Varicella Vaccine in Renal Transplantation Patients
Varicella vaccine should be administered to seronegative renal transplant candidates BEFORE transplantation, ideally at least 4 weeks prior to surgery, but is contraindicated after transplantation due to the risk of vaccine-strain infection in immunosuppressed patients. 1, 2
Pre-Transplant Vaccination Strategy
The optimal approach is to vaccinate all VZV-seronegative patients while they are on the transplant waiting list, before immunosuppression begins. 3, 1
Evidence Supporting Pre-Transplant Vaccination:
Vaccination prior to transplantation dramatically reduces morbidity and mortality: In 704 pediatric renal transplant recipients, pretransplant vaccination reduced varicella incidence from 45% in unvaccinated patients to 12% in vaccinated patients, with zero deaths related to varicella-zoster virus in the vaccinated group. 3
The vaccine is safe and effective in end-stage renal disease patients: 77% of VZV-seronegative kidney transplant candidates achieved positive VZV-IgG levels after two doses given 6 weeks apart, with 82% showing increased VZV-specific CD4+ memory T-cells. 4
Approximately 3% of patients on the kidney transplant waiting list are seronegative for VZV, making screening and vaccination a cost-effective strategy. 5
The vaccine should be given at least 4 weeks before transplantation to ensure adequate immune response and safety. 1
Vaccination Protocol for Transplant Candidates:
- Screen all renal transplant candidates for VZV antibodies 5
- Administer two doses of live attenuated varicella vaccine (Oka strain) at 6-week intervals to seronegative patients 4, 5
- Verify seroconversion 6-12 weeks after completing the series 4
- Only 5-10% of adult patients in the United States are seronegative, with higher percentages in tropical countries 3
Post-Transplant Contraindication
Live attenuated varicella vaccine is absolutely contraindicated after renal transplantation due to documented risk of vaccine-strain disseminated infection. 3, 1, 2
Critical Safety Evidence:
A documented case of vaccine-derived varicella-zoster infection occurred in a 49-year-old kidney transplant recipient who developed skin rash and interstitial infiltrates three weeks after receiving the live vaccine, with Oka-vaccine strain detected in plasma by PCR. 2
The vaccine remains controversial in adult solid-organ recipients post-transplant, with efficacy unknown and safety concerns including reactivation of the Oka strain, transmission to others, and development of zoster. 3
All live vaccines are generally contraindicated within 3-6 months of renal transplant due to intensified immunosuppression. 1, 6
Post-Transplant Outcomes in Vaccinated Patients:
Vaccination before transplant provides lasting protection: The incidence of zoster was only 7% in pediatric renal recipients who received the vaccine pre-transplant, compared to 38% in those who developed primary infection after transplant. 3
None of the vaccine non-responders suffered from primary VZV after transplantation, suggesting some degree of protection even without detectable antibodies. 4
Household Contact Vaccination
Seronegative household contacts and healthcare workers should receive varicella vaccine to create a protective barrier around the immunosuppressed transplant recipient. 3
- Vaccination of household contacts is recommended by the American Academy of Pediatrics to prevent transmission to immunocompromised patients 3
- Healthcare workers who develop a rash after vaccination should avoid contact with transplant recipients, though the risk of transmission is very small 3
Common Pitfalls to Avoid
- Do not administer live varicella vaccine to patients already on immunosuppression or after transplantation—this can cause life-threatening disseminated vaccine-strain infection 2
- Do not assume all adult patients are immune—screen all transplant candidates for VZV antibodies, as 5-10% of U.S. adults remain seronegative 3
- Do not