two newer pneumococcal conjugate vaccines,
study found that vaccination for coronavirus disease
PCV15 (Vaxneuvance) and PCV20 (Prevnar 20), approved
2019 (COVID-19) in the dialysis clinic reduced dispar-
in 2021, are now part of the recommendations, leading to
ities in the vaccination rate among patients receiving
the removal of PCV13 wherever the newer vaccines are
dialysis.1 Clearly, it would be logical to conclude that the
available. Eventually, pneumococcal vaccination would
practice of vaccination in the dialysis clinic will lead to
likely involve just 1 dose of PCV20 in a person’s lifetime
better vaccination coverage, even without literature
(Fig 1), as mentioned below:
supporting it. Another advantage would be that dialysis
centers are more likely to have a robust vaccination • For patients who have not received any previous pneu-
record. mococcal vaccine, the ACIP recommends 1 dose of

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 Sam et al

Table 1. Common Vaccines for Influenza, Pneumococcal Pneumonia, and Hepatitis B

Year Approved
Vaccine Brand Name Disease by FDA Indication Effectiveness
PPSV23 Pneumovax (Merck) Pneumococcus 1983
PCV13 Prevnar 13 (Pfizer) Pneumococcus 2011 Covers additional
serotypes
PCV15 Vaxneuvance (Merck) Pneumococcus 2021
PCV20 Prevnar 20 (Pfizer) Pneumococcus 2021
Fluzone Quadrivalent Influenza 2013
(Sanofi)
Fluzone high dose Influenza 2014 Age > 65 y More effective
Quadrivalent (Sanofi) because it has 4
times the antigen*
Hepatitis B Recombivax (Merck) Hepatitis B 1986
Vaccine
(Recombinant)
Hepatitis B Engerix-B (Glaxo- Hepatitis B 1989
Vaccine Smith-Kline)
(Recombinant)
HepB-CpG Heplisav-B (Dynavax) Hepatitis B 2017 More effective
than other Hep B
vaccines

PCV20 (which completes their vaccinations) OR PCV15 There is widespread consensus that all patients receiving
plus 1 dose of PPSV23 at least 1 year later, with a possible dialysis should be vaccinated against influenza annually.
minimum interval of 8 weeks for immunocompromised However, from 2014 to 2017, only 72.1% of patients
patients (this does not include dialysis by itself unless the receiving dialysis were vaccinated.5 Questions about
patient receiving dialysis is receiving immunosuppressive influenza vaccination in patients receiving dialysis are as
medications). Not all dialysis units may have these newer follows:
vaccines available. and they should continue to use
1. Should all patients receiving dialysis receive a high-dose
PCV13 until the newer vaccines become available. For
influenza vaccination, or only those >65 years old?
patients who only received PPSV23 previously, the ACIP
recommends a single dose of PCV15 or PCV20 at least 1 2. When is the best time to vaccinate patients receiving
year after PPSV23. dialysis?
• For patients who received PCV13 previously, the In 2014, the US Food and Drug Administration (FDA)
recommendation is PPSV23 at least 8 weeks later and up approved the Fluzone high-dose quadrivalent influenza
to 3 total doses (2 doses before age of 65 ≥ 5 years apart, vaccine (Sanofi Pharmaceutical) for people > 65, which
and the last dose after age of 65 > 5 years after the contains 4× greater antigen and elicits a higher antibody
previous dose). Alternatively, 1 dose of PCV20 may be response; however, both available influenza vaccines are
administered to complete the vaccinations. quadrivalent (ie, 4 targeted variants of influenza, 2A and
2B forms). Currently, the high-dose vaccine is recom-
No further vaccination is needed for patients who mended only for patients older than 65 years, regardless of
already completed the PCV13 and PPSV23 series. For being immunocompromised. In 2018, a study examining
further information, see pneumococcal vaccine timing for the high-dose vaccine in patients receiving dialysis during
adults: https://www.cdc.gov/vaccines/vpd/pneumo/ the 2015-2016 and 2016-2017 influenza seasons
downloads/pneumo-vaccine-timing.pdf demonstrated a decrease in hospitalizations in 2016-2017
but not in 2015-2016 compared with the regular dose
Influenza Vaccination vaccine. No improvement in death rates in either influenza
Influenza infection is associated with significant morbidity season was demonstrated.6 Another study showed more
and mortality in the general population, especially the promising results with the high-dose quadrivalent vac-
elderly. The consequences of infection in patients receiving cine.7 An analysis of USRDS data between the 2010 and
dialysis are likely even more alarming. In a study of pa- 2015 influenza seasons found the risk for mortality, hos-
tients receiving hemodialysis with diabetes, 17% of pa- pitalizations due to influenza or pneumonia, and
tients not vaccinated were diagnosed with influenza, influenza-like illness did not differ between patients who
compared with only 6.3% among vaccinated patients received the high-dose vaccine versus the standard-dose
(likely some influenza infections in both groups were not vaccine.8 However, the study may have been biased
diagnosed by testing).4 because most of the patients receiving the high-dose

