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Skrzat-Klapaczyńska A, Kowalska J, Fijołek F, Paciorek M, Bieńkowski C, Krogulec D, Horban A. Vaccination against COVID-19 among healthcare workers as a cocoon strategy for people living with HIV. J Virus Erad 2024; 10:100377. [PMID: 38983868 PMCID: PMC11228949 DOI: 10.1016/j.jve.2024.100377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/01/2024] [Accepted: 06/09/2024] [Indexed: 07/11/2024] Open
Abstract
Introduction Healthcare professionals working in infectious disease units are often engaged in the care of patients with HIV infection. A cocoon vaccination strategy may protect those who are immunocompromised from a severe course of COVID-19. Methods The research was conducted between January 2021 and June 2022. The study participants were 450 healthcare workers (HCWs) from the Hospital for Infectious Diseases in Warsaw who were vaccinated against COVID-19 with the BNT162b2 mRNA vaccine (Pfizer-BioNTech) -, thefirst available type of vaccine in Poland. Sera were collected according to the schedule of the study. Statistical analyses were performed with non-parametric tests: Wilcoxon's test was used to compare dependent numerical variables, and Fisher's exact test and the Chi-squared test to compare categorical variables. A p value of <0.05 was considered statistically significant. Results Among the 450 HCWs working in the Hospital for Infectious Diseases in Warsaw 412 (91,5 %) were vaccinated against COVID-19. In total 170 (41,3 %) vaccinated HCWs were included in the final analysis. Their median age was 51 years [interquartile range (IQR): 41-60 years] and median body mass index (BMI) was 25.10 [IQR: 22.68-29.03]. Most of the cohort consisted of women (n = 137, 80.59 %), with the majority working directly with patients (n = 137, 73.21 %). It was found that as early as 14 days after the second dose of the vaccine, 100 % of the study participants achieved a positive result for SARS CoV-2 S-RBD antibodies. There were 168 subjects who had had a COVID-19 diagnosis before entering study and after vaccination 65 HCWs was diagnosed with COVID-19. Conclusions Due to the fact that people living with HIV with severe immunodeficiency may have an incomplete immune response to COVID vaccination and be at risk of a severe course of the disease, the cocoon strategy of vaccinating medical personnel may be beneficial for these patients.
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Affiliation(s)
- Agata Skrzat-Klapaczyńska
- Department of Adults' Infectious Diseases, Hospital for Infectious Diseases, Medical University of Warsaw, Poland
- Ward 7, Hospital for Infectious Diseases, 01-201, Warsaw, Poland
| | - Justyna Kowalska
- Department of Adults' Infectious Diseases, Hospital for Infectious Diseases, Medical University of Warsaw, Poland
- Ward 7, Hospital for Infectious Diseases, 01-201, Warsaw, Poland
| | - Filip Fijołek
- Ward 7, Hospital for Infectious Diseases, 01-201, Warsaw, Poland
| | - Marcin Paciorek
- Department of Adults' Infectious Diseases, Hospital for Infectious Diseases, Medical University of Warsaw, Poland
- Ward 7, Hospital for Infectious Diseases, 01-201, Warsaw, Poland
| | - Carlo Bieńkowski
- Department of Adults' Infectious Diseases, Hospital for Infectious Diseases, Medical University of Warsaw, Poland
- Ward 7, Hospital for Infectious Diseases, 01-201, Warsaw, Poland
| | - Dominika Krogulec
- Department of Adults' Infectious Diseases, Hospital for Infectious Diseases, Medical University of Warsaw, Poland
- Ward 7, Hospital for Infectious Diseases, 01-201, Warsaw, Poland
| | - Andrzej Horban
- Department of Adults' Infectious Diseases, Hospital for Infectious Diseases, Medical University of Warsaw, Poland
- Ward 7, Hospital for Infectious Diseases, 01-201, Warsaw, Poland
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Enilama O, Yau K, Er L, Atiquzzaman M, Oliver MJ, Romney MG, Leis JA, Abe KT, Qi F, Colwill K, Gingras AC, Hladunewich MA, Levin A. Humoral Response Following 3 Doses of mRNA COVID-19 Vaccines in Patients With Non-Dialysis-Dependent CKD: An Observational Study. Can J Kidney Health Dis 2024; 11:20543581231224127. [PMID: 38292817 PMCID: PMC10826386 DOI: 10.1177/20543581231224127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/12/2023] [Indexed: 02/01/2024] Open
Abstract
Background Chronic kidney disease (CKD) is associated with a lower serologic response to vaccination compared to the general population. There is limited information regarding the serologic response to coronavirus disease 2019 (COVID-19) vaccination in the non-dialysis-dependent CKD (NDD-CKD) population, particularly after the third dose and whether this response varies by estimated glomerular filtration rate (eGFR). Methods The NDD-CKD (G1-G5) patients who received 3 doses of mRNA COVID-19 vaccines were recruited from renal clinics within British Columbia and Ontario, Canada. Between August 27, 2021, and November 30, 2022, blood samples were collected serially for serological testing every 3 months within a 9-month follow-up period. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) anti-spike, anti-receptor binding domain (RBD), and anti-nucleocapsid protein (NP) levels were determined by enzyme-linked immunosorbent assay (ELISA). Results Among 285 NDD-CKD patients, the median age was 67 (interquartile range [IQR], 52-77) years, 58% were men, 48% received BNT162b2 as their third dose, 22% were on immunosuppressive treatment, and COVID-19 infection by anti-NP seropositivity was observed in 37 of 285 (13%) patients. Following the third dose, anti-spike and anti-RBD levels peaked at 2 months, with geometric mean levels at 1131 and 1672 binding antibody units per milliliter (BAU/mL), respectively, and seropositivity rates above 93% and 85%, respectively, over the 9-month follow-up period. There was no association between eGFR or urine albumin-creatinine ratio (ACR) with mounting a robust antibody response or in antibody levels over time. The NDD-CKD patients on immunosuppressive treatment were less likely to mount a robust anti-spike response in univariable (odds ratio [OR] 0.43, 95% confidence interval [CI]: 0.20, 0.93) and multivariable (OR 0.52, 95% CI: 0.25, 1.10) analyses. An interaction between age, immunoglobulin G (IgG) antibody levels, and time was observed in both unadjusted (anti-spike: P = .005; anti-RBD: P = .03) and adjusted (anti-spike: P = .004; anti-RBD: P = .03) models, with older individuals having a more pronounced decline in antibody levels over time. Conclusion Most NDD-CKD patients were seropositive for anti-spike and anti-RBD after 3 doses of mRNA COVID-19 vaccines and we did not observe any differences in the antibody response by eGFR.
