Hepatitis B vaccination in chronic kidney disease patients: a call for novel vaccines

A Comprehensive Review of Hepatitis B Vaccine Nonresponse and Associated Risk Factors

Hepatitis B virus (HBV) infection remains a significant global health concern worldwide, contributing to high rates of mortality and morbidity, including chronic hepatitis B, cirrhosis, and hepatocellular carcinoma (HCC). Universal vaccination programs have significantly reduced the rate of HBV transmission; however, a subset of individuals fail to develop a protective immune response following vaccination and are termed nonresponders. A comprehensive search strategy using the PubMed, Google Scholar, and Web of Science databases was employed to search for relevant studies using keywords including "hepatitis B vaccine", "vaccine nonresponse", "immunogenicity", "immune response to the hepatitis B vaccine", and "associated risk factors". Factors influencing the vaccine's response include demographic factors, such as age and sex, with increased nonresponse rates being observed in older adults and males. Obesity, smoking, and alcohol consumption are lifestyle factors that decrease the vaccine response. Medical conditions, including diabetes, chronic kidney and liver diseases, HIV, celiac disease, and inflammatory bowel disease, affect the vaccine response. Major histocompatibility complex (MHC) haplotypes and genetic polymorphisms linked to immune regulation are genetic factors that further influence the vaccine's effectiveness. To reduce the global burden of hepatitis B infection, it is essential to understand these factors to improve vaccine effectiveness and develop individualized vaccination strategies.

Overt and occult hepatitis B virus infection detected among chronic kidney disease patients on haemodialysis at a Tertiary Hospital in Ghana

Hepatitis B virus (HBV) infection is endemic in Ghana and chronic kidney disease patients on haemodialysis are a high-risk group for HBV infection. We determined the prevalence of overt and occult HBV infection among haemodialysis patients at the Korle Bu Teaching Hospital in Ghana. 104 consenting End Stage Renal Disease patients on long-term haemodialysis were recruited for the study and their socio-demographic, clinical and laboratory information were obtained using structured questionnaire. All the participants were tested for the hepatitis B surface antigen (HBsAg). The HBsAg-negative participants were re-tested for hepatitis B surface antibody (HBsAb), hepatitis B core antibody (HBcAb) and HBV DNA using chemiluminescence and Roche COBAS Ampli-Prep/TaqMan analyser and real-time polymerase chain reaction. Eight (7.7%) of the total participants were positive for HBsAg. Among the 96 HBsAg-negative participants, 12.5% (12) were HBcAb-positive, 7.3% (7) had detectable HBV DNA (mean = 98.7±53.5 IU/mL) and 40.6% (39) were positive for HBsAb. Five out of the 7 HBV DNA-positive participants were males and only one participant was negative for HBcAb. Seventy-three out of the 96 HBsAg-negative participants were vaccinated and 37 of these vaccinated individuals had significant HBsAb titres (mean = 423.21± 380.72 IU/mL). Our data demonstrated that the prevalence of overt and occult HBV infection among the haemodialysis (HD) patients was 7.7% and 7.3%, respectively, and only 50.7% of those who showed proof of vaccination were protected from HBV infection.

Development of monoclonal antibodies to target the large surface protein of hepatitis B virus and their use in therapeutic and diagnostic applications

Over 250 million people are living with chronic infection caused by the hepatitis B virus (HBV). HBV has three surface proteins, namely small (SHBs), medium (MHBs) and large (LHBs), and they play different roles in the virus life cycle. The approved hepatitis B vaccine only contains the SHBs protein and many studies have focused on characterising the functional domains in SHBs. Although the LHBs protein is less studied, recent studies have shown that it plays important roles in mediating viral entry, replication and assembly. Over the years, there have been major advancements in monoclonal antibody (mAb) discovery tools and multiple mAbs have been developed to specifically target the preS1 domain in LHBs. We summarise the HBV infection systems and antibody discovery strategies that have been utilised by various research groups to assess the potential use of anti-preS1 mAbs as therapeutic antibodies against HBV or in the development of new diagnostic assays.