2 Kidney Med Vol 6 | Iss 3 | March 2024 | 100775

Sam et al

Pneumonia vaccination
3 5
2 4
1
Received Has received Has not Has not
Never PCV13 but not PCV13. Last received received
received PPSV23 in the PPSV23, PCV13, last PCV13, last
PCV13 or past patient was PPSV23 was PPSV23 was
PPSV23 > 65 years of < 1 year ago >1 year ago
age

Administer
Administer PCV20 PPSV23 (8 weeks
Wait until it is 1 Administer
OR after PCV13
year since PCV15, or
PCV15 followed administration, No more PPSV23, then PCV20. If not
by PPSV23 need total of 3 vaccination administer available
(minimum of 8 doses, 5 years needed PCV15, or administer
weeks after apart, if below 65
PCV20. If PCV13
PCV15). years of age) OR
PCV15 or
If neither vaccine administer one
PCV20 not
is available, then dose of PCV20
available,
administer PCV13 administer
first followed by PCV13
PPSV23 8 weeks
later

Figure 1. Pneumonia vaccine protocol. To undergo pneumonia vaccination we need a record of the previous vaccinations that pa-
tients have received. Following to be noted:

1. Prevnar 15 or 20 vaccine is only given once in lifetime of the patient.

2. PPSV23 vaccine can be given as many as 3 times in the life of the patient.
3. One dose of Prevnar 20 will complete a patient’s pneumonia vaccination.
4. One dose of Prevnar 15 will require one additional dose of PPSV23 to complete vaccination series.
5. Prevnar 15 or 20 vaccine cannot be given up to a year after receiving PPSV23 vaccine.
6. PPSV23 can be given as early as 8 weeks after giving Prevnar 15.
7. PPSV23 is readministered 5 years after giving first dose in patients less than 65 year of age and then again after age of 65,
assuming at least 5 years elapsed since the last dose.
8. After age 65, only 1 dose of PPSV23 is necessary.

vaccine were older. An analysis of the younger than 65 should be adjusted. All patients should receive influenza
years group still did not show a benefit for the higher dose vaccination, even late in the influenza season.
vaccine, but the number of patients in this sample may Quadrivalent inactivated influenza vaccines (IIV4), some
have been low, and it is likely that the standard dose group of which are egg-based, make egg allergy a contraindication
may still have been younger and with fewer comorbid (although it may be safe to give egg-containing vaccines to
conditions than the high dose group because this was not a most patients with egg allergies) (https://www.cdc.gov/
prospective study. flu/prevent/egg-allergies.htm). By contrast, the quadriva-
In most years, the influenza season is from October to lent recombinant influenza vaccine (RIV4) is produced in an
May, with influenza typically peaking in December until insect cell line with no viruses or eggs. Quadrivalent live
February. The Center for Disease Control (CDC) recom- attenuated influenza vaccine (LAIV4) is approved for ages 2-
mends administering the influenza vaccine in the United 49 years and is given intranasally. It is contraindicated for
States before the end of October. Data suggest that giving immunocompromised patients, their close contacts and
the vaccine earlier (ie, August) will result in the waning of caregivers, pregnant women, and asthmatic patients; how-
its effectiveness before the end of the influenza season. At ever, many patients receiving dialysis can receive this vac-
least 1 study found that administering the vaccine from cine despite some degree of immunosuppression from the
late October to mid-November was ideal9; however, there kidney disease.
have been reports of influenza infections as early as More detailed CDC and World Health Organization (WHO)
October in some years. For populations in the southern recommendations for influenza vaccination are available at
hemisphere, the recommended months for administration https://www.cdc.gov/flu/professionals/acip/summary/

