What considerations are needed for a Peritoneal Dialysis (PD) patient with Impaired renal function being treated for shingles?

Management of Shingles in Peritoneal Dialysis Patients

Peritoneal dialysis (PD) patients with shingles should be treated with oral valacyclovir or acyclovir with appropriate dose adjustments for renal impairment, and careful monitoring of the peritoneal catheter site to prevent infection transmission.

Antiviral Treatment Considerations

Medication Selection and Dosing

• For uncomplicated herpes zoster (shingles) in PD patients:
  • Oral valacyclovir is preferred due to better bioavailability and less frequent dosing 1
  • Oral acyclovir is an acceptable alternative 1
  • Famciclovir may be considered for patients who cannot tolerate acyclovir, as it has shown better renal safety profile in patients with renal dysfunction 2

Dose Adjustments for Renal Impairment

• Antiviral medications require dose adjustment in PD patients:
  • Valacyclovir: 1g every 24 hours for PD patients (reduced from standard 1g TID)
  • Acyclovir: 800mg twice daily (reduced from standard 800mg 5 times daily)
  • Treatment should continue until all lesions have scabbed 1

Severe or Disseminated Disease

• For disseminated or invasive herpes zoster in PD patients:
  • Intravenous acyclovir is recommended 1
  • Temporary reduction in immunosuppressive medications if applicable 1
  • Consider hospitalization for severe cases with close monitoring of renal function

PD-Specific Considerations

Peritoneal Dialysis Management

• Continue peritoneal dialysis during shingles treatment with these precautions:
  • Ensure proper exit site care to prevent secondary infection
  • Maintain meticulous hand hygiene before and after PD exchanges 1
  • Monitor peritoneal fluid for signs of infection (cloudiness, increased WBC) 3

Catheter Site Precautions

• If shingles lesions are near the catheter exit site:
  • Apply separate dressing to shingles lesions to prevent viral contamination
  • Consider temporary transfer to hemodialysis if lesions directly involve the catheter site
  • Increase frequency of exit site inspection and care 3

Residual Kidney Function Preservation

• Preserve residual kidney function during treatment:
  • Avoid nephrotoxic agents that may further compromise kidney function 4
  • Monitor fluid status carefully to avoid dehydration 4
  • Consider measuring residual kidney function before and after treatment 4

Infection Control Measures

Preventing Transmission

• Implement infection control measures:
  • Patient should wear a surgical mask if lesions are on the face or upper body 1
  • Maintain physical separation of at least 6 feet from other patients 1
  • Cover all lesions with clean, dry dressings
  • Limit exposure to immunocompromised individuals until lesions have crusted

Environmental Considerations

• Environmental precautions in the dialysis unit:
  • Clean surfaces with virucidal agents 1
  • Emphasize hand hygiene for all staff and patients 1
  • Consider scheduling the patient at the end of the day or in an isolation area until lesions have crusted

Pain Management

Acute Pain Control

• For pain management during acute shingles:
  • Start with acetaminophen for mild pain (dose-adjusted for renal impairment)
  • For moderate to severe pain, consider gabapentin with dose adjustment for PD patients
  • Avoid NSAIDs due to potential negative impact on residual kidney function 4

Prevention of Post-herpetic Neuralgia

• To reduce risk of post-herpetic neuralgia:
  • Early initiation of antiviral therapy (within 72 hours of rash onset) is critical
  • Consider low-dose amitriptyline or gabapentin for patients at high risk of post-herpetic neuralgia
  • Monitor for and promptly treat breakthrough pain

Monitoring and Follow-up

• Regular assessment of:
  • Lesion healing and pain control
  • Peritoneal dialysis adequacy
  • Signs of secondary bacterial infection
  • Medication side effects
  • Residual kidney function 4

Special Considerations

• PD patients have higher risk of developing herpes zoster compared to the general population 5
• Consider zoster vaccination for PD patients without active disease to prevent future episodes 1
• Be vigilant for potential complications in this immunocompromised population, including disseminated disease and secondary bacterial infections 6

By following these guidelines, nephrology providers can effectively manage shingles in PD patients while maintaining peritoneal dialysis therapy and preserving residual kidney function.