Immunogenicity and safety of SARS-CoV-2 vaccine in hemodialysis patients: A systematic review and meta-analysis

Rationale and objective

COVID-19 vaccination is the most effective way to prevent COVID-19. For chronic kidney disease patients on long-term dialysis, there is a lack of evidence on the pros and cons of COVID-19 vaccination. This study was conducted to investigate the immunogenicity and safety of COVID-19 vaccines in patients on dialysis.

Methods

PubMed, MEDLINE, EMBASE, and the Cochrane Library were systemically searched for cohort, randomized controlled trials (RCTs), and cross-sectional studies. Data on immunogenicity rate, antibody titer, survival rate, new infection rate, adverse events, type of vaccine, and patient characteristics such as age, sex, dialysis vintage, immunosuppression rate, and prevalence of diabetes were extracted and analyzed using REVMAN 5.4 and Stata software. A random effects meta-analysis was used to perform the study.

Results

We screened 191 records and included 38 studies regarding 5,628 participants. The overall immunogenicity of dialysis patients was 87% (95% CI, 84-89%). The vaccine response rate was 85.1 in hemodialysis patients (HDPs) (1,201 of 1,412) and 97.4% in healthy controls (862 of 885). The serological positivity rate was 82.9% (777 of 937) in infection-naive individuals and 98.4% (570 of 579) in patients with previous infection. The Standard Mean Difference (SMD) of antibody titers in dialysis patients with or without previous COVID-19 infection was 1.14 (95% CI, 0.68-1.61). Subgroup analysis showed that the immunosuppression rate was an influential factor affecting the immunogenicity rate (P < 0.0001). Nine studies reported safety indices, among which four local adverse events and seven system adverse events were documented.

Conclusions

Vaccination helped dialysis patients achieve effective humoral immunity, with an overall immune efficiency of 87.5%. Dialysis patients may experience various adverse events after vaccination; however, the incidence of malignant events is very low, and no reports of death or acute renal failure after vaccination are available, indicating that vaccine regimens may be necessary.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42022342565, identifier: CRD42022342565.

Hepatitis B Vaccination in Advanced Chronic Kidney Disease: A Quality Improvement Project at a Veteran Affairs Chronic Kidney Disease Clinic

Hepatitis B vaccination is recommended in all patients with end-stage kidney disease (ESKD). However, only 50–60% of these patients achieve protective antibody levels if immunized after starting dialysis. Strategies to overcome this low seroconversion rate include a 6-month vaccination schedule starting earlier [chronic kidney disease (CKD) stage 4 and 5] to ensure immunity when patients progress to ESKD. We conducted a quality improvement program to immunize pre-dialysis patients. Patients who were found to have a negative baseline serology with a negative hepatitis B surface antibody level (HBsAb) were offered vaccination on a 6-month schedule (0, 1 and 6 months) with one of two available vaccines within the VA system (Recombivax™ or Engerix™). HBsAb titers were checked 3–4 months later, and titers ≥ 12 mIU/mL were indicative of immunity at VA. Patients who did not seroconvert were offered a repeat schedule of three more doses. We screened 198 patients (187 males and 11 females) with CKD 4 and 5 [glomerular filtration rate (GFR) < 29 mL/min/1.73 m²]. The median age of this cohort was 72 years (range 38–92 years). During the study period of 5 years (2015–2020), 10 patients were excluded since their GFR had improved to more than 30 mL/min/1.73 m², 24 others had baseline immunity and 2 refused vaccination. The hepatitis B vaccination series was not started on 106 patients. Of the remaining 56, 12 patients progressed to ESKD and started dialysis before completion of the vaccination schedule, 6 expired and 1 did not come to clinic in 2020 due to the pandemic. Of the 37 patients who completed the vaccination schedule, 16 achieved seroconversion with adequate HBsAb titers, 10 did not develop immunity despite a second hepatitis B vaccination series, while 11 did not get a second series. Given the low seroconversion rate, albeit in a small cohort, vaccination should be considered in patients with earlier stages of CKD. Other options include studies on FDA approved vaccines of shorter duration. We plan to increase awareness among nephrologists, patients and nursing staff about the importance of achieving immunity against hepatitis B.