Kidney Med Vol 6 | Iss 3 | March 2024 | 100775 3

 Sam et al

summary-recommendations.htm https://www.who.int/ A preliminary study showed a higher antibody

teams/immunization-vaccines-and-biologicals/policies/who- response rate with 3 doses of HepB-CpG compared with
recommendations-for-routine-immunization—summary-tables 4 doses of Engerix-B in patients with chronic kidney
disease.12 A study of these patients at a mean follow up
Hepatitis B Vaccination of 2.5 years indicated that titers were higher with 3
Three hepatitis B vaccine formulations are available. doses of HepB-CpG than Engerix. A more recent study
Recombivax HB (Merck) and Engerix-B (Glaxo-Smith- of 119 patients receiving hemodialysis, 75 of whom
Kline) are manufactured from viral proteins generated in completed the protocol, tested the efficacy of 4 doses of
yeast through recombinant DNA technology and have an HepB-CpG (20 μg) at 0, 4, 8, and 16 weeks. Anti-HBs
aluminum adjuvant. The third vaccine, HepB-CpG; sold as testing was performed each week of vaccine adminis-
Heplisav-B by Dynavax, is the newest of the 3 and will be tration and at week 20. Titers > 10 mlU/mL were
discussed later. For the 2 original vaccines, 3 doses are found in 56.8% after 2 doses, 78.7% after 3 doses, and
recommended for the general population, but for patients 89.3% after 4 doses.13 By comparison, antibody titers
receiving dialysis, higher vaccine doses (40 mcg vs 10 mcg >10 mlU/mL were found in 73.7% of patients receiving
for Recombivax HB vaccine) or additional doses are rec- 4 doses of 40 mcg Engerix and 64.3% in patients
ommended per vaccination series (3 doses of Recombivax receiving 3 doses of 40 mcg Recombivax. At least one
HB and 4 of Engerix-B) because patients receiving dialysis large dialysis organization has used this article to
have subnormal immune responses to these vaccines.10 A develop a 4-dose protocol for Heplisav-B. As noted
second series is indicated if seroconversion does not occur above, the CDC and ACIP guidelines suggest adminis-
after the first vaccine series. If a second full hepatitis B tering 2 doses followed by serologic testing and
vaccine series fails to induce an HbsAb titer > 10 mIU/mL, repeating the 2-dose series if needed.
the patient is considered a nonresponder, and no further Over the last year, many dialysis providers in the US and
vaccine doses are indicated. The overall response rate to likely other countries have moved to vaccinate their pa-
vaccination in the dialysis population with these regimens tients according to the above schedule with the HepB-CpG
is, at best, 70%. New evidence supports administering a vaccine. HepB-CpG vaccine may soon replace other hep-
series of the newer vaccine, Heplisav-B, if the patient has atitis B vaccines in dialysis units worldwide. Fig 2 dem-
not responded to the older vaccines. onstrates an algorithm for hepatitis B vaccination.
Once seroconversion occurs, patients should have
annual surface antigen and quantitative HbsAb testing. A Severe acute respiratory syndrome coronavirus 2
booster vaccine should be administered when antibody vaccination
titers drop below 10 mIU/mL. Not checking HepBsAg As of mid-2023, there were 9 vaccines approved for use by
in recently vaccinated patients is recommended because the WHO against COVID-19: ChAdOx1-S (Astra-Zeneca),
antigen levels may persist up to 2 weeks after vaccina- BBV152 (Bharat Biotech), Ad26.CoV2.S (Johnson and
tion, leading to false-positive results, possible unnec- Johnson), BNT162b2 (Pfizer), mRNA-1273 (Moderna),
essary isolation, and repeat testing.11 We recommend NVX-CoV2373 (Novavax manufactured under 2 different
not to isolate these patients because it may result in brand names in India and Europe), VLA2001 (Valneva),
more harm than benefit. Given the suboptimal sero- BBIBP-CorV (Sinopharm), and CoronaVac (Sinovac)
conversion response among patients receiving dialysis, it (Table 2).14-16 Two of the above vaccines (BNT162b2 and
is recommended to immunize previously unvaccinated mRNA-1273) are mRNA vaccines, 3 are inactivated virus
advanced patients with chronic kidney disease to hepa- vaccines (BBIBP-CorV, CoronaVac, and BBV152), 2 are
titis B and pneumococcal disease before dialysis adenovirus vector-based vaccines (ChAdOx1-S and
initiation. Ad26.CoV2.S), 1 is inactivated, adjuvanted whole virus
In 2017, a third recombinant hepatitis B vaccine vaccine (VLA2001) and 1 is adjuvanted protein vaccine
became available in the United States (HepB-CpG; sold as (NVX-CoV2373). Four of the vaccines (Ad26.CoV2.S,
Heplisav-B by Dynavax), and in 2021 it received approval BNT162b2, mRNA-1273, and NVX-CoV2373) are
by the European Commission Marketing Authorization. approved by the US FDA for, at a minimum, emergency
Heplisav-B contains a novel immunostimulatory adjuvant use. As of August 2021 and January 2022, respectively, the
and requires administration of only 2 doses (1 month BNT162b2 (aged 16 years and older) and mRNA-1273
apart) versus 3 doses required for Recombivax or Engerix. (aged 18 years and older) vaccines have received full
The CDC and ACIP recommendations suggest serologic FDA approval and have emergency use authorization for
testing 1-2 months after the second dose for patients children 6 months and older in the United States. The
receiving hemodialysis. If anti-HBs titers are <10 mIU/mL, original regimen for all of these vaccines was 2 doses
then another 2 doses of HepB-CpG should be given, fol- spaced 2-4 weeks apart, except for Ad26. The CoV2.S
lowed by anti-HBs testing (> 2 complete hepatitis B vac- vaccine (currently recommended only for people who
cine series are not recommended) (https://www.cdc.gov/ cannot take or refuse the mRNA vaccines) was 1 dose.
mmwr/volumes/67/wr/mm6715a5.htm). These vaccines are recommended for ages > 12, 3 months