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Affiliation(s)
- Omosomi Enilama
- Experimental Medicine, Department of Medicine, The University of British Columbia, Vancouver, Canada
- Nephrology Research Program, Providence Research, Vancouver, BC, Canada
| | - Kevin Yau
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Nephrology, Department of Medicine, Unity Health Toronto, ON, Canada
| | - Lee Er
- BC Renal, Vancouver, BC, Canada
| | | | - Matthew J. Oliver
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Ontario Renal Network, Toronto, ON, Canada
| | - Marc G. Romney
- Department of Pathology and Laboratory Medicine, St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Jerome A. Leis
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kento T. Abe
- Department of Molecular Genetics, University of Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | - Freda Qi
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | - Karen Colwill
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | - Anne-Claude Gingras
- Department of Molecular Genetics, University of Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | - Michelle A. Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Ontario Renal Network, Toronto, ON, Canada
| | - Adeera Levin
- BC Renal, Vancouver, BC, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
- St. Paul’s Hospital, Vancouver, BC, Canada
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Habib MB, Ali K, Rahhal A, Obeidat I, Altermanini M, Sawaf B, Latif TA, Hamad A, Bougmiza I, Aly SI, Mahmoud KM. Determinants of vaccine adherence among non-dialysis chronic kidney disease patients in Qatar. Qatar Med J 2024; 2023:33. [PMID: 38187993 PMCID: PMC10770734 DOI: 10.5339/qmj.2023.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/29/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is a global health problem. Reduced innate and adaptive immunological responses predispose CKD patients to infections. Despite the clinical and epidemiological importance of CKD and the great value of vaccination as a prophylactic measure, the utilization of recommended vaccines in Qatar has not yet been evaluated. METHODS We conducted a cross-sectional study to estimate the level of influenza, pneumococcal, and hepatitis B vaccination and the predictors of adherence to these recommended vaccines among non-dialysis CKD patients receiving renal ambulatory care in Qatar from 1 September 2020 to 30 April 2021. Complete vaccination was defined as receiving the three vaccines, and partial vaccination was defined as receiving one or two vaccines. The full and partial vaccination predictors were assessed using multivariate logistic regression and reported as odds ratio (OR) with p<0.05 indicating statistical significance. RESULTS 416 non-dialysis CKD patients were included in our analysis. 73% were males; the mean age was 56 ± 15 years. More than 50% of the patients were from the Middle East, followed by 36% from Asia. Most patients had concurrent hypertension, concurrent diabetes mellitus, and were stage V CKD. Only 12% of the patients were fully vaccinated, while 73% received partial vaccination. The predictors of vaccination included age, gender, Asian origin, employment, living conditions, concurrent medical conditions, CKD stage, allergy to medications, and use of injectable medications. Only stage V CKD positively predicted adherence to full and partial vaccinations in non-dialysis CKD patients. CONCLUSION There is very low adherence to the recommended vaccines in CKD patients, with a prevalence of complete vaccination of 12% only. Increased public awareness about the importance of vaccination in CKD may improve the adherence rates among these patients in Qatar.
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Affiliation(s)
- Mhd Baraa Habib
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Khaled Ali
- Community Medicine Department, Hamad Medical Corporation, Doha, Qatar ORCID iD: 0000-0002-8073-4375
| | - Alaa Rahhal
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Obeidat
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Bisher Sawaf
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Tarek Abdel Latif
- Nephrology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Abdullah Hamad
- Nephrology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Iheb Bougmiza
- Community Medicine Department, Primary Health Care Corporation, Doha, Qatar
| | - Sahar Ismail Aly
- Nephrology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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Chang PY, Lin CJ, Chen HC, Fan HC, Kuo H. 23-valent pneumococcal polysaccharide vaccine and the risk of renal progression in older patients with chronic kidney disease. Prev Med 2023; 177:107753. [PMID: 37931660 DOI: 10.1016/j.ypmed.2023.107753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The 23-valent pneumococcal polysaccharide vaccine (PPSV23) ensures favorable outcomes and reduces the risk of cardiac events in patients on dialysis. However, the effect of PPSV23 vaccination on renal function remains unknown, particularly in patients with chronic kidney disease (CKD). Therefore, we investigated the association between PPSV23 efficacy and renal progression in older patients (age ≥ 75 years) with CKD. METHODS This multicenter, longitudinal cohort study was conducted using data (2008-2016) from the Epidemiology and Risk Factors Surveillance of CKD database. This database was associated with Taiwan's National Health Insurance Research Database (for period: 2008-2019). A total of 1195 older patients with CKD were recruited from 14 hospitals and communities across Taiwan. Renal progression was defined as a > 25% reduction in estimated glomerular filtration rate from the baseline value. RESULTS A significant reduction in the risk of renal progression was observed in patients who had received PPSV23 (adjusted hazard ratio [HR]: 0.57; 95% confidence interval [CI]: 0.35-0.91). However, when stratified by CKD stage, this significant reduction was observed in patients with early-stage CKD but not in those with late-stage CKD. Furthermore, a significant reduction in the risk of renal progression was noted in male patients and those with hypertension. CONCLUSION Our findings support the protective effect of PPSV23 against renal deterioration in older patients with CKD.
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Affiliation(s)
- Po-Ya Chang
- Department of Leisure Industry and Health Promotion, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan.
| | - Chun-Ji Lin
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Hao-Cheng Chen
- Division of Pulmonology, Landseed International Hospital, Taoyuan City, Taiwan
| | - Hueng-Chuen Fan
- Department of Pediatrics, Tungs' Taichung Metroharbor Hospital, Taichung City, Taiwan
| | - Hsuchung Kuo
- Division of Nephrology, Saint Paul's Hospital, Taoyuan City, Taiwan.
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Different Types of Chronic Inflammation Engender Distinctive Immunosenescent Profiles in Affected Patients. Int J Mol Sci 2022; 23:ijms232314688. [PMID: 36499016 PMCID: PMC9735546 DOI: 10.3390/ijms232314688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022] Open
Abstract
Immunosenescence encompasses a spectrum of lymphocyte phenotypic alterations. The aim of the study was to evaluate immunosenescent effect of two different forms of chronic inflammation, Systemic Lupus Erythematosous (SLE), a systemic autoimmune disease, and End-Stage Kidney Disease (ESKD), a chronic inflammatory disorder. Certain lymphocyte surface molecules, including CD31, CD45RA, CCR7, CD28, CD57, for T, and IgD, CD27 for B lymphocytes, were analyzed by flow cytometry in 30 SLE and 53 ESKD patients on hemodialysis (HD), and results were compared to 31 healthy controls (HC) of similar age, gender, and nationality. Significant Lymphopenia was evident in both SLE and ESKD-HD patients, compared to HC, affecting B cells 75.4 (14.4−520.8), 97 (32−341), and 214 (84−576) cells/μL, respectively, p < 0.0001, and CD4 cells 651.2 (71.1−1478.2), 713 (234−1509), and 986 (344−1591) cells/μL, respectively, p < 0.0001. The allocation of B cell subpopulations was remarkably different between SLE and ESKD-HD patients. SLE showed a clear shift to senescence (CD19IgD-CD27−) cells, compared to ESKD-HD and HC, 11.75 (10)% vs. 8 (6) vs. 8.1 (10), respectively. Regarding T lymphocytes, Central Memory CD8 cells predominated in both SLE and ESKD-HD patients compared to HC, 53 (50)%, 52 (63), and 24 (64)%, respectively, while ESKD-HD but not SLE patients also had increased expression of CD4CD28− and CD8CD28− cells. In conclusion, both diseases are followed by significant lymphopenia; however, the senescent phenomenon affects the B lymphocyte compartment in SLE patients and T lymphocytes in ESKD-HD patients.