Recommendations of the Italian society for infectious and tropical diseases (SIMIT) for adult vaccinations

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.

Long-term persistent immunogenicity after successful standard and triple-dosed hepatitis B vaccine in hemodialysis patients: A 3-year follow-up study in China

BACKGROUND

Although the efficacy of hepatitis B vaccines among hemodialysis patients has been documented, the long-term persistence of immunogenicity in this population remains largely unknown. We explored the long-term persistence of immunogenicity induced by different hepatitis B vaccine regimens in hemodialysis patients.

METHODS

In initial study, we conducted a randomized, multicenter, double-blind, parallel-controlled trial among hemodialysis patients in 13 hospitals in Shanxi Province, China. A total of 352 hemodialysis patients were allocated to receive 3-dose 20 μg (IM20 group) and 3-dose 60 μg (IM60 group) recombinant hepatitis B vaccine at months 0, 1, and 6. Vaccine-induced immune responses were measured at month 7. In this study, the responders (anti-HBs ≥ 10 mIU/mL) were followed up at months 18, 24, 30, 36 and 42, respectively. We used the generalized log-rank test and generalized estimating equations (GEE) to analyze the long-term durability of responses and the kinetics of anti-HBs levels, respectively.

RESULTS

A total of 284 patients were involved in the extended follow-up period. The duration of vaccine-induced response with 75% of patients maintained protective antibody were 12 months and 18 months in the IM20 group and IM60 group, respectively (P = 0.291). The long-term persistent immunogenicity induced by 3-dose 60 μg was more satisfactory than that by 3-dose 20 μg hepatitis B vaccine in patients with hemodialysis duration ≥ five years (P = 0.023). The peak anti-HBs levels in 100-1000 mIU/mL or ≥ 1000 mIU/mL were more likely to maintain long-term protective antibody compared to anti-HBs levels in 10-100 mIU/mL (P ＜ 0.05). The kinetic profile was similar between the two groups (P = 0.334).

CONCLUSION

High-dose 60 μg hepatitis B vaccine could lead a satisfactory long-term durability of immunogenicity among patients with hemodialysis duration of five years or more. Peak anti-HBs level after vaccination was associated with the long-term persistence of immunogenicity.

Knowledge, Attitudes and Practices of Flu Vaccination in Hemodialysis Patients

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.

The Improvement of Immune Effect of Recombinant Human Beta-Defensin 2 on Hepatitis B Vaccine in Mice

Immunization with hepatitis B vaccine is an effective measure for prevention and control of hepatitis B Virus (HBV) infection. Although lots of efforts to improve the effect of hepatitis B vaccine have been made, the function of human beta defensin 2 (hBD2) on hepatitis B vaccine keeps unclear. In this article, we report that hBD2 not only promoted the activation and maturation of immature dendritic cells (iDCs) by increasing MHC II and CD86 expression, but it also significantly upregulated the mRNA level of IL-6 and IL-12B in mouse bone marrow-derived dendritic cells. The serum concentrations of IFN-γ in mice stimulated with 300 ng hBD2 increased from 25.21 to 42.04 pg/mL, with a time extension from 4 to 12 h post-injection. During the process of three times immunization (1, 14, 28 days) with 3 μg hepatitis B vaccine combined with or without 300 ng hBD2 with a 2 week interval in BALB/c mice, the antibody against HBsAg (HBsAb) concentration in serum at every time point of observation in the combined group was statistically higher than the hepatitis B vaccine group. The serum concentration of IgG2a subclass HBsAb on the 14th day post last injection in the combined group was significantly higher than the hepatitis B vaccine group. Further, the splenic cells from the mice treated with both hBD2 and hepatitis B vaccine possessed a greater ability to produce a surface antigen of hepatitis B virus (HBsAg) specific IFN-γ than those treated with hepatitis B vaccine alone. The percentages of CD3⁺/CD4⁺ T cells and CD3⁺/CD8⁺ T lymphocytes in spleens from the mice treated with 300 ng hBD2 were statistically higher than the phosphate buffered saline group. These data suggest that hBD2 improves iDC maturation and the immune efficiency of hepatitis B vaccine in BALB/c mice.

