Immunization in children with chronic renal failure: a practical approach

Abstract

The prevention of systemic viral and bacterial infections by effective vaccination represents an essential task of pediatric nephrologists caring for children with chronic renal failure (CRF) undergoing renal transplantation (RTPL) with life-long immunosuppression. This review addresses three issues: risk of vaccine-preventable diseases, safety, immunogenicity, and clinical efficacy of available vaccines, and implementation of immunization guidelines. Infections (including vaccine-preventable infections) represent the leading cause of morbidity and mortality in children on dialysis and after RTPL. Vaccination in children with CRF and after RTPL is safe and does not cause reactivation of an immune-related renal disease or rejection after RTPL. Children with CRF generally produce protective serum antibodies to primary vaccinations with killed or component vaccines and live virus vaccines; some children on dialysis and after RTPL may not respond optimally, requiring repeated vaccination. Proof of vaccine efficacy is absence of disease, which can only be confirmed in large cohort studies. A few observational studies provide evidence that vaccination has contributed significantly, at least in the western hemisphere, to the low prevalence of vaccine-preventable diseases among children with CRF. Close cooperation between the local pediatrician/practitioner and the pediatric nephrologist is essential for successful implementation of the vaccination schedule.

Selected Primary Care Issues and Comorbidities in Children Who Are on Maintenance Dialysis

“…In particular, all children who are on dialysis should be immunized against Streptococcus pneumoniae, varicella, and influenza (5), and all live virus vaccines (e.g., measles-mumps-rubella, varicella) with the exception of oral polio are safe, as are inactivated or component vaccines. Some programs provide standard rotavirus immunization of infants who are on dialysis since the licensing of live rotavirus vaccines and recommendations for their routine use (7).…”

“…Obligate protein loss through the peritoneal space in combination with decreased appetite, resulting in decreased protein and energy intake, play the major role in the development of protein-energy malnutrition in children who are on peritoneal dialysis (24). Intradialytic (5,(7)(8)(9)(10). DTaP, diphtheria-tetanus toxoid-acellular pertussis vaccine; HB, hepatitis B; HiB, Haemophilus influenzae type B conjugate vaccine; IPV, inactivated polio virus vaccine; MCV4, meningococcal conjugate vaccine; MMR, measles-mumps-rubella vaccine; MPSV4, meningococcal polysaccharide vaccine; PCV7, pneumococcal conjugate vaccine; PPV23, pneumococcal polysaccharide vaccine; Td, tetanus and low-dosage diphtheria toxoid vaccine.…”

“…Many of these infections are preventable by immunizations. Current guidelines for immunization in children are derived from small studies (4) or represent expert opinion (5).…”

Vaccination Practices in Pediatric Dialysis Patients Across Europe. A European Pediatric Dialysis Working Group and European Society for Pediatric Nephrology Dialysis Working Group Study

“…Studies suggest that children with CKD and RTx candidates should also be protected against varicella, influenza, hepatitis B, and Streptococcus pneumoniae, if not included in their national universal immunization schedule [3, 4, 9]. Although vaccination in children with CKD is safe, vaccination coverage among children with CKD remains low due to safety concerns and doubts about vaccine immunogenicity and efficacy [4, 5]. In addition, data on the immunization practices in pediatric CKD and dialysis patients are scarce.…”

“…Available guideline recommendations for children with CKD are derived from small or single center studies, or represent the opinion of a group of experts. Therefore, immunization recommendations vary between countries and even between different health authorities [4]. …”