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 anti-HBs titers to determine if protection already exists and to assess the need for vaccination, as patients with history of nephrotic syndrome often have reduced immune response to hepatitis B vaccination. 1

Pre-Vaccination Assessment

• Check anti-HBs titers before vaccination to determine if the patient already has protective immunity (defined as anti-HBs ≥10 mIU/mL) 1
• Review the patient's current renal function status, as this will influence the vaccination protocol 1
• Determine if the patient is currently on any immunosuppressive medications that might affect vaccine response 2
• Assess for any active nephrotic syndrome relapse, as this would significantly reduce antibody response due to urinary loss of immunoglobulins 3

Importance of Titer Testing

• Titer testing is highly indicative and essential in this population, as patients with history of nephrotic syndrome have been shown to have significantly lower seroconversion rates to hepatitis B vaccination 4, 2
• Studies show that children with steroid-sensitive nephrotic syndrome have significantly lower antibody titers and response rates to hepatitis B vaccination compared to healthy controls 4
• In one study, only 48% of children with nephrotic syndrome achieved protective anti-HBs titers (≥10 mIU/mL) after standard vaccination 2

Vaccination Protocol for Patients with History of Nephrotic Syndrome

• If the patient has normal renal function currently, the recommended vaccination schedule is:

  • Recombivax HB: 10 μg at 0,1, and 6 months, or
  • Engerix-B: 20 μg IM at 0,1, and 6 months 1

• If the patient has impaired renal function, consider a higher dose regimen:

  • Recombivax HB: 40 μg at 0,1, and 6 months, or
  • Engerix-B: 40 μg IM at 0,1,2, and 6 months 1

Post-Vaccination Monitoring

• Check anti-HBs titers 1-2 months after completing the vaccination series to confirm adequate immune response (defined as anti-HBs ≥10 mIU/mL) 1
• For patients who do not achieve protective titers after the initial series, revaccinate with a complete second series 1
• Consider annual monitoring of anti-HBs titers in this patient population due to risk of waning immunity 1

Special Considerations and Pitfalls

• Patients with history of steroid-resistant nephrotic syndrome have even lower seroprotection rates (35.7%) compared to those with steroid-sensitive disease (63.6%) 2
• Consider double-dose vaccination strategy for patients with history of nephrotic syndrome to improve seroconversion rates 2
• Be aware that during active nephrotic syndrome, serum IgG levels may be transiently reduced due to proteinuria, potentially affecting antibody measurement 3
• Some case reports have described nephrotic syndrome relapses following hepatitis B vaccination, though causality is difficult to establish 5

Algorithm for Approach

1. Check anti-HBs titers before vaccination
2. If titers ≥10 mIU/mL: No vaccination needed
3. If titers <10 mIU/mL:
   • Assess current renal function
   • If normal renal function: Standard adult dose
   • If impaired renal function: Higher dose regimen
4. Check post-vaccination titers 1-2 months after completing series
5. If post-vaccination titers <10 mIU/mL: Administer second complete series
6. Monitor titers annually