What should be ruled out in a patient with a history of Nephrotic (kidney disease characterized by excessive excretion of protein in the urine) syndrome before administering the Hepatitis B vaccine and is titre (a measure of the concentration of antibodies in the blood) indicative of the patient's immune response?

Hepatitis B Vaccination in a Patient with History of Nephrotic Syndrome

Before administering the Hepatitis B vaccine to a patient with history of nephrotic syndrome, you should check their anti-HBs titers to determine if they have adequate immunity, as patients with history of nephrotic syndrome often have reduced immune response to hepatitis B vaccination. 1

Pre-Vaccination Assessment

• Rule out active nephrotic syndrome with proteinuria, as this can affect vaccine response and potentially trigger relapse 2, 3
• Check current immunosuppressive medication status, as immunosuppression significantly reduces vaccine response 1, 3
• Determine previous hepatitis B vaccination history and timing 1
• Measure anti-HBs titers before vaccination to determine if protection already exists or if revaccination is needed 1, 4
• Assess renal function status, as the vaccination schedule differs based on kidney function 1

Importance of Antibody Titers

• Anti-HBs titer is the definitive indicator of protection against hepatitis B infection 4
• A protective level is defined as anti-HBs ≥10 mIU/mL 1, 4
• Patients with history of nephrotic syndrome have significantly lower seroconversion rates compared to healthy individuals 5, 3
• In steroid-sensitive nephrotic syndrome, only 48-64% of patients achieve protective antibody levels compared to >90% in healthy controls 3, 5
• Steroid-resistant nephrotic syndrome patients have even lower seroprotection rates (35.7%) 3

Vaccination Protocol Based on Renal Function

For Normal Renal Function:

• Standard adult dose: Recombivax HB 10 μg or Engerix-B 20 μg at 0,1, and 6 months 1
• Check anti-HBs titers 1-2 months after completing the series 1, 4

For Impaired Renal Function:

• Pre-dialysis: Recombivax HB 10 μg or Engerix-B 20 μg at 0,1, and 6 months 1, 4
• Dialysis-dependent: Recombivax HB 40 μg or Engerix-B 40 μg at 0,1, and 6 months (Engerix-B adds a dose at 2 months) 1, 4
• Higher doses are recommended due to reduced immune response in kidney disease 1, 4

Post-Vaccination Monitoring

• Check anti-HBs titers 1-2 months after completing vaccination series 1, 4
• If titers are <10 mIU/mL, administer a complete second series of vaccination 1, 4
• For non-responders after second series, consider alternative strategies such as double-dose vaccination 4, 6
• In patients with history of nephrotic syndrome, annual monitoring of anti-HBs titers is recommended 1, 4

Special Considerations for Nephrotic Syndrome

• Patients with history of nephrotic syndrome may have impaired B-cell memory responses to vaccines 7
• Vaccination during disease remission provides better immune response than during active disease 3, 7
• Consider double-dose vaccination strategy for better seroconversion rates 3, 6
• Be aware that vaccines may potentially trigger relapses in some patients with nephrotic syndrome 2
• Newer adjuvanted hepatitis B vaccines (like HBV-AS04) may elicit better immune response in patients with renal impairment 6

Conclusion

Anti-HBs titers are crucial for determining protection against hepatitis B in patients with history of nephrotic syndrome. Due to their reduced immune response, these patients require careful monitoring of antibody levels after vaccination, and may need modified vaccination schedules or higher doses to achieve adequate protection 1, 3.