Long-term durability of immunogenicity induced by standard and triple-dose hepatitis B vaccine in patients receiving methadone maintenance treatment

OBJECTIVES

We explored the long-term immunogenicity induced by 60 μg and 20 μg hepatitis B vaccines among patients receiving methadone maintenance treatment (MMT).

METHODS

In initial study, a randomized controlled trial was conducted, in which patients receiving MMT were administered 20 µg (IM20 group) or 60 µg (IM60 group) hepatitis B vaccines at months 0, 1, and 6. In this study, the responders at month 7 were followed-up at months 18, 30, and 42 to estimate long-term immunogenicity.

RESULTS

The response rate decreased from 78.0% (39/50) to 31.1% (14/45) in the IM20 group, and from 86.0% (43/50) to 50.0% (20/40) in the IM60 group from month 7 to 42. Vaccine-induced responses in 75% of patients were observed for 14.2 months in the IM20 group and for 20.0 months in the IM60 group, and differences between these two groups were non-significant (P > 0.05).

CONCLUSION

The three-dose 20 µg and 60 µg hepatitis B vaccines showed similar rapid hepatitis B surface antibody decreases. Abbreviations: HBV, hepatitis B virus; MMT, methadone maintenance treatment; HCC, hepatocellular carcinoma; HBsAg, hepatitis B surface antigen; anti-HBs, hepatitis B surface antibody; HR, hazard ratio; CI, confidence interval; IQR, interquartile range; GEE, generalized estimated equation.

Genetic Polymorphisms within Interferon-λ Region and Interferon-λ3 in the Human Pathophysiology: Their Contribution to Outcome, Treatment, and Prevention of Infections with Hepatotropic Viruses

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Genetic polymorphisms within the interferon λ (IFN-λ) chromosomal region, mainly rs12979860 of IFN-λ4 gene (IFNL4), are known as associated with spontaneous hepatitis C virus (HCV) resolution and sustained viral response to therapy with pegylated interferon- α and ribavirin. Strong linkage disequilibrium of IFNL4 rs12979860 with IFNL4 rs368234815, which is casually associated with HCV spontaneous and therapeutical eradication, at least partially explains favorable HCV outcomes attributed to major homozygosity in rs12979860. Effects of IFN-based antiviral treatment are associated with pretreatment expression of the IFN-λ1 receptor, expression of hepatic IFN-stimulated genes, production of IFN- λ4, and preactivation of the JAK-STAT signaling. Nowadays direct-acting antivirals (DAAs) became a potent tool in the treatment of hepatitis C, but IFN-λs are still under investigation as potential antivirals and might be an option in HCV infection (DAA resistance, recurrent viremia, adverse effects).

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Patients with altered immunocompetence are especially prone to infections. In uremic subjects, polymorphisms within the IFN-λ chromosomal region associate with spontaneous HCV clearance, similarly like in the non-uremic population. Circulating IFN-λ3 shows a positive correlation with plasma titers of antibodies to surface antigen of hepatitis B virus (anti-HBs), which are crucial for protection against hepatitis B virus. More efficient anti-HBs production in the presence of higher IFN-λ3 levels might occur due to IFN-λ3-induced regulation of indoleamine 2,3-dioxygenase (IDO) expression. IFN-stimulated response element is a part of IDO gene promoter. It is worth further investigation whether IDO gene, circulating IDO, genetic polymorphisms within the IFN-λ region, and circulating IFN-λ3 act in concordance in immunological response to hepatotropic viruses.