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Babel N, Hugo C, Westhoff TH. Vaccination in patients with kidney failure: lessons from COVID-19. Nat Rev Nephrol 2022; 18:708-723. [PMID: 35999285 PMCID: PMC9397175 DOI: 10.1038/s41581-022-00617-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 02/06/2023]
Abstract
Infection is the second leading cause of death in patients with chronic kidney disease (CKD). Adequate humoral (antibody) and cellular (T cell-driven) immunity are required to minimize pathogen entry and promote pathogen clearance to enable infection control. Vaccination can generate cellular and humoral immunity against specific pathogens and is used to prevent many life-threatening infectious diseases. However, vaccination efficacy is diminished in patients with CKD. Premature ageing of the immune system and chronic systemic low-grade inflammation are the main causes of immune alteration in these patients. In the case of SARS-CoV-2 infection, COVID-19 can have considerable detrimental effects in patients with CKD, especially in those with kidney failure. COVID-19 prevention through successful vaccination is therefore paramount in this vulnerable population. Although patients receiving dialysis have seroconversion rates comparable to those of patients with normal kidney function, most kidney transplant recipients could not generate humoral immunity after two doses of the COVID-19 vaccine. Importantly, some patients who were not able to produce antibodies still had a detectable vaccine-specific T cell response, which might be sufficient to prevent severe COVID-19. Correlates of protection against SARS-CoV-2 have not been established for patients with kidney failure, but they are urgently needed to enable personalized vaccination regimens.
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Affiliation(s)
- Nina Babel
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany.
- Center for Translational Medicine and Immune Diagnostics Laboratory, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany.
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Center for Advanced Therapies (BeCAT) and Berlin Institute of Health, Berlin, Germany.
| | - Christian Hugo
- Medizinische Klinik und Poliklinik III, Universitätsklinikum, Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timm H Westhoff
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany
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Arnold F, Huzly D, Tanriver Y, Welte T. Response to SARS-CoV-2 vaccines in patients receiving B-cell modulating antibodies for renal autoimmune disease. BMC Infect Dis 2022; 22:734. [PMID: 36104663 PMCID: PMC9472190 DOI: 10.1186/s12879-022-07722-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Effective SARS-CoV-2 vaccination in patients receiving treatment with B-cell depleting agents is challenging. Information on vaccination responses in these patients are a valuable tool to develop efficient vaccination regimens. Methods In this single-center retrospective observational study, we report the humoral and cellular response in 34 patients receiving anti-CD20 antibody treatment for renal immune disease. Results After base immunization with SARS-CoV-2-vaccines, 92.0% developed a cellular, 32.4% a humoral response. Humoral immunity correlated with B-cell counts and the timespan between anti-CD20 antibody treatment and vaccination. All patients with > 21/µl B-cells, or > 197 days after treatment showed humoral response. Conclusions Adequate timing of SARS-CoV-2-vaccinations after anti-CD20 antibody treatment and CD19 measurements are crucial to generate immunity. Awaiting partial B-cell recovery by postponing regularly scheduled anti-CD20 treatment should be considered in patients with stable immune disease. Trial registration: This study has been retrospectively registered in the German Clinical Trials Register (DRKS00027049) on 29/10/2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07722-7.
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Opsonophagocytic activity against Streptococcus pneumoniae in Indigenous and non-Indigenous patients with severe chronic kidney disease immunized with 13-valent pneumococcal conjugate vaccine. Vaccine 2022; 40:4594-4602. [PMID: 35738971 DOI: 10.1016/j.vaccine.2022.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/20/2022]
Abstract
Adults with chronic kidney disease (CKD) are at high risk of pneumococcal infections and recommended to receive pneumococcal immunization. Some studies suggest that previous immunization with 23-valent pneumococcal polysaccharide vaccine (PPV23) may decrease the immunogenicity of 13-valent pneumococcal conjugate vaccine (PCV13). Via quantitation of serum IgG, IgM, and IgA specific to 7 pneumococcal serotypes (3, 6B, 9V, 14, 19A, 19F, 23F), we recently found that the response to PCV13 in previously PPV23 immunized patients with severe CKD was inferior compared to PPV23 naïve patients. As a follow-up of the previous study, we assessed the titers of opsonizing antibodies specific to 13 vaccine serotypes in sera collected as per the original clinical trial protocol. Opsonophagocytic activity (OPA) titers were determined in 57 previously PPV23-immunized (Group 1) and 72 PPV23-naïve (Group 2) patients pre- and post-PCV13 immunization (days 28 and 365). Pre-immunization, the geometrical mean titers (GMT) for 3/13 serotype-specific antibodies were significantly higher in Group 1 than in Group 2. PCV13 induced a significant GMT rise in both groups; an increase in 5/13 serotype-specific GMTs in Group 1 and 12/13 GMTs in Group 2 was present at one year post-immunization. Fold increase in GMTs by day 28 ranged between 2.4 (serotype 1) and 24.6 (serotype 6A) in Group 1, and between 4.3 (serotype 3) and 67.0 (serotype 6A) in Group 2. The fold increase was significantly larger in Group 2 than in Group 1 for serotypes 1, 4, 7F, and 18C. Patients of Indigenous ethnic background had significantly higher GMT for serotypes 6B and 23F at baseline, and for serotypes 5, 6B, 14, 18C, 19A, 19F, and 23F at Day 28 post-immunization, compared to the non-Indigenous counterpart. Conclusions: Patients with severe CKD developed functionally active pneumococcal antibodies post-PCV13 immunization. Previously administered PPV23 had a negative impact on several serotype-specific OPA responses to PCV13 that lasted for at least one year post-immunization. ClinicalTrials.gov ID: NCT02370069.
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Sim JJL, Lim CC. Influenza Vaccination in Systemic Lupus Erythematosus: Efficacy, Effectiveness, Safety, Utilization, and Barriers. Am J Med 2022; 135:286-296.e9. [PMID: 34563493 DOI: 10.1016/j.amjmed.2021.08.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 12/19/2022]
Abstract
Influenza increases morbidity and mortality in systemic lupus erythematosus (SLE) and lupus nephritis but is preventable through vaccination. This systematic review of PubMed, Embase, CENTRAL, WHO Clinical Trials, and ClinicalTrials.gov publications until August 2021 identified 45 reports (16,596 patients), including 8.5% with renal involvement or lupus nephritis: 9 studies (10,446 patients) on clinical effectiveness, 20 studies (1327 patients) on vaccine efficacy, 22 studies (1116 patients) on vaccine safety, 14 studies (4619 patients) on utilization rates, and 5 studies (3220 patients) on barriers. Pooled seroconversion rates ranged between 46% and 56%, while seroprotection rates ranged from 68% to 73% and were significantly associated with age and disease duration. Influenza infection was lower in vaccinated patients with systemic lupus erythematosus compared with unvaccinated patients. Disease activity scores did not change significantly after vaccination and reported flares were mild to moderate. Pooled current vaccination rate was 40.0% (95% confidence interval [CI]: 33.7%-46.5%) with significant heterogeneity and associated with the gross domestic product (P = .002) and disease duration (P = .001). Barriers to vaccination were the lack of doctor recommendation (57.4%) and concerns over the safety or efficacy of the vaccine (12.7%).
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Affiliation(s)
- Jackie Jia Lin Sim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cynthia Ciwei Lim
- Department of Renal Medicine, Singapore General Hospital, Singapore.
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Andreoni M, Sticchi L, Nozza S, Sarmati L, Gori A, Tavio M. Recommendations of the Italian society for infectious and tropical diseases (SIMIT) for adult vaccinations. Hum Vaccin Immunother 2021; 17:4265-4282. [PMID: 34524945 PMCID: PMC8828129 DOI: 10.1080/21645515.2021.1971473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/30/2021] [Accepted: 08/18/2021] [Indexed: 12/14/2022] Open
Abstract
Vaccination prevents 2-3 million deaths worldwide every year. Nevertheless, vaccine-preventable diseases (VPDs) still cause a considerable number of deaths especially in subjects belonging to "risk groups." These are represented by older adults, immunocompromised individuals and all subjects with underlying chronic medical conditions (cardiovascular, pulmonary, renal and liver chronic diseases, diabetes, immunodeficiency disorders). They have a weaker immune system and, if infected, are more likely to develop severe complications of their condition or of the preventable-infectious disease. This document summarizes the recommendations for vaccination of the main Global Institutional Organizations and analyses the risks of comorbidities associated with infectious disease and the benefits of vaccination for each specific group. The document provides a clear, practical and authoritative guide to adult vaccination.