4 Kidney Med Vol 6 | Iss 3 | March 2024 | 100775

Sam et al

No previous vaccina on
HepliSav-B available

Yes No

Previous vaccina on Previous vaccina on No previous

HepliSav-B
HepliSav-B available HepliSav-B not vaccina on,
20 mcg 2
available HepliSav-B not
doses one
month available
Hep BsAb ter Hep BsAb ter
apart
Nega ve Posi ve Give series of
Hep BsAb ter a er 2 Nega ve Posi ve Engerix-B (40 mcg)
months Has received Con nue or Recombivax (40
Con nue 2 series of to monitor mcg) in doses
to monitor Engerix-B or
suggested for
Posi ve Recombivax
Nega ve dialysis pa ents

2 more doses Con nue No

Yes
of HepliSav-B (20 to monitor
mcg) 1 month Await Give 2nd series of Engerix (40 mcg)
apart HepliSav-B or Recombivax (40 mcg)
availability

Figure 2. Hepatitis B vaccine protocol.

after the last dose of the COVID-19 vaccine (after the FDA; none are truly quantitative. In addition, the level of
primary series) or infection with the virus. Because the protection from infection is not known. The discussion below
Omicron variant has many more mutations17 than the should therefore be viewed within this context.
original strain, as opposed to the Delta variant, which re- As a consequence of natural infection, a mean antispike
ported 4 mutations, the original vaccines may not be as antibody titer of 212 UA/mL (551 BAU/mL) is seen in
protective against infection.15 Even the original vaccines patients receiving dialysis a year after severe COVID-19
seem to still protect against severe disease. Newer bivalent infection.18 After 2 doses of BNT162b2 vaccine, 82% of
versions of the BNT162b2 and mRNA-1273 vaccines, first patients receiving dialysis reported neutralizing antibodies
available in fall 2022, elicit higher antibody titers against compared with 100% of healthy controls (with a median
the newer Omicron variants of the virus.16 Most recently, percent inhibition of 51% in patients receiving dialysis and
an updated COVID-19 vaccine has become available for the 98% in controls).19 The antibody response rate in patients
fall and winter of 2023-2024. receiving transplant seems to be much lower than that of
As per the FDA, testing for antibody levels should not be patients receiving dialysis.20 Overall, patients receiving
used to evaluate a person’s level of immunity from COVID-19. dialysis do not seem to be as immunocompromised as
Many tests are under emergency use authorization from the patients receiving immunosuppression for organ

