Hepatitis B Vaccination of Hemodialysis Patients

Hepatitis B Vaccine

"Hepatitis B vaccination is recommended for all susceptible chronic hemodialysis patients. Vaccination is recommended for pre-end-stage renal disease patients before they become dialysis dependent and for peritoneal and home dialysis patients because they might require in-center hemodialysis.

“Patients with uremia who were vaccinated before they required dialysis have been shown to have higher seroconversion rates and antibody titers. The response may also be better in children.”

Dosage and Schedule

"For patients undergoing hemodialysis and for other immunosuppressed patients, higher vaccine doses or increased number of doses are required. A special formulation of one vaccine is now available for such persons (Recombivax HB, 40 μg/mL)".

“If an adult patient begins the vaccine series with a standard dose before beginning hemodialysis treatment, then moves to hemodialysis treatment before completing the series, complete the series using the higher dose recommended for hemodialysis patients. No specific recommendations have been made for higher doses for pediatric hemodialysis patients. If a lower than recommended vaccine dose is administered to either adults or children, the dose should be repeated.”

Immunogenicity and Duration of Immunity

"Although data concerning the response of pediatric hemodialysis patients to vaccination with standard pediatric doses are lacking, protective levels of antibody occur in 75% -97% of those who receive higher dosages (20-μg) on either the 3- or the 4-dose schedule."

"Limited data are available on the duration of immune memory after hepatitis B vaccination in . . . dialysis patients. No clinically important HBV infections have been documented among immunocompromised persons who maintain protective levels of anti-HBs. . . .However, among hemodialysis patients who respond to the vaccine, clinically significant HBV infection has been documented in persons who have not maintained anti-HBs concentrations of >10 mIU/mL."

Serologic Testing

Testing after vaccination is recommended for persons (including hemodialysis patients) whose subsequent clinical management depends on knowledge of their immune status. "Testing should be performed 1-2 months after administration of the last dose of the vaccine series by using a method that allows determination of a protective level of anti-HBs (>10 mIU/mL)."

"Persons found to have anti-HBs levels of <10 mIU/mL after the primary vaccine series should be revaccinated. Administration of three doses on an appropriate schedule . . ., followed by anti-HBs testing 1-2 months after the third dose, is usually more practical than serologic testing after one or more doses of vaccine."

"Persons who do not respond to revaccination should be tested for HBsAg. If the HBsAg test result is positive, the persons should receive appropriate management . . . and any household, sexual, or needle-sharing contacts should be identified and vaccinated. Persons who test negative for HBsAg should be considered susceptible to HBV infection and should be counseled about precautions to prevent HBV infection and the need to obtain HBIG postexposure prophylaxis for any known or likely parenteral exposure to HBsAg-positive blood."

Booster Doses

"For hemodialysis patients, the need for booster doses should be assessed by annual antibody to hepatitis B surface antigen (anti-HBs) testing. A booster dose should be administered when anti-HBs levels decline to <10 mIU/mL."

Reference

Guidelines for Vaccinating Kidney Dialysis Patients and Patients with Chronic Kidney Disease

summarized from
Recommendations of the Advisory Committee on Immunization Practices (ACIP)