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Affiliation(s)
- Massimo Andreoni
- UOC Infectious diseases Tor Vergata Polyclinic, University Hospital Viale, Rome, Italy
| | - Laura Sticchi
- Hygiene Unit, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Silvia Nozza
- Medical Director, San Raffaele Hospital, Milan, Italy
| | - Loredana Sarmati
- UOC Infectious diseases Tor Vergata Polyclinic, University Hospital Viale, Rome, Italy
| | - Andrea Gori
- UOC Infectious Diseases, Irccs Ca’Granda Foundation, Maggiore Policlinico Hospital, Milan, Italy
| | - Marcello Tavio
- UOC Division of Emerging Infectious Diseases and Immunosuppressed, AOU Ospedali Riuniti of Ancona, Ancona, Italy
| | - Society for Infectious and Tropical Diseases (SIMIT)
- UOC Infectious diseases Tor Vergata Polyclinic, University Hospital Viale, Rome, Italy
- Hygiene Unit, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
- Medical Director, San Raffaele Hospital, Milan, Italy
- UOC Infectious Diseases, Irccs Ca’Granda Foundation, Maggiore Policlinico Hospital, Milan, Italy
- UOC Division of Emerging Infectious Diseases and Immunosuppressed, AOU Ospedali Riuniti of Ancona, Ancona, Italy
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Runyo F, Matignon M, Audureau E, Vindrios W, Boueilh A, Gomart C, Grimbert P, Gallien S, Melica G. Infectious disease consultation is effective in boosting vaccine coverage in patients awaiting kidney transplantation: A French prospective study. Transpl Infect Dis 2021; 23:e13607. [PMID: 33773002 DOI: 10.1111/tid.13607] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 02/11/2021] [Accepted: 03/14/2021] [Indexed: 01/23/2023]
Abstract
Recommended preventive strategies before kidney transplantation include screening and treatment of latent tuberculosis infection (LTBI), and updating of the recommended vaccines. We prospectively evaluated in dedicated infectious diseases consultations, from 2014 to 2018, the clinical and vaccination data of new adult kidney allograft candidates. Patients were offered an updated vaccination schedule, if appropriate, and were screened for LTBI using chest imaging and interferon gamma release assay (IGRA). Overall, 467 patients with median age of 58 [46-66] years were evaluated, of whom 302 patients (65%) were men (sex ratio 1.83), and 333 (71%) were on dialysis. Main causes of renal insufficiency were diabetes (25%) and autoimmune nephropathies (18%). The vaccination coverage was low and varied according to the different types of vaccines and patients. Vaccination or immunization rates were 24%, 6%, 54%, and 51% for tetanus-diphtheria-polio-acellular pertussis, Pneumococcus, hepatitis B, and seasonal influenza, respectively. ID consultation successfully rose patients' vaccinations coverage, in fulfillment with recommendations, in 465 (99%) patients. LTBI treatment was administered in 78 (16.7%) patients and caused drug-related adverse events in 9 (11%). A dedicated infectious disease consultation should become a critical tool for coordinating infection prevention strategies.
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Affiliation(s)
- Florence Runyo
- Infectious Diseases Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France.,Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France
| | - Marie Matignon
- Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France.,DHU (Département Hospitalo-Universitaire) A-TVB, IMRB (Institut Mondor de Recherche Biomédicale) - EA 7376 CEpiA (Clinical Epidemiology And Ageing Unit), Université Paris-Est-Créteil, UPEC, Créteil, France
| | - Etienne Audureau
- Public Health Deparment, Groupe Hospitalier Henri-Mondor/Albert Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France
| | - William Vindrios
- Infectious Diseases Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France.,INSERM U955, Team 16, IMRB Créteil, Créteil, France
| | - Anna Boueilh
- Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France
| | - Camille Gomart
- Microbiology Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France
| | - Philippe Grimbert
- Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France.,DHU (Département Hospitalo-Universitaire) A-TVB, IMRB (Institut Mondor de Recherche Biomédicale) - EA 7376 CEpiA (Clinical Epidemiology And Ageing Unit), Université Paris-Est-Créteil, UPEC, Créteil, France
| | - Sébastien Gallien
- Infectious Diseases Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France.,INSERM U955, Team 16, IMRB Créteil, Créteil, France
| | - Giovanna Melica
- Infectious Diseases Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, AP-HP (Assistance Publique-Hôpitaux de Paris), Créteil, France.,INSERM U955, Team 16, IMRB Créteil, Créteil, France
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12
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Knowledge, Attitudes and Practices of Flu Vaccination in Hemodialysis Patients. Vaccines (Basel) 2021; 9:vaccines9020077. [PMID: 33498996 PMCID: PMC7912544 DOI: 10.3390/vaccines9020077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/04/2021] [Accepted: 01/19/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hemodialysis (HD) patients have an increased risk of morbidity and mortality due to infections. Despite the positive effect of vaccinations, the implementation of this method of prophylaxis is low. OBJECTIVES This study aimed to explore the knowledge, attitudes and practices of flu vaccination among HD patients of two different dialysis centers. METHODS A total of 193 patients (mean age 63.6 years), who voluntarily agreed to participate in an anonymous survey related to influenza vaccination, were enrolled in this cross-sectional study. RESULTS A total of 45% of patients declared that they took regular, annual flu vaccination. In this group, 87.4% believed that vaccinations were effective. This opinion strongly correlated with the frequency of regular vaccinations (r = 0.56, p < 0.01). Multivariate logistic regression revealed that this opinion is an independent predictor of regular vaccinations with adjusted OR 9.86 (95% CI 4.36, 22.33). Groups of patients who had been irregularly or never vaccinated reject vaccinations for the following reasons: fear of adverse events-29.2%, conviction that vaccination was ineffective-26.4%, and lack of information about vaccination-22.6%. CONCLUSION Knowledge among HD patients about the benefits of vaccinations is poor. Therefore, educational activities are required. Active vaccination promotion and education of patients rejecting this method of prevention play a key role in improving standards of care for HD patients.
