Can a shingles (Herpes Zoster) vaccine and an inactivated influenza (flu) vaccine be administered on the same day to a patient with Chronic Kidney Disease (CKD) stage IV and impaired renal function?

Concurrent Administration of Shingles and Flu Vaccines in Stage IV CKD

Yes, you can and should administer both the shingles vaccine and inactivated influenza vaccine on the same day to a patient with Stage IV CKD, given at separate anatomic sites. 1

Vaccine Selection and Administration

Influenza Vaccine Choice

• Use inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV), NOT live attenuated influenza vaccine (LAIV) in patients with Stage IV CKD due to their immunocompromised state from uremia. 1
• Stage IV CKD patients have impaired innate and adaptive immunity, making them functionally immunosuppressed. 2

Shingles Vaccine Choice

• Administer Shingrix (recombinant zoster vaccine, RZV), which is the preferred shingles vaccine and is inactivated/recombinant, not live. 3
• Shingrix requires two doses: the second dose should be given 2-6 months after the first dose. 3

Concurrent Administration Protocol

• Both vaccines can be administered simultaneously at separate anatomic sites (e.g., one in each deltoid). 1
• Inactivated vaccines do not interfere with immune responses to other inactivated vaccines. 1
• Studies specifically demonstrate no interference when IIV and zoster vaccine are given concomitantly, with similar antibody responses whether given together or 4 weeks apart. 1, 3

Clinical Rationale for Stage IV CKD Patients

Increased Disease Risk

• CKD patients face significantly elevated risk of both influenza complications and herpes zoster. 2, 4, 5
• The risk of herpes zoster is 1.60 times higher in CKD patients compared to the general population (HR 1.60; 95% CI 1.41-1.81). 5
• Dialysis therapy (which Stage IV CKD patients may soon require) independently increases herpes zoster risk (OR 3.29; 95% CI 1.05-10.36). 4

Vaccine Efficacy Considerations

• Vaccinate earlier in CKD progression rather than later, as immune responses decline with worsening renal function. 2
• Seroconversion rates are lower in CKD patients compared to healthy adults, making timely vaccination before further immune deterioration critical. 2
• Stage IV CKD represents an optimal window—patients are immunocompromised enough to warrant urgent vaccination but not yet on dialysis where responses may be further blunted. 2, 4

Safety Profile

Adverse Events

• Concurrent administration may increase local injection site reactions and systemic symptoms (fever, myalgia), but these are typically mild to moderate. 1
• No serious safety concerns have been identified with simultaneous administration of these vaccines. 1, 3
• The safety profile of Shingrix coadministered with influenza vaccine showed no evidence of interference or unexpected adverse events. 3

Monitoring

• Counsel patients to expect potentially increased reactogenicity when both vaccines are given together, particularly injection site pain and fatigue. 3
• Consider administering vaccines in different limbs to help distinguish which vaccine may be causing local reactions if they occur. 1

Common Pitfalls to Avoid

• Do not delay vaccination to give vaccines separately—this creates missed opportunities and leaves patients vulnerable during the delay period. 6
• Do not use LAIV in CKD patients—their immunocompromised state contraindicates live vaccines. 1
• Do not mix vaccines in the same syringe—always use separate injection sites. 1, 6
• Do not wait for "better" renal function—immune responses worsen as CKD progresses, making earlier vaccination preferable. 2
• Do not forget to schedule the second Shingrix dose in 2-6 months, as both doses are required for optimal protection. 3