Table 2. Vaccines Against Severe Acute Respiratory Syndrome Coronavirus 2

Original Number of
Company Making Approved Approved Doses
Vaccine the Vaccine by WHO by US FDA Age Approved Recommended
ChAdOx1-S Astra-Zeneca Yes No >18 y 2
Ad26.CoV2.S Johnson and Johnson Yes Emergency use >18 y 1
approval for
patients not
eligible for mRNA
vaccine
BNT162b2 Pfizer Yes Full approval for >6 mo of age to 5 y 2
>5 y of age (EUA)
mRNA-1273 Moderna Yes Full approval for >6 mo of age to 17 y 2
>18 y of age (EUA)
BBIBP-CorV Sinopharm Yes No >18 y 2
CoronaVac Sinovac Yes No >18 y 2
NVX-CoV2373 Novavax Yes No >18 y 2
Gam-COVID-Vac Sputnik V No No 2
Abbreviations: EUA, emergency use authorization, FDA, Food and Drug Administration; WHO, World Health Organization.

Kidney Med Vol 6 | Iss 3 | March 2024 | 100775 5

 Sam et al

transplants, but they are more immunocompromised than mortality rate from COVID in unvaccinated patients
patients with many other chronic diseases (demonstrated receiving dialysis compared with those who were
by the fact that the response for instance to hepatitis B vaccinated.17
vaccination is lower in patients receiving dialysis compared It has clearly been demonstrated that antibody titers
with patients with many other chronic diseases). In 1 wane over time in the general population, an effect that
study, adequate antibody response was seen in 92% of may be even more pronounced in patients receiving
patients receiving peritoneal dialysis, 84% of patients dialysis. Davidovic et al31 found that adequate antibody
receiving hemodialysis, and only 26% of patients receiving seroconversion rates against COVID-19 in patients
kidney transplant after 2 doses of COVID vaccines. This is receiving hemodialysis decline from 97.9% at baseline to
especially true if the patient receives B cell depleting 65.8% at 6 months. A third dose of vaccines has been
therapy such as rituximab or belatacept.21 However, pre- shown to increase the serologic response32-34 in
liminary data indicate that the immune response to natural addition to lowering the incidence of severe COVID
infection may be similar in patients receiving kidney illness.35,36 A fourth dose of the vaccine also seems to
transplant compared with the response in normal controls, increase the humoral response but possibly not as
which may be a reflection of more severe illness.22 helpful in patients who already have low antibody ti-
Previous COVID-19 infection clearly augments the ters.37,38 A study found a lower risk of severe COVID
antibody response. In 1 study of 186 patients receiving illness after 4 doses compared with 3 doses of the
hemodialysis, the antibody titers were clearly higher in BNT162b2 vaccine.39 It seems patients receiving dialysis
this subgroup of 38 patients with previous COVID infec- who already have received the Ad26.COV2.S vaccine have
tion.23 Among patients with past history of COVID infec- a higher antibody response if they receive the booster dose
tion, all 38 patients were responders to 2 vaccine doses, with mRNA vaccine compared with receiving the booster
97% at maximum titers. Of the patients with no history of with additional Ad26.COV2.S vaccine.40 The bivalent
COVID infection, 86% were responders with less than 70% mRNA booster vaccines also benefits patients receiving
at maximum titer. dialysis, especially those who have not had previous
In a study, the mRNA-1273 vaccinated patients reported breakthrough infection.41 Whether patients receiving dial-