Natural immunity against Haemophilus influenzae type a and B-cell subpopulations in adult patients with severe chronic kidney disease

Individuals suffering from severe chronic kidney disease (CKD) are immunocompromised and therefore highly susceptible to various infections including Haemophilus influenzae type a (Hia), an emerging pathogen in North American Indigenous populations. Immunocompromised Indigenous adults are considered a target for a new Hia vaccine under development. In an attempt to foresee their response to Hia immunization, we studied natural immunity against Hia and B-cell subpopulations in sixty patients with CKD residing in a geographic region with noticeable presence of Hia invasive disease. Serum bactericidal activity (SBA) against Hia, concentrations of IgG and IgM antibodies specific to Hia capsular polysaccharide, and B-cell subpopulations were studied in patients with CKD and 35 healthy controls of the same age. Of the patients with CKD, proportions and absolute numbers of B-cell subpopulations were determined for 28 patients. The patients had lower SBA titres compared to controls. Although no significant differences in anti-Hia IgG or IgM antibody concentrations between control and CKD groups were found, IgM antibody concentrations were higher in Indigenous than non-Indigenous patients. Patients with CKD had a higher proportion of B cells (CD19+), class switched memory B cells (CD19+CD27+IgM-) and a lower proportion of CD19+CD27-IgM- B cells compared to healthy controls. Non-Indigenous patients with CKD had significantly higher proportions of IgM memory B cells and CD19+CD27-IgM- B cells compared to Indigenous patients with no significant difference in absolute numbers. Because 72% of CKD patients had detectable SBA titres and 100% had detectable IgG and IgM antibodies it is possible that a portion of IgM memory B cells and class switched memory B cells are specific for Hia resulting from a natural exposure to the pathogen. The data suggest that a Hia-conjugate vaccine may be immunogenic in adult patients with CKD as it will potentially induce re-activation of immunological memory against Hia.

Vaccination in Chronic Kidney Disease

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).

Vaccination practices in dialysis patients: A narrative review

In a period of turmoil concerning vaccination practices, there is a serious conflict between scientifically reasonable, evidence-based guidelines and the far-fetched rumors or misconceptions concerning the vaccination practices in the general population. When a significant portion of the medical and paramedical personnel may be deliberately unvaccinated against common biological agents, achieving effective vaccination rates in the dialysis population may be complicated. Vaccination rates are unacceptably low in dialysis patients and seroconversion rates are even lower; further, serological follow-up is generally poor. The particularly anergic immune system of the advanced chronic kidney disease patients is partly a cause of both high rates of infection and low rates of seroconversions. This narrative review is an effort to summarize current knowledge concerning the vaccination practices in dialysis patients with some specific recommendations based on these facts. Of particular interest is a new vaccine, the Zoster Recombinant, Adjuvanted Vaccine (Shingrix), which we will include in our discussion.

Circulating Interferon-λ3, Responsiveness to HBV Vaccination, and HBV/HCV Infections in Haemodialysis Patients

The IFN-λ3 gene (IFNL3) plays a role in HCV clearance. We investigated circulating IFN-λ3 and IFNL3 SNPs in haemodialysis patients who differed in their response to HBV vaccination and their HBV/HCV infection status. In 201 patients, plasma IFN-λ3 was determined using ELISA. IFNL3 SNPs (rs12979860, rs8099917) were genotyped using HRM analysis. Differences in IFN-λ3 levels were shown between responders and nonresponders to HBV vaccination and between HBsAg-positive patients and those who developed anti-HBs after infection and became HBsAg negative. HBV vaccine responders without HCV resolution revealed lower IFN-λ3 than noninfected responders. HBsAg/HCV RNA-positive subjects showed lower IFN-λ3 than patients positive only for HCV RNA or subjects who resolved both infections. Circulating IFN-λ3 correlated positively with anti-HBs and negatively with positive HCV RNA testing in the adjusted regression analyses. HBV vaccine nonresponders, HBsAg-positive patients, and subjects with replicating HCV composed a group with unfavourable outcomes. Responders to HBV vaccination, subjects who became HBsAg negative, and those who cleared HCV were analysed as having favourable outcomes. The latter showed higher IFN-λ3 but did not differ in distribution of IFNL3 SNPs compared with subjects with unfavourable outcomes. Higher IFN-λ3 concentrations are associated with response to HBV vaccination, self-limited HBV infection, and HCV resolution.

