636 [80] and different health authorities [73–76], all inactivated vaccine and toxoids are safe and effective when used in dialysis patients with the same doses and schedules as recommended for immuno[.]
636 [80] and different health authorities [73–76], all inactivated vaccine and toxoids are safe and effective when used in dialysis patients with the same doses and schedules as recommended for immunocompetent persons There is no contraindication for live vaccines (except a precaution for live-attenuated influenza vaccine) in dialysis patients unless they are on immunosuppressive medications [73–76] Accordingly, diphtheria, tetanus, acellular pertussis (DTaP), Haemophilus influenzae type b, polio, measles-mumps-rubella (MMR), Streptococcus pneumoniae, varicella zoster, and hepatitis B vaccines continue to be recommended Parallel to modifications in standard schedules, rotavirus vaccine, tetravalent conjugated meningococcal vaccine, hepatitis A vaccine, and finally human papillomavirus (HPV) vaccine have been included in the immunization schedule of dialysis patients BCG vaccine is recommended before the age of 6 years in some countries [73–76, 80] In the following sections, available data concerning vaccine response in pediatric dialysis patients is provided, and any modification of the standard schedule that may be required for children on dialysis will be discussed Diphtheria, Tetanus, and Pertussis Vaccine Diphtheria/tetanus toxoids and acellular pertussis (DTaP) vaccine should be administered in infants as recommended for healthy children After three primary dose series, booster doses at 12–23 months (DTaP-containing vaccines), 4–6 years, and 9–15 years of age (tetanus, reduced diphtheria, acellular pertussis – Tdap) are recommended Thereafter, tetanus and diphtheria toxoids (Td) 10 years apart are given [73–76] A multicenter study in infants vaccinated while on dialysis revealed protective antibody titers to both diphtheria and tetanus toxoids in 7/8 patients (88%) [81] Studies in older children and A N Chua and S A Bakkaloğlu young adults on dialysis showed seroconversion after diphtheria and/or tetanus toxoids at a rate of 69–89% compared to 93–100% in healthy children [82, 83] On the other hand, in older children, the rates of patients with a positive pretransplant vaccination titer against DTP were 38.5%, 60.0%, and 21.3%, respectively [84] Thus, in older children on dialysis, efforts should be made to ensure that booster immunizations against tetanus and diphtheria are provided aemophilus influenzae Type b (Hib) H Conjugate Vaccine In a multicenter study performed by the Pediatric Peritoneal Dialysis Study Consortium, antibody levels were measured in ten infants vaccinated with Hib conjugate vaccine while on dialysis [85] This study found that 9/10 (90%) patients had protective antibody levels after vaccination and that antibody levels remained protective for as long as 22 months postvaccination [85] In another study, antibody levels measured 2 months after the third dose of Hib conjugate vaccine were protective in all 42 pediatric dialysis patients studied [86] Thus, this vaccine appears to be highly immunogenic in pediatric dialysis patients, and these children should receive this vaccine according to the standard schedule Hepatitis B Vaccine Suboptimal response to hepatitis B vaccine is well documented among adult dialysis patients, and as such the ACIP recommends that adult patients on dialysis receive an augmented dose of 40 μg of either Recombivax HB or Engerix-B [87] In children, there are only a few studies Two small case series of pediatric CKD/dialysis patients and RTx recipients demonstrated that three doses of 5 μg (age 10 years) or 20 μg hepatitis B vaccines resulted in a protective antibody titer 33 Immune Function and Immunizations in Dialyzed Children of ≥10 mIU/mL in more than 90% of cases (91– 97%), if checked 2 months after the final immunization [86, 88] Another prospective study revealed a seroconversion rate of 72% (n = 26/36) following three dose series of 10 μg hepatitis B vaccine in children with CKD stages II–V [89] Revaccination with full doses is recommended for persons who not develop protective antibody levels Despite vaccination, 15% of pediatric RTx candidates were seronegative [90] Current recommendations specify that dialysis patients less than 20 years of age receive 10 μg hepatitis B immunization according to the standard schedule (0–1–6 months), with the caveat that “higher doses might be more immunogenic” in pediatric HD patients [74, 76] A recent retrospective multicenter study on pediatric HD patients showed that seroconversion rates are highest when administered 10 μg multidose boosters (97%) or 20 μg single- or multidose boosters (86% and 83%) compared to the augmented (40 μg) booster dose(s) Therefore, no specific recommendations have been made for augmented doses for pediatric hemodialysis patients [91] Regardless of the dose of vaccine given, the ACIP recommends that postvaccination testing be performed 1–2 months after the primary series is completed and that up to three additional doses be given to patients who not develop protective antibody levels (>10 mIU/ mL) Antibody levels should then be measured annually and booster doses provided to patients if antibody levels fall 12 months >12 months >12 months (6–9 months under specific circumstances) 2, 4, 6, 12–15 months 15 months to 18 years, unvaccinated Min 6 weeks to 6 months Inactive influenza Varicella Hepatitis A MMR Diphtheria, tetanus, acellular pertussis (DTaP)-containing vaccines IPV Age 0–10 years 11–19 years Vaccine HBV Two annual doses in autumn Two annual doses in autumn (two annual doses for the first time immunization 12 years two doses minimum 4 weeks apart Two doses 6 months apart Two doses (min 4 weeks apart) Four dose series Three doses with an interval of 1–2 months Three primary dose series 0.25 or 0.5 mla 0.5 ml 0.5 ml 0.5 ml 0.5 ml 0.5 ml 0.5 ml 0.5 ml 0.5 ml Schedule Three-dose schedule Dose mcg/dose 10 mcg/dose IM IM IM SC IM SC IM/SC Route of administration IM Table 33.1 Recommended immunization schedule in children with chronic kidney disease and on dialysis Booster doses at 12–23 months (DTaP-containing vaccines), 4–6 years, and 9–15 years of age (tetanus, reduced diphtheria, acellular pertussis – Tdap) Thereafter, Td 10 years apart Immunization recommendation depends on epidemiology of disease in the region Complete the immunization series or check the IgG level for hepatitis A at the time of diagnosis Timing of doses depends on the epidemiology in the region Complete the immunization series or check the IgG level for MMR at the time of diagnosisb Booster dose between and 10 years of age Revaccination 1 year after the third dose Complete the immunization series or check the IgG level for varicella at the time of diagnosisb Booster doses Postimmunization testing for anti-HBs is recommended for dialysis patients 4–8 weeks after completion of schedule If immunization completed before, determine anti-HBs at time of diagnosis If anti-HBs 10 years in the USA >2 mo in Europe Conjugated meningococcal vaccines (monovalent-A, C, bivalent-CY, quadrivalent– ACYW) MenB HPV As soon as possible from 9 years of age First dose 6–14 weeks 6 days Last dose at 8 months As soon as possible after birth 0.5 ml 6 weeks (min) to 59 months HIB 33 Immune Function and Immunizations in Dialyzed Children 641 ... vaccination or had at least a fourfold increase in antibody levels following immunization [94] Because this vaccine contains only inactivated virus, it may be safely given to dialysis patients who are... vaccination schedule [78] Furthermore, another recent European multicenter study showed that one third of pediatric nephrology centers reported not checking MMR antibodies during dialysis period... zoster infection posttransplant, there have been several studies to evaluate the immunogenicity of this vaccine in children with kidney failure and on dialysis Early studies using the previously