2.98-fold higher antibody titer than those vaccinated with ysis should receive severe acute respiratory syndrome
the BNT162b2 vaccine.24 A study on ChAdOx1-S vaccine coronavirus 2 (SARS-CoV-2) vaccines yearly with the
found the vaccine provided suboptimal antibody protection general population or every 6 months because of being
in patients with COVID-19 infection from variants of immunocompromised is still a matter of debate, but there
concern if they did not have previous COVID-19 infection.25 are preliminary data reporting that every 6 month
Finally, a study from Thailand on Coronavac (Sinovac administration may be beneficial.42 Our recommendation
Biotech) vaccine in 60 Chinese patients receiving dialysis is for all patients receiving dialysis to receive a dose of
and 30 healthy controls found an anti-RBD antibody titer of SARS-CoV-2 current recommended mRNA vaccine every 6
590 AU/mL in patients receiving dialysis and 1,767 in months.
healthy controls.26 Another study from Chile compared 81 An interesting study found that the humoral response to
patients receiving hemodialysis who received BNT162b2 hepatitis B vaccination may improve in patients receiving
vaccine with 127 patients receiving hemodialysis who dialysis after administration of SARS-CoV-2 vaccine.43 In
received the CoronaVac vaccine.27 The humoral response to this study, 6 out of 16 nonresponder patients reported
the BNT162b2 was superior to that of the CoronaVac vaccine adequate hepatitis B surface antibody titers after a booster
with 98.8% of patients in the BNT162b2 vaccine group dose shortly after receiving the SARS-CoV-2 vaccine (all
having an adequate antibody titer at 4 months after the received the Energix vaccine). Further, more definite studies
booster shot as opposed to 86.6% in the CoronaVac vacci- would be helpful to determine if there is an optimal period
nated group.27 In the general population, mRNA vaccines between administrations of the different vaccines.
are shown to elicit major short-term antibody responses COVID-19 vaccination may be associated with flu-like
which wane over 3-6 months; these data are lacking in pa- symptoms, such as fevers, chills, malaise and myalgias
tients receiving dialysis.15 However, the adenovirus vector within the first 24-48 hours in one-third to half of patients
vaccines elicit a much lower initial antibody response, but receiving dialysis who receive mRNA vaccines.44,45 The
this response lasts longer, up to at least 8 months. Forum of ESRD Networks (and other organizations) have
A multicenter observational cohort study of 1,323 pa- created educational posters and flyers to help patients make
tients receiving dialysis in London having experienced informed decisions: https://esrdnetworks.org/resources-
COVID-19 infection found a decrease in hospitalizations news/covid-19-information-resources/resources-for-kid-
by 75% and mortality by 88% in those having previously ney-patients/
completed a 2-dose vaccination with BNT162b2 or
AZD1222 compared with unvaccinated dialysis patients.28 RSV Vaccination
The above results have been duplicated in other One of the newest vaccines to become available is the
studies,29,30 with 1 large observational study from a large vaccine for respiratory syncytial virus, which can cause
dialysis organization showing more than twice the disease not only in the pediatric group but can be severe

