How to Give Varicella Zoster Vaccine in a CKD Patient on Hemodialysis
Administer the recombinant zoster vaccine (Shingrix/RZV) as a 2-dose series (0.5 mL each) intramuscularly in the deltoid muscle, with doses given 2-6 months apart, ideally before transplantation if planned. 1
Vaccine Selection and Rationale
Use only the recombinant zoster vaccine (RZV/Shingrix) in hemodialysis patients—never the live attenuated vaccine (Zostavax). 2, 3 The live vaccine is contraindicated in immunocompromised patients due to risk of disseminated disease, while RZV is specifically approved for immunocompromised adults aged ≥18 years. 1, 3
Hemodialysis patients have significant immunosuppression that increases their risk of herpes zoster infection and reactivation, making vaccination particularly important in this population. 4, 5 Recent evidence suggests RZV may provide additional benefits beyond zoster prevention, including reduced risks of kidney disease progression, cardiovascular events, and mortality in CKD patients. 6
Administration Protocol
Dosing Schedule
- Standard schedule: First dose at Month 0, second dose at 2-6 months later 1
- Accelerated schedule option: For patients who would benefit from shorter vaccination (e.g., imminent transplant), doses can be given 1-2 months apart 1
Preparation and Injection Technique
- Reconstitute the lyophilized antigen powder with the supplied AS01B adjuvant suspension
- Gently swirl until completely dissolved (do not shake vigorously)
- Administer 0.5 mL intramuscularly in the deltoid region of the upper arm
- Use reconstituted vaccine immediately or refrigerate at 2-8°C and use within 6 hours 1
Timing Considerations
Pre-Dialysis or Maintenance Hemodialysis
- Vaccinate as soon as indicated—no need to delay
- Can be given on dialysis days or non-dialysis days
- No specific timing relative to dialysis session is required
Pre-Transplant Candidates
- Strongly prioritize vaccination before transplantation 2
- Complete the 2-dose series while still on dialysis when immune response is better than post-transplant
- Avoid live vaccines within 4 weeks of transplantation, but RZV is not a live vaccine 2
- If transplant is imminent, use the 1-2 month accelerated schedule 1
Expected Response and Monitoring
Hemodialysis patients have impaired immune responses to vaccines compared to healthy individuals. 5, 7 However, RZV demonstrates good immunogenicity even in immunocompromised populations:
- Approximately 88% of immunocompromised patients mount significant antibody responses 8
- Two-dose completion is critical for optimal protection
- Consider serologic testing post-vaccination in high-risk patients to identify non-responders, though this is not routinely required 8
Safety Profile
RZV has an acceptable safety profile in immunocompromised patients. 3 Common reactions include injection site pain, fatigue, and myalgia. Be aware of:
- Guillain-Barré syndrome: Increased risk in the 42 days post-vaccination (rare but documented) 1
- Syncope: Have patients sit or lie down during and after vaccination 1
- Have epinephrine available for potential anaphylaxis 1
Critical Pitfalls to Avoid
- Do not use live zoster vaccine (Zostavax) in dialysis patients—this is contraindicated 2, 3
- Do not delay vaccination waiting for "optimal" timing—vaccinate as soon as eligible
- Do not give only one dose—both doses are essential for adequate protection
- Do not assume prior varicella infection provides sufficient protection against zoster in immunocompromised patients
- Do not wait until after transplant to initiate vaccination—immune response will be significantly worse post-transplant 2
Post-Transplant Scenario
If the patient was not vaccinated pre-transplant, RZV can still be given post-transplant, but wait at least 2 months after transplantation when immunosuppression is less intense, and ideally 2-6 months post-transplant. 2 However, pre-transplant vaccination is strongly preferred.