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13
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Ulanova M, Huska B, Desbiens A, Gaultier GN, Domonkos V, McCready WG. Immunogenicity and safety of the 13-valent pneumococcal conjugate vaccine in 23-valent pneumococcal polysaccharide vaccine-naïve and previously immunized adult patients with severe chronic kidney disease. Vaccine 2020; 39:699-710. [PMID: 33358702 DOI: 10.1016/j.vaccine.2020.12.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/23/2020] [Accepted: 12/09/2020] [Indexed: 01/06/2023]
Abstract
Individuals with chronic kidney disease (CKD) are at high risk of pneumococcal infections and recommended to receive the 23-valent pneumococcal polysaccharide vaccine (PPV23). Although the 13-valent pneumococcal conjugate vaccine (PCV13) has been found to have higher immunogenicity compared to PPV23 in adults with some immunocompromising conditions, previous PPV23 immunization may decrease the immunogenicity of PCV13. We assessed immunogenicity and safety of PCV13 in 74 PPV23-naïve and 58 previously PPV23-immunized (>1 year ago) patients with severe (stage 4-5) CKD. Serum IgG, IgM, and IgA specific to seven serotypes, i.e. 3, 6B, 9V, 14, 19A, 19F, 23F were quantified pre- and 4 weeks and one year post-immunization. Baseline concentrations for most serotype-specific IgG and IgM, and serotype 3-specific IgA were higher in previously PPV23-immunized compared to PPV23-naïve patients. Immunization with PCV13 significantly increased almost all serotype-specific IgG, all IgA and some IgM; an increase in some serotype-specific IgG and IgM lasted for one year. Fold increases in antibody concentrations and the proportion of individuals with >2-fold increase post-immunization were generally larger in PPV23-naïve than previously immunized patients for most serotype-specific IgG and some IgA. The data show that in patients with CKD who received previous PPV23 immunization over one year ago, the antibody response to PCV13 was inferior compared to pneumococcal vaccine naïve study participants. In both groups, the lowest response to PCV13 was found for serotype 3. Patients of Indigenous ethnic background demonstrated a superior immune response to PCV13 compared to the non-Indigenous counterpart that could partially be related to Indigenous study participants' younger age. Although we found that previous PPV23 immunization could contribute to the more frequent occurrence of systemic adverse events post PCV13 immunization, those did not exceed the mild to moderate range.
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Affiliation(s)
- Marina Ulanova
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada.
| | - Brenda Huska
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada.
| | - Angele Desbiens
- Northern Ontario School of Medicine, Thunder Bay, ON, Canada
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14
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Haddiya I. Current Knowledge of Vaccinations in Chronic Kidney Disease Patients. Int J Nephrol Renovasc Dis 2020; 13:179-185. [PMID: 32801834 PMCID: PMC7394503 DOI: 10.2147/ijnrd.s231142] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 07/03/2020] [Indexed: 12/11/2022] Open
Abstract
Chronic kidney disease (CKD) patients are at high risk for infectious complications. This is partly due to their dysfunctional immune system, especially in advanced CKD stages. Vaccination represents an important prevention strategy in these patients, as several studies have reported lower infection rates and significantly reduced morbidity and mortality in hospitals adopting vaccination protocols. However, vaccination rates are particularly low in these patients, and the diminished immune responsiveness remains the main issue of vaccination in CKD patients. Besides, there are various immunization protocols across the world in the absence of optimal vaccination policies. This paper aims to discuss the current knowledge of vaccination in this immunocompromised group of patients based on recent evidence and recommendations.
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Affiliation(s)
- Intissar Haddiya
- Department of Nephrology, Laboratory of Epidemiology, Clinical Research and Public Health, Faculty of Medicine and Pharmacy of Oujda, University Mohamed Premier, Oujda, Morocco
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15
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Boyer-Suavet S, Cremoni M, Dupeyrat T, Zorzi K, Brglez V, Benzaken S, Esnault V, Seitz-Polski B. Functional immune assay using interferon-gamma could predict infectious events in end-stage kidney disease. Clin Chim Acta 2020; 502:287-292. [DOI: 10.1016/j.cca.2019.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 12/19/2022]
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16
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Angeletti A, Zappulo F, Donadei C, Cappuccilli M, Di Certo G, Conte D, Comai G, Donati G, La Manna G. Immunological Effects of a Single Hemodialysis Treatment. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E71. [PMID: 32059426 PMCID: PMC7074458 DOI: 10.3390/medicina56020071] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 12/19/2022]
Abstract
Immune disorders, involving both innate and adaptive response, are common in patients with end-stage renal disease under chronic hemodialysis. Endogenous and exogenous factors, such as uremic toxins and the extracorporeal treatment itself, alter the immune balance, leading to chronic inflammation and higher risk of cardiovascular events. Several studies have previously described the immune effects of chronic hemodialysis and the possibility to modulate inflammation through more biocompatible dialyzers and innovative techniques. On the other hand, very limited data are available on the possible immunological effects of a single hemodialysis treatment. In spite of the lacking information about the immunological reactivity related to a single session, there is evidence to indicate that mediators of innate and adaptive response, above all complement cascade and T cells, are implicated in immune system modulation during hemodialysis treatment. Expanding our understanding of these modulations represents a necessary basis to develop pro-tolerogenic strategies in specific conditions, like hemodialysis in septic patients or the last session prior to kidney transplant in candidates for receiving a graft.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola-Malpighi Hospital, University of Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (C.D.); (M.C.); (G.D.C.); (D.C.); (G.C.); (G.D.)
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17
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Kling K, Wichmann O, Burchard G. [Travel vaccinations for certain groups of persons]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 63:85-92. [PMID: 31811312 DOI: 10.1007/s00103-019-03067-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The number of international travelers has been continuously increasing in recent decades. Among travelers, there are more and more people at an increased risk for acquiring diseases that could be prevented by vaccines or for the development of a severe course of disease. Risk groups in travel medicine are senior travelers, children, pregnant and breast-feeding women, persons with pre-existing medical conditions, and persons who visit their friends and relatives abroad (VFR). Individuals in these groups require attention during pretravel advice consultations, particularly with regards to recommended vaccinations. On the other hand, for some risk groups, particular vaccines cannot be given for safety reasons or because the response to vaccines is reduced. Not all risk groups or each vaccine have sufficient evidence available, so each patient's risks and benefits must be weighed during pretravel consultation. In this article, the particularities for each risk group with respect to pretravel immunization are highlighted.
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Affiliation(s)
- Kerstin Kling
- Fachgebiet Impfprävention, Robert Koch-Institut, Seestraße 10, 13353, Berlin, Deutschland.
| | - Ole Wichmann
- Fachgebiet Impfprävention, Robert Koch-Institut, Seestraße 10, 13353, Berlin, Deutschland
| | - Gerd Burchard
- Bernhard-Nocht-Institut für Tropenmedizin, Hamburg, Deutschland.,Ständige Impfkommission (STIKO), Berlin, Deutschland
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18
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Xiaoyan J, Rongyi C, Xuesen C, Jianzhou Z, Jun J, Xiaoqiang D, Xiaofang Y. The difference of T cell phenotypes in end stage renal disease patients under different dialysis modality. BMC Nephrol 2019; 20:301. [PMID: 31383007 PMCID: PMC6683494 DOI: 10.1186/s12882-019-1475-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 07/19/2019] [Indexed: 12/11/2022] Open
Abstract
Background Impaired T cell immune function exists in end-stage renal disease (ESRD) patients. Dialysis treatment may lead to changes in T cell subsets. In the present study, we aimed to identify alterations of T cell phenotypes in ESRD patients, especially in those receiving peritoneal dialysis (PD), and analyze the potential associated factors. Methods In the present study, 110 PD patients and 110 age/gender-matched hemodialysis (HD) patients who met the inclusion criteria were studied. Pre-dialysis blood samples were obtained and analyzed by flow cytometry to detect the expression of CD45RO and CCR7. Univariate and multivariate regression analyses were used to determine the factors associated with the alteration of T cell phenotypes. Results In all dialysis patients, age was associated with the frequencies of both CD4+ and CD8+ naïve T cells, effector memory (EM) T cells and effector memory RA (EMRA) T cells but not central memory (CM) T cells. Dialysis modality was also associated with T cell subsets. Compared with HD patients, PD patients showed an increase in both CD4+ and CD8+ CM T cells and a reduction in both CD4+ and CD8+ EM and EMRA T cells. However, the number of CD4+ naïve T cells was lower and the number of CD8+ naïve T cells was higher in PD patients than those in HD patients. In PD patients, further multivariate analysis revealed that the frequency of CD4+ naïve T cells was positively associated with nPCR, while the frequency of CD8+ naïve T cells was negatively associated with age. Conclusion In dialysis patients, the dialysis modality and age influence T cell subsets. There is a progression from naïve to effector T cells in HD patients compared with PD patients. In PD patients, different factors may influence the frequencies of CD4+ and CD8+ naïve T cells.
