What is the treatment for a patient with End-Stage Renal Disease (ESRD) on peritoneal dialysis who has developed shingles?

Treatment of Shingles in ESRD Patients on Peritoneal Dialysis

For an ESRD patient on peritoneal dialysis with uncomplicated shingles, treat with oral acyclovir or valacyclovir until all lesions have scabbed, with dose adjustments for renal function. 1

Treatment Approach

For Uncomplicated Herpes Zoster (Localized Shingles)

• Oral antiviral therapy is the standard treatment for uncomplicated shingles in ESRD patients, using either acyclovir or valacyclovir 1
• Continue treatment at least until all lesions have completely scabbed to ensure adequate viral suppression 1
• Famciclovir may be considered as an alternative, particularly if there are concerns about acyclovir-related nephrotoxicity, though this is less relevant in anuric ESRD patients 2

For Disseminated or Invasive Herpes Zoster

• Intravenous acyclovir is required if the infection is disseminated (lesions in >3 dermatomes) or invasive 1
• Temporarily reduce immunosuppressive medications if the patient is on any immunosuppression 1
• Continue IV acyclovir until clinical response is achieved, then switch to oral antiviral agents (acyclovir, valacyclovir, or famciclovir) to complete 14-21 days total treatment 1

Infection Control Considerations

Standard Precautions in the Dialysis Unit

• The patient should wear a surgical mask during dialysis sessions to prevent droplet transmission 1
• Maintain physical separation of at least 6 feet from other dialysis patients 1
• Implement contact precautions in addition to standard precautions, as herpes zoster is highly contagious 1
• Airborne precautions are needed if disseminated zoster is suspected or the patient is immunocompromised 1

Dosing Adjustments for ESRD

Critical Dosing Considerations

• Standard doses of acyclovir and valacyclovir require significant reduction in ESRD patients, even though specific doses aren't detailed in the transplant guidelines 1
• Post-dialysis dosing may be appropriate for certain antiviral agents to avoid additional vascular access complications 3
• Famciclovir has been reported as safer in patients with acute renal failure compared to acyclovir, though both require dose adjustment 2

Peritoneal Dialysis-Specific Concerns

Risk Assessment

• Peritoneal dialysis patients may have increased infection risk if on immunosuppressive agents, though this is more relevant for transplant recipients 1
• Standard peritoneal dialysis can continue during shingles treatment with appropriate infection control measures 1
• No specific contraindications exist for continuing peritoneal dialysis during herpes zoster treatment 1

Common Pitfalls to Avoid

• Do not delay antiviral treatment while waiting for culture confirmation, as early treatment (within 72 hours of rash onset) is most effective 1
• Do not use standard doses of acyclovir or valacyclovir without adjustment for ESRD, as this increases toxicity risk 1
• Do not assume the infection is uncomplicated without careful examination for dissemination, particularly in immunocompromised patients 1
• Avoid additional vascular access devices for IV medication administration when possible to preserve venous patency for future hemodialysis access if needed 3

Monitoring During Treatment

• Assess lesions daily for progression or signs of dissemination 1
• Monitor for complications including post-herpetic neuralgia, secondary bacterial infection, or systemic involvement 1
• Ensure adequate dialysis continues as antiviral therapy does not interfere with peritoneal dialysis efficacy 1