Primary seroresponses to double-dose compared with standard-dose hepatitis B vaccination in patients with chronic kidney disease: a systematic review and meta-analysis

Background

Clinical guidelines recommend double-dose hepatitis B vaccination for patients requiring dialysis, due to an increased risk of hepatitis B infection and reduced vaccine responsiveness. There are no recommendations for patients with chronic kidney disease (CKD) prior to dialysis.

Methods

We performed a systematic review and meta-analysis of randomized and quasi-randomized trials comparing efficacy (seroresponses) and harms of double-dose compared with standard-dose hepatitis B vaccination in patients with CKD, including those requiring dialysis. A systematic literature search (CENTRAL, MEDLINE and EMBASE) was performed using a predetermined search strategy. Relative risks were calculated from pooled data using a random-effects model with subgroup analysis by dialysis requirement and vaccine type.

Results

Seven studies (501 patients) fulfilled review criteria: four in patients receiving dialysis and three in patients not receiving dialysis. The incidence of seroconversion was not increased with double-dose vaccination overall [risk ratio (RR) 1.17, 95% confidence interval (CI) 0.98-1.39], by dialysis requirement or vaccine type. The incidence of seroprotection (reported by only four studies) was increased with double-dose vaccination overall (RR 1.53, 95% CI 1.17-2.00) but not by dialysis requirement. Adverse events were not reported by treatment arm, precluding comparison. The overall quality of included studies was moderate to low.

Conclusions

The current data do not support clinical guideline recommendations for administering double-dose vaccination for patients with CKD as seroconversion was not improved and seroprotection was inadequately assessed. Large high-quality studies are required to overcome the current evidence gap regarding vaccine dosing in CKD.

Immunogenicity, antibody persistence, and safety of the 60 μg hepatitis B vaccine in hemodialysis patients: a multicenter, randomized, double-blind, parallel-controlled trial

BACKGROUND

To evaluate the immunogenicity, antibody persistence, and safety of the 60 µg hepatitis B vaccine in hemodialysis patients in China.

METHODS

We conducted a multicenter, randomized, double-blind, parallel-controlled trial including 352 hemodialysis patients who were centrally randomized in a ratio of 1:1 to receive a 20 µg (IM20 group) or 60 µg (IM60 group) recombinant hepatitis B vaccine at months 0, 1, and 6.

RESULTS

The vaccine-elicited antibody responses peaked at month 7, and declined at month 12. At month 7, the IM60 group had stronger GMC of anti-HBs, and a higher proportion of seroconversion and high-level response than the IM20 group did (P < 0.05). Better immune responses were observed in the IM60 group, especially for those aged or in the high-frequency hemodialysis population.

CONCLUSION

The high dose 60 µg recombinant hepatitis B vaccines elicited stronger immune responses than the 20 µg hepatitis B vaccine did among hemodialysis patients.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, number NCT02963714.

Role of hemokinin-1 in health and disease

Hemokinin-1 (HK-1), the newest tachykinin encoded by the Tac4 gene was discovered in 2000. Its name differs from that of the other members of this peptide family due to its first demonstration in B lymphocytes. Since tachykinins are classically found in the nervous system, the significant expression of HK-1 in blood cells is a unique feature of this peptide. Due to its widespread distribution in the whole body, HK-1 is involved in different physiological and pathophysiological functions involving pain inflammation modulation, immune regulation, respiratory and endocrine functions, as well as tumor genesis. Furthermore, despite the great structural and immunological similarities to substance P (SP), the functions of HK-1 are often different or the opposite. They both have the highest affinity to the tachykinin NK1 receptor, but HK-1 is likely to have a distinct binding site and signalling pathways. Moreover, several actions of HK-1 different from SP have been suggested to be mediated via a presently not identified own receptor/target molecule. Therefore, it is very important to explore its effects at different levels and compare its characteristics with SP to get a deeper insight in the different cellular mechanisms. Since HK-1 has recently been in the focus of intensive research, in the present review we summarize the few clinical data and experimental results regarding HK-1 expression and function in different model systems obtained throughout the 16years of its history. Synthesizing these findings help to understand the complexity of HK-1 actions and determine its biomarker values and/or drug development potentials.