6 Kidney Med Vol 6 | Iss 3 | March 2024 | 100775

Sam et al

for adults over the age of 65. As of May of 2023, 2 vac- Table 3. Live and Inactivated Vaccines48
cines were approved by the FDA for adults older than 60 Live Vaccinesa Inactivated Vaccines
years.46 According to the CDC website, individual over 60 Haemophilus influenzae
BCG
years who have chronic medical conditions such as kidney Influenza (LAIV) Inactivated influenza
disease should consider getting vaccinated. The 2 available MMR Hepatitis A
vaccines are: RSV Pre F3 (Arexvy), made by Galaxo Smith Varicella Hepatitis B
Yellow fever Tetanus
Kline (against RSV-A), and RSV Pre F (Abrysvo), made by V. cholerae Pertussis
Pfizer (against RSV-A and B). Both are recombinant RSV F Typhoid 21a (oral) Inactivated polio
protein antigen vaccines. A study of over 34,000 in- Smallpox/monkeypox Pneumococcal
dividuals showed the RSV PreF vaccine to have an efficacy (Jynneos) Meningococcal
Rabies
of 67% in preventing lower respiratory tract disease and Human papillomavirus
62% efficacy for preventing RSV-associated acute respira- Japanese encephalitis
tory illness.47 Another study of RSVPreF3 vaccine on over Traveler’s diarrhea and cholera
24,000 people, found this vaccine to be 94% effective in (oral)
a
Live vaccines are not appropriate for immunosuppressed patients.
preventing severe RSV-related lower respiratory tract dis-
ease and 72% effective in preventing RSV infection in
general.48 At this point, it seems the vaccine has some
residual efficacy, even 2 years after administration. initial dose may be given routinely). Pertussis is a highly
Consistent with CDC recommendation here, it is recom- contagious disease, causing prolonged cough, which
mended that patients receiving dialysis over the age of 60 used to be seen only in children during the prevaccina-
seriously consider and receive an RSV vaccine. The optimal tion era but now is not uncommon in adults. The inci-
dence of pertussis infections is on the rise, thus making it
frequency of recurrent administration of the vaccine is yet
more important to vaccinate everyone who is a candi-
to be established but likely to be at least every other year.
date. Sustained immunity to pertussis following the
Again, it would be preferable if this vaccine can also be
vaccine does not appear to be lifelong, necessitating at
given in the dialysis unit to optimize adherence.
least 1 dose of Tdap after the age of 11.
Other Vaccinations Not Routinely Given During • In cases of wounds requiring prophylaxis, a dose of the
Dialysis tetanus and diphtheria toxoid (Td) vaccine should be
given, in case there is no documented history of Tdap
Recommendations for the below-mentioned vaccines in
vaccination previously. In addition, the Td vaccine
the dialysis population are the same as those in the general
should be routinely given every 10 years.
population, with most not having been studied extensively
• Measles, mumps, and rubella (MMR) vaccine: Immunity
in patients receiving dialysis.3
rates to these diseases are high after just 1 dose of the
• Herpes zoster: The 2 vaccines against herpes zoster vaccine and even higher after 2 doses.51 The vaccine is
include a recombinant zoster vaccine (RZV) and a live now routinely given to children. People who were born
zoster vaccine (ZVL). RZV is recommended for patients before 1957 are usually not vaccinated but can be
aged older than 50 years and consists of a series (at least assumed to have had natural infections and immunity.
2 months apart).49 The RZV was introduced to the The immunity to these vaccines usually wanes somewhat
market after ZVL was routinely given, but it has been with time, but protection from infection may be longer
shown to be more efficacious. As a result, ZVL has been lasting than serologic conversion. The measles compo-
removed from the US market. Patients experiencing an nent of the vaccine is a live attenuated virus, whereas the
active zoster infection should have their infection cleared other 2 components are recombinant vaccines. The MMR
before being vaccinated (some have suggested waiting as vaccine (and other live attenuated virus vaccines such as
long as 1 year). If a patient has received ZVL in the past, rotavirus, varicella, yellow fever, cholera, and smallpox)
it is still suggested to vaccinate them with a full course of should therefore be avoided in patients receiving
RZV (given its superior efficacy and duration of immunosuppression.
immunity).
In cases of outbreaks of measles or rubella, 2 doses of
• Tetanus, diphtheria, and acellular pertussis (Tdap): There
MMR vaccines given at least 28 days apart should be given
are currently 2 available vaccines for adults (Adacel and
to those who are incompletely immunized. However, in
Boostrix, both Tdap) given as 0.5 mL intramuscular in-
cases of mumps outbreaks, a third dose of the MMR vac-
jections.50 In addition, there are 2 vaccines intended for
cine should be given to people who have already had 2
infants and children (Daptacel and Infanrix, both DTaP).
doses of the vaccine previously.
For the most part, adult vaccines are once in a lifetime
single injection with the caveat that pregnant patients • One should follow recommendations for the general
should receive an extra dose with each pregnancy (repeat population for giving other vaccines to patients receiving
vaccinations are in general not harmful but not indicated dialysis, such as cholera, hepatitis A, hemophilus,
except a second dose of Adacel after > 8 years from the papillomavirus, Japanese encephalitis virus, rotavirus,