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Affiliation(s)
- Jiao Xiaoyan
- Department of Nephrology, Zhongshan Hospital, Fudan University, NO180, Feng'lin Road, Shanghai, 200032, China.,Shanghai Medical Center for Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Chen Rongyi
- Department of Nephrology, Zhongshan Hospital, Fudan University, NO180, Feng'lin Road, Shanghai, 200032, China.,Shanghai Medical Center for Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Cao Xuesen
- Department of Nephrology, Zhongshan Hospital, Fudan University, NO180, Feng'lin Road, Shanghai, 200032, China.,Shanghai Medical Center for Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China
| | - Zou Jianzhou
- Department of Nephrology, Zhongshan Hospital, Fudan University, NO180, Feng'lin Road, Shanghai, 200032, China.,Shanghai Medical Center for Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China
| | - Ji Jun
- Department of Nephrology, Zhongshan Hospital, Fudan University, NO180, Feng'lin Road, Shanghai, 200032, China.,Shanghai Medical Center for Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China
| | - Ding Xiaoqiang
- Department of Nephrology, Zhongshan Hospital, Fudan University, NO180, Feng'lin Road, Shanghai, 200032, China.,Shanghai Medical Center for Kidney, Shanghai, China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China.,Shanghai Institute of Kidney and Dialysis, Shanghai, China
| | - Yu Xiaofang
- Department of Nephrology, Zhongshan Hospital, Fudan University, NO180, Feng'lin Road, Shanghai, 200032, China. .,Shanghai Medical Center for Kidney, Shanghai, China. .,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China. .,Shanghai Institute of Kidney and Dialysis, Shanghai, China.
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19
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Loftus MJ, Yong MK, Wilson S, Peleg AY. Fatal disseminated visceral varicella zoster virus infection in a renal transplant recipient. Transpl Infect Dis 2019; 21:e13062. [PMID: 30756453 DOI: 10.1111/tid.13062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/23/2019] [Accepted: 02/07/2019] [Indexed: 12/12/2022]
Abstract
We report a case of fatal disseminated varicella zoster virus (VZV) with delayed-onset rash in a 66-year-old female more than 2 years following uncomplicated deceased donor renal transplantation. Whilst on a stable regimen of maintenance immunosuppression, the patient presented with chest and abdominal pain with concomitant hepatitis and pancreatitis. After pursuing multiple other potential causes of her symptoms, the correct diagnosis of VZV was only suspected after the development of a widespread vesicular rash-11 days after her initial symptoms. Despite antiviral therapy and inotropic support in the intensive care unit, the patient died. Simultaneous VZV hepatitis and pancreatitis in solid organ transplant recipients is uncommon. The new inactivated VZV vaccines have the potential to prevent post-transplant infections, with promising early clinical data on safety and efficacy in renal transplant recipients. VZV is an important preventable infection that should be considered in immunocompromised patients, even in the absence of rash.
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Affiliation(s)
- Michael J Loftus
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
| | - Michelle K Yong
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Scott Wilson
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia.,Department of Microbiology, Infection and Immunity Program, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
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20
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Reddy S, Chitturi C, Yee J. Vaccination in Chronic Kidney Disease. Adv Chronic Kidney Dis 2019; 26:72-78. [PMID: 30876620 DOI: 10.1053/j.ackd.2018.10.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/05/2018] [Accepted: 10/07/2018] [Indexed: 12/15/2022]
Abstract
Infections after cardiovascular disease are the second most common cause of death in the chronic kidney disease population. Vaccination is an important component of maintaining health and wellness in patients with kidney disease. There is a changing epidemiologic landscape for several vaccine-preventable illnesses from childhood to adulthood and unfounded public perception of safety concerns. Several mechanisms have been proposed to cause inadequate vaccine protection in this high-risk group with chronic kidney disease. These have led to recent advances in new designs for vaccination strategies in kidney disease. In this article, we discuss the current evidence and recommendations for vaccination in those with kidney disease and needing renal replacement therapy (dialysis and transplant).
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21
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Humoral immunity to memory antigens and pathogens is maintained in patients with chronic kidney disease. PLoS One 2018; 13:e0195730. [PMID: 29659606 PMCID: PMC5901993 DOI: 10.1371/journal.pone.0195730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/28/2018] [Indexed: 01/29/2023] Open
Abstract
Patients with chronic kidney disease (CKD) have an increased risk of infection and poorer responses to vaccination. This suggests that CKD patients have an impaired responsiveness to all antigens, even those first encountered before CKD onset. To examine this we evaluated antibody responses against two childhood vaccine antigens, tetanus (TT) and diphtheria toxoids (DT) and two common pathogens, cytomegalovirus (CMV) and Salmonella enterica serovar Enteritidis (SEn) in two independent cohorts consisting of age-matched individuals with and without CKD. Sera were evaluated for antigen-specific IgG titres and the functionality of antibody to SEn was assessed in a serum bactericidal assay. Surprisingly, patients with CKD and control subjects had comparable levels of IgG against TT and DT, suggesting preserved humoral memory responses to antigens encountered early in life. Lipopolysaccharide-specific IgG titres and serum bactericidal activity in patients with CKD were also not inferior to controls. CMV-specific IgG titres in seropositive CKD patients were similar or even increased compared to controls. Therefore, whilst responses to new vaccines in CKD are typically lower than expected, antibody responses to antigens commonly encountered prior to CKD onset are not. The immunodeficiency of CKD is likely characterised by failure to respond to new antigenic challenges and efforts to improve patient outcomes should be focussed here.
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22
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Maldonado AQ, Johnson D, Trofe-Clark J. Barriers to vaccination in renal transplant recipients. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 04/05/2017] [Accepted: 04/21/2017] [Indexed: 12/19/2022]
Affiliation(s)
| | - David Johnson
- Department of Pharmacy Services; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Jennifer Trofe-Clark
- Department of Pharmacy Services; Hospital of the University of Pennsylvania; Philadelphia PA USA
- Renal, Electrolyte Hypertension Division; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
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23
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Abstract
PURPOSE OF REVIEW Altered differentiation and activation of T-cell subsets occur in patients with chronic kidney disease (CKD), but the impact on graft rejection and protective immunity during transplantation are not fully understood. RECENT FINDINGS Patients with CKD have decreased frequency of naïve T cells, accumulation of activated, terminally differentiated memory cells, and skewed regulatory versus T helper 17 ratio. Naïve and memory T-cell subsets do not appear to improve following kidney transplantation. Retained thymic output is associated with acute rejection, whereas naïve lymphopenia and accumulation of CD8 TEMRA cells correlate with long-term graft dysfunction. CD28 memory cells accumulate during CKD and appear to confer protection against acute rejection under standard immunosuppression and possibly costimulation blockade. T cells bearing CD57 are also increased in patients with CKD and may underlie rejection during costimulation blockade. SUMMARY The mechanisms by which CKD alters the differentiation and activation status of T-cell subsets is poorly understood. Further research is also needed to understand which cell populations mediate rejection under various immunosuppressive regimens. To date, there is little use of animal models of organ failure in transplant immunology research. CKD mouse models may help identify novel pathways and targets to better control alloimmunity in posttransplant.