Antibody response to HBV vaccination on dialysis does not correlate with the development of deNovo anti-HLA antibodies after renal transplantation

BACKGROUND

Response to Hepatitis B virus (HBV) vaccination can be diminished in some (50-80%) but not all dialysis patients. We hypothesized, that the response to vaccination on dialysis may correlate with the development of anti-HLA antibodies after renal transplantation and might therefore be a valuable parameter to predict alloresponses.

METHODS

The response to HBV vaccination on dialysis and the development of deNovo anti-HLA antibodies post-transplant was analyzed in 188 non-immunized renal transplant recipients. The response to HBV vaccination was evaluated by measuring the anti-HBs titer at time of transplantation. Anti-HLA antibodies post-transplant were monitored by serial measurements by means of Luminex. Acute rejection episodes, graft loss and renal dysfunction were assessed within a median follow-up of 5.5years.

RESULTS

One hundred and forty-one patients (75%) exhibited an adequate immune response to HBV vaccination on dialysis. Vaccine responder (R) and none responder (NR) did not differ with respect to age, gender and BMI, while R spend significantly more time on dialysis before transplantation (4.58±3.35 vs 3.23±2.55 years, p=0.033). More NR developed deNovo anti-HLA antibodies (27.7 vs 22.7%, p=0.554) and donor-specific anti-HLA antibodies (23.4 vs 14.2%, p=0.173) in comparison to R. Accordingly, the number of acute rejections was higher in NR as compared to R (36.1 vs 24.1%, p=0.130) while graft survival was similar in both groups.

CONCLUSION

Contrary to our hypothesis antibody response to HBV vaccination on dialysis does not predict the development of anti-HLA antibodies post transplant.

Antibodies to HBV surface antigen in relation to interferon-λ3 in hemodialysis patients

AIM

To investigate circulating IFN-λ3 and IFNL3 polymorphisms in hemodialysis (HD) patients differing in HBV surface antigen antibody (anti-HBs) production.

METHODS

The study included 106 HBV-vaccinated HD patients (88 developed anti-HBs) and 36 HBV-infected HD subjects (27 developed anti-HBs). Plasma IFN-λ3 (enzyme-linked immunosorbent assay) and rs12979860 (C>T) and rs8099917 (T>G) in IFNL3 (high-resolution melting curve analysis) were analyzed with regard to the association with anti-HBs production in response to HBV vaccination or infection. The results were adjusted for gender, age, cause of renal disease, dialysis vintage, dialysis modality, IFN-λ3, and 25(OH)D as appropriate.

RESULTS

HBV vaccine responders had higher circulating IFN-λ3 (ng/L) than non-responders (120, 36-233 vs. 53, 33-109, P<0.000001). Patients who generated anti-HBs after HBV infection also had higher circulating IFN-λ3 levels than those who did not (133, 35-215 vs. 71, 9-229, P=0.043). The IFN-λ3 concentration correlated with the anti-HBs titer in vaccinated (r=0.614, P<0.000001) and infected patients (r=0.589, P=0.0002). Plasma IFN-λ3 was the only significant indicator of responsiveness to HBV vaccination (adjusted P=0.018) and remained the only significant associate for the development of post-infection anti-HBs (adjusted P=0.049). A plasmaIFN-λ3 level of 85.5ng/L was thecut-off value for theprognosis of an anti-HBs titer below vs. equal to or over 10IU/L in the entire group of HD patients (ROC sensitivity 68.7%, specificity 85.2%, and AUC 0.827). Significant associations were not found between IFN-λ3 and IFNL3 rs12979860. Subjects treated with low flux HD that harbored the TT genotype in rs8099917 showed higher IFN-λ3 levels than patients bearing the G allele in rs8099917 (139, 68-233 vs. 103, 9-208, P=0.049).