Kidney Med Vol 6 | Iss 3 | March 2024 | 100775 7

 Sam et al

Table 4. Current Recommendations for Vaccines Commonly ARTICLE INFORMATION

Administered in Dialysis Facilities (Assuming no Previous
Authors’ Full Names and Academic Degrees: Ramin Sam, MD,
Vaccination) Laura Rankin, MD, Ifeoma Ulasi, MD, Luc Frantzen, MD, Dorothea
Disease Vaccine Recommendation Nitsch, MD, David Henner, MD, Donald Molony, MD, John
Wagner, MD, Jing Chen, MD, Sanjay Kumar Agarwal, MD, Andrew
Pneumococcus PCV20 (1 dose)
Howard, MD, Ralph Atkinson, MD, Daniel Landry, DO, Stephen O
Influenza Fluzone (yearly if <65 y of age) Pastan, MD, Kamyar Kalantar-Zadeh, MD
Fluzone high dose (yearly if >65 y
of age) Authors’ Affiliations: Division of Nephrology, Zuckerberg San
Francisco General Hospital, University of California, San Francisco
Hepatitis B Heplisav-B (2 doses 1 mo apart)
(RS); Kidney Specialists of Central Oklahoma, Oklahoma City,
Severe acute respiratory mRNA bivalent biannual booster Oklahoma (LR); Division of Nephrology, University of Nigeria,
syndrome coronavirus 2 shot after 2 baseline doses Enugu, Nigeria (IU); College of Medicine, University of Nigeria,
Ituku-Ozalla Campus, Enugu, Nigeria (IU); Service de Nephrologie,
Hopital Saint Joseph, Marseilles, France (LF); Department of
tick-borne encephalitis, meningococcal, rabies, typhoid, Epidemiology, London School of Hygiene and Tropical Medicine,
London, United Kingdom (DN); Department of Non-communicable
dengue, and yellow fever vaccines, until further data are Disease Epidemiology, London School of Hygiene and Tropical
available.52 Most of these vaccines are recommended for Medicine, London, United Kingdom (DN); Division of Nephrology,
countries that have a significant burden of disease and are Berkshire Medical Center, Pittsfield, Massachusetts (DH); Division
able to vaccinate large portions of their population. The of Nephrology, University of Texas McGovern Medical School,
hepatitis A vaccine may be the exception because the Houston, Texas (DM); Division of Renal Diseases and
Hypertension, McGovern Medical School, University of Texas
population in highly endemic countries develops disease Health, Houston, Texas (DM); Division of Nephrology, New York
in childhood, where the manifestations are minor but City Health + Hospitals/Kings County, Brooklyn, New York (JW);
they develop long-lasting immunity. This vaccine is best Division of Nephrology, Huashan Hospital, Fudan University,
given to population, at risk in areas of the world where Shanghai, China (JC); Division of Nephrology, All India Institute of
hepatitis A is not endemic. In addition, BCG vaccination Medical Sciences, New Delhi, India (SKA); Nephrology and Renal
Transplant Medicine, Marengo Asia Hospital, Gurugram and
is recommended by the WHO in countries that have a Faridabad, Haryana, India (SKA); Metropolitan Nephrology
high prevalence of Mycobacterium tuberculosis or Mycobacterium Associates PC, Clinton, Maryland (AH); Nephrology Associates,
leprae infection. It is usually given during childhood, but P.C., Nashville, Tennessee (RA); Division of Nephrology, University
adults should receive it too if not vaccinated. Materials on of Massachusetts Chan Medical School-Baystate, Springfield,
monkeypox vaccines do not specifically reference con- Massachusetts (DL); Division of Nephrology, Emory University
School of Medicine, Atlanta, Georgia (SOP); Renal Division,
siderations for patients receiving dialysis, although the 2 Department of Medicine, Emory University School of Medicine,
available differ in that one is based on a live, replicating Atlanta, Georgia (SOP); Division of Nephrology, University of
competent virus, thought to be problematic for immu- California, School of Medicine, Los Angeles, California (KK-Z).
nocompromised hosts (Table 3).53 Address for Correspondence: Ramin Sam, MD, Zuckerberg San
Francisco General Hospital, 1001 Potrero Ave, Building 100, Rm
342, San Francisco, CA 94110. Email: [email protected]
Support: None.
CONCLUSIONS Financial Disclosure: The authors declare that they have no
relevant financial interests.
Vaccinating the patient receiving dialysis is of paramount
Peer Review: Received April 27, 2023. Evaluated by 2 external peer
importance because infection is a major cause of reviewers, with direct editorial input from the Editor-in-Chief.
morbidity and mortality in this population, and obser- Accepted in revised form September 24, 2023.
vational data suggest a degree of protection from vac-
cines. Patients receiving dialysis are more likely to be
diagnosed with serious infections, including influenza,
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