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Affiliation(s)
- Pamela D Winterberg
- aPediatric Nephrology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta bEmory Transplant Center, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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24
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Wiedermann U, Sitte HH, Burgmann H, Eser A, Falb P, Holzmann H, Kitchen M, Köller M, Kollaritsch H, Kundi M, Lassmann H, Mutz I, Pickl WF, Riedl E, Sibilia M, Thalhammer F, Tucek B, Zenz W, Zwiauer K. [Guidelines for vaccination of immunocompromised individuals]. Wien Klin Wochenschr 2016; 128 Suppl 4:337-76. [PMID: 27457874 DOI: 10.1007/s00508-016-1033-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/04/2016] [Indexed: 12/14/2022]
Abstract
Immunosuppression of various origins is associated with an increased risk of infection; therefore the prevention of infectious diseases by vaccination is especially important in immunocompromised patients. However, the response to vaccinations is often reduced in these risk groups and the application of live vaccines is contraindicated during immunosuppression.In the following expert statement, recommendations for vaccination were created on the basis of current evidence and theoretical/immunological considerations. A first, general part elaborates on efficacy and safety of vaccinations during immunosuppression, modes of action of immunosuppressive medications and recommended time intervals between immunosuppressive treatments and vaccinations. A core piece of this part is a graduation of immunosuppression into three stages, i. e. no relevant immunosuppression, mild to moderate and severe immunosuppression and the assignment of various medications (including biologicals) to one of those stages; this is followed by an overview of possible and necessary vaccinations in each of those stages.The second part gives detailed vaccination guidelines for common diseases and therapies associated with immunosuppression. Primary immune deficiencies, chronic kidney disease, diabetes mellitus, solid and hematological tumors, hematopoetic stem cell transplantation, transplantation of solid organs, aspenia, rheumatological-, gastroenterologic-, dermatologic-, neurologic diseases, biologicals during pregnancy and HIV infection are dealt with.These vaccination guidelines, compiled for the first time in Austria, aim to be of practical help for physicians to facilitate and improve vaccination coverage in immunocompromised patients and their household members and contact persons.
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Affiliation(s)
- Ursula Wiedermann
- Institut für Spezifische Prophylaxe und Tropenmedizin, Medizinische Universität Wien, Kinderspitalgasse 15, 1090, Wien, Österreich.
| | - Harald H Sitte
- Institut für Pharmakologie, Medizinische Universität Wien, Wien, Österreich
| | - Heinz Burgmann
- Klinische Abteilung für Infektionen und Tropenmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Alexander Eser
- Klinische Abteilung für Gastroenterologie und Hepatologie, Medizinische Universität Wien, Wien, Österreich
| | - Petra Falb
- Medizinmarktaufsicht, Agentur für Gesundheit und Ernährungssicherheit, Wien, Österreich
| | | | - Maria Kitchen
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Marcus Köller
- Sozialmedizinisches Zentrum Sophienspital, Wien, Österreich
| | - Herwig Kollaritsch
- Institut für Spezifische Prophylaxe und Tropenmedizin, Medizinische Universität Wien, Kinderspitalgasse 15, 1090, Wien, Österreich
| | - Michael Kundi
- Institut für Umwelthygiene, Medizinische Universität Wien, Wien, Österreich
| | - Hans Lassmann
- Abteilung für Neuroimmunologie, Medizinische Universität Wien, Wien, Österreich
| | | | - Winfried F Pickl
- Institut für Immunologie, Medizinische Universität Wien, Wien, Österreich
| | - Elisabeth Riedl
- Universitätsklinik für Dermatologie, Medizinische Universität Wien, Wien, Österreich
| | - Maria Sibilia
- Institut für Krebsforschung, Medizinische Universität Wien, Wien, Österreich
| | - Florian Thalhammer
- Klinische Abteilung für Infektionen und Tropenmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Barbara Tucek
- Medizinmarktaufsicht, Agentur für Gesundheit und Ernährungssicherheit, Wien, Österreich
| | - Werner Zenz
- Klinische Abteilung für allgemeine Pädiatrie, Medizinische Universität Graz, Graz, Österreich
| | - Karl Zwiauer
- Klinische Abteilung für Kinder- und Jugendheilkunde, Universitätsklinikum St. Pölten, St. Pölten, Österreich
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Grzegorzewska AE, Świderska MK, Warchoł W. Antibodies to hepatitis B virus surface antigen and survival of hemodialysis patients - a prospective study. Expert Rev Vaccines 2016; 15:1063-74. [PMID: 27166852 DOI: 10.1080/14760584.2016.1188697] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Antibodies to hepatitis B virus (HBV) surface antigen (anti-HBs) may develop in response to HBV vaccination or infection. We investigated whether anti-HBs are an independent predictor of survival in hemodialysis (HD) patients. METHODS A 6-year prospective study was conducted in 532 HD patients. Survival analyses were performed using the Kaplan-Meier method and the Cox proportional hazard model. RESULTS In HBV non-infected patients, age (P = 0.005), coronary artery disease (P = 0.002), and non-response to HBV vaccine (P = 0.008) were the independent risk factors of all-cause mortality. In HBV infected patients, the only independent predictor of all-cause mortality was coronary artery disease (P = 0.002). CONCLUSION The ability to produce the protective anti-HBs titer in response to HBV vaccine is a positive predictor of survival in HBV non-infected HD patients.
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Affiliation(s)
- Alicja E Grzegorzewska
- a Department of Nephrology, Transplantology and Internal Diseases , Poznan University of Medical Sciences (PUMS) , Poznań , Poland
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Arsenijevic D, Montani JP. Uninephrectomy in Rats on a Fixed Food Intake Potentiates Both Anorexia and Circulating Cytokine Subsets in Response to LPS. Front Immunol 2015; 6:641. [PMID: 26734008 PMCID: PMC4686617 DOI: 10.3389/fimmu.2015.00641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 12/07/2015] [Indexed: 12/20/2022] Open
Abstract
Recent human studies have suggested that mild reduction in kidney function can alter immune response and increase susceptibility to infection. The role of mild reduction in kidney function in altering susceptibility to bacterial lipopolysaccharide (LPS) responses was investigated in uninephrectomized rats compared to Sham-operated controls rats 4 weeks after surgery. Throughout the 4 weeks, all rats were maintained under mild food restriction at 90% of ad libitum intake to ensure the same caloric intake in both groups. In comparison to Sham, uninephrectomy (UniNX) potentiated LPS-induced anorexia by 2.1-fold. The circulating anorexigenic cytokines granulocyte-macrophage colony stimulating factor, interferon-γ, tumor necrosis factor-α, and complement-derived acylation-stimulating protein were elevated after LPS in UniNX animals compared to Sham animals. Interleukin(IL)1β and IL6 pro-inflammatory cytokines were transiently increased. Anti-inflammatory cytokines IL4 and IL10 did not differ or had a tendency to be lower in UniNX group compared to Sham animals. LPS-induced anorexia was associated with increased anorexigenic neuropeptides mRNA for pro-opiomelanocortin, corticotrophin-releasing factor, and cocaine–amphetamine-regulated transcript in the hypothalamus of both Sham and UniNX groups, but at higher levels in the UniNX group. Melanocortin-4-receptor mRNA was markedly increased in the UniNX group, which may have contributed to the enhanced anorexic response to LPS of the UniNX group. In summary, UniNX potentiates pro-inflammatory cytokine production, anorexia, and selected hypothalamic anorexigenic neuropeptides in response to LPS.