CONCLUSION

In HD patients, circulating IFN-λ3 strongly correlates with anti-HBs production after HBV vaccination and infection. IFNL3 rs8099917 polymorphisms seem to be associated with IFN-λ3 plasma levels in HD subjects.

Antibodies to hepatitis B virus surface antigen and survival of hemodialysis patients - a prospective study

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.

Novel Perspectives on the Hepatitis B Virus Vaccine in the Chronic Kidney Disease Population

Background

The prevalence and incidence rates of hepatitis B virus (HBV) among patients undergoing maintenance dialysis in developed countries have declined over the last 2 decades thanks to the implementation of numerous infection control procedures in dialysis units, including the hepatitis B vaccine. It is well known that the immune response against HBV vaccine is unsatisfactory in the chronic kidney disease (CKD) population. The seroprotection rate after the HB vaccine schedule is low and the anti-HB titers are reduced, falling logarithmically over time.

Purpose

We did an extensive review of the medical literature on the mechanisms underlying the reduced response rate towards the HBV vaccine in patients with CKD. The efficacy and safety of HBV vaccines for use in the CKD population was also evaluated.

Results

Currently available vaccines against HBV are mostly plasma-derived or manufactured by recombinant DNA technology (yielding the S protein of the HBV envelope). The most promising strategy to enhance the immune response toward the HBV vaccine in the dialysis population is given by adjuvanted vaccines. Second-generation recombinant HB vaccines provided with a novel adjuvant (AS04, made of 3- O-4′-desacyl-monophosphoryl lipid A adsorbed on aluminum phosphate) demonstrated improved immunogenicity but a number of patients with an unsatisfactory response still occurs. Additional second-generation vaccines containing nonaluminum-based adjuvant systems such as AS02 (3- O-desacyl-4′-monophoshoryl lipid A and QS21) or 1018 (a Toll-like receptor 9 agonist) have shown higher immunogenicity and acceptable safety in the CKD population. The evidence in patients with end-stage renal disease is extremely limited on the use of third-generation vaccines, recombinant HBV vaccines expressed in mammalian cells containing S/Pre-S antigens.

Conclusions

The immunogenicity of HBV vaccines in patients with CKD is suboptimal but novel technologies promise to give better results in the near future.

Hepatitis B revaccination in HIV-infected vaccine non-responders: is double dosing always necessary?

Limited data exist on hepatitis B revaccination strategies for HIV-infected individuals who do not develop immunity after the first vaccination series. A retrospective cohort study was conducted to assess the immunogenicity of the second series of hepatitis B vaccine given in standard dosing (SD) and double dosing (DD) strategies among Thai HIV-infected adults during the period from January 2006 to December 2014. Of the 120 eligible patients, 68 (57%) were men, median age was 38 years old, 87 (73%) received SD and 33 (27%) received DD revaccination. The demographic and clinical characteristics of SD and DD groups were comparable. The overall vaccine response rate was significantly higher in DD group than SD group (97% vs. 70%; p = 0.001). Independent factors associated with no response to hepatitis B revaccination were receipt of SD vaccine (adjusted odds ratio [aOR] 16.04; p = 0.009), age ≥ 40 years (aOR 3.66; p = 0.009) and CD4 cell count at the time of revaccination less than 450 cells/µL (aOR 2.96; p = 0.04). These findings suggest that DD hepatitis B revaccination series should be given in HIV-infected patients who were at least 40 years old or had CD4 counts less than 450 cells/µL after no response to the first vaccination series.

Prophylactic vaccinations in chronic kidney disease: Current status

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.