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Affiliation(s)
- Denis Arsenijevic
- Division of Physiology, Department of Medicine, University of Fribourg, Fribourg, Switzerland; National Center of Competence in Research Kidney Control of Homeostasis (Kidney.CH), Zurich, Switzerland
| | - Jean-Pierre Montani
- Division of Physiology, Department of Medicine, University of Fribourg, Fribourg, Switzerland; National Center of Competence in Research Kidney Control of Homeostasis (Kidney.CH), Zurich, Switzerland
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Bitsori M, Galanakis E. Vaccine-preventable infection morbidity of patients with chronic kidney disease and cocoon vaccination strategies. Expert Rev Vaccines 2015; 14:1385-95. [PMID: 26289972 DOI: 10.1586/14760584.2015.1075397] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Individuals with chronic kidney disease (CKD) are vulnerable to vaccine-preventable infections due to impaired immunity, immunosuppressive treatments and dialysis. Protection of CKD patients by vaccination is hampered by reduced efficacy of vaccines and safety concerns for transplant candidates or recipients. 'Cocooning' vaccination policies, targeting the protection of a vulnerable individual through immunization of close contacts, have recently been introduced for infants and, to a lesser degree, for high-risk groups of immunocompromised individuals. In this article, we discuss the potentiality of implementing cocoon strategies for the high-risk group of CKD patients and conclude that this not yet officially recommended policy can substantially contribute to protection against infection and motivate vaccination among families and healthcare workers.
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Affiliation(s)
- Maria Bitsori
- a Department of Paediatrics, University Hospital, Heraklion 71003, Greece
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Vandecasteele SJ, Ombelet S, Blumental S, Peetermans WE. The ABC of pneumococcal infections and vaccination in patients with chronic kidney disease. Clin Kidney J 2015; 8:318-24. [PMID: 26034594 PMCID: PMC4440476 DOI: 10.1093/ckj/sfv030] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 04/13/2015] [Indexed: 01/04/2023] Open
Abstract
Background In the general population, pneumococcal polysaccharide vaccines (PPV) decrease the incidence of invasive pneumococcal disease (IPD) whereas the impact on the prevention of noninvasive pneumococcal disease is less clear. As compared with PPV, pneumococcal conjugate vaccines (PCV) provoke a higher, longer-lasting immune response resulting in a 45% decreased incidence in vaccine-type pneumonia, and a 75% decrease in vaccine-type IPD. Methods Literature review on pneumococcal vaccination in end-stage renal disease. Results As compared with the general population, patients with chronic kidney disease (CKD) suffer increased mortality and morbidity from pneumococcal disease (PD), being up to 10-fold for those treated with dialysis. Numerous, usually small and methodological heterogeneous studies demonstrate that PPV provokes a serological response in dialysis patients, kidney transplant recipients, children with nephrotic syndrome and CKD patients receiving immunosuppressive medication. This response is of less intensity and duration than in healthy controls. Similar observations were made for the PCV. The protective value of these vaccine-elicited anti-pneumococcal antibodies in the CKD population remains to be substantiated. For patients treated with dialysis, epidemiological data demonstrate a correlation—which does not equal causality—between pneumococcal vaccination status and a slightly decreased total mortality. Clinical outcome data on the effectiveness of pneumococcal vaccination in the prevention of morbidity and mortality in the CKD population are lacking. Conclusions Awaiting better evidence, pneumococcal vaccination should be advocated in all patients with CKD, as early in their disease course as possible. The ACIP schedule recommends a PCV-13 prime vaccination followed by a PPV-23 repeated vaccine at least 8 weeks later in pneumococcal non-vaccinated patients, and a PCV-13 vaccine at least 1 year after the latest PPV vaccine in previously vaccinated patients. In the UK, vaccination with PPV-23 only is recommended. There exist no good data supporting re-vaccination after 5 years in the dialysis population.
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Affiliation(s)
- Stefaan J. Vandecasteele
- Department of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge-Oostende, Brugge 8000, Belgium
| | - Sara Ombelet
- Department of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge-Oostende, Brugge 8000, Belgium
| | - Sophie Blumental
- Paediatric Infectious Diseases, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - Willy E. Peetermans
- Department of Internal Medicine and Infectious Diseases, University Hospital Leuven, Leuven, Belgium
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Grzegorzewska AE. Prophylactic vaccinations in chronic kidney disease: Current status. Hum Vaccin Immunother 2015; 11:2599-605. [PMID: 25911956 PMCID: PMC4685704 DOI: 10.1080/21645515.2015.1034915] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/09/2015] [Accepted: 03/22/2015] [Indexed: 12/17/2022] Open
Abstract
In this review, recent data on results concerning prophylactic vaccinations against hepatitis B virus, influenza viruses, and pneumococci are presented. Effects of active immunization in chronic kidney disease depend on category of glomerular filtration rate (GFR). The lower GFR category the better results of response to vaccination. Abnormalities in toll-like receptors and down-regulation of B-cell activating factor receptor in transitional B cells were recently included into uremia-associated deficits in immunocompetence. Development of novel, more potent vaccines containing toll-like receptor agonists as adjuvants may help to achieve more effective immunization against hepatitis B virus in immunocompromised patients. Experimental studies announce further vaccine adjuvants. A vaccine against hepatitis C virus is not available yet, but promising results were already obtained in the experimental and preliminary clinical studies. Prophylactic vaccinations against influenza viruses and pneumococci become increasingly popular in dialysis facilities due to their proved benefits.
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Affiliation(s)
- Alicja E Grzegorzewska
- Department of Nephrology, Transplantology, and Internal Diseases; Poznań University of Medical Sciences; Poznań, Poland
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30
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Grzegorzewska AE. Hepatitis B vaccination in chronic kidney disease patients: a call for novel vaccines. Expert Rev Vaccines 2014; 13:1317-26. [PMID: 25148051 DOI: 10.1586/14760584.2014.944508] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The protective immunization rates in response to hepatitis B vaccination in chronic kidney disease (CKD) patients are lower than response rates in the general population because of genetic and CKD-related factors as well as logistic problems with a proper providing of the recommended vaccination schedules. This review focuses on third-generation vaccines and adjuvanted vaccines commercially introduced in some countries, investigated in clinical trials, especially involving CKD patients or used only in the experimental studies. In order to improve the immunization rate, the use of third-generation vaccines (yeast-derived pre-S2/S HBV vaccines, mammalian cell-derived pre-S2/S HBV vaccines, mammalian cell-derived pre-S1/pre-S2/S HBV vaccines), novel adjuvants (AS04, AS02, phosphorothioate oligodeoxyribonucleotide, hemokinin-1, a polysaccharide based on delta inulin, nano-complex Hep-c, cyclic diguanylate) or immunostimulants for enhancement of immunogenicity of existing recombinant hepatitis B vaccines is tried to improve results of hepatitis B vaccination prior to dialysis commencement or already on renal replacement therapy.
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Affiliation(s)
- Alicja E Grzegorzewska
- Chair and Department of Nephrology, Transplantology and Internal Diseases Poznań University of Medical Sciences (PUMS), 60-355 Poznań, 49 Przybyszewskiego Blvd Poznań, Poland
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Esposito S, Mastrolia MV, Ghio L, Paglialonga F, Terranova L, Scala A, Edefonti A, Principi N. Influenza immunization in hemodialyzed or kidney transplanted adolescents and young adults. Expert Rev Vaccines 2014; 13:1059-66. [DOI: 10.1586/14760584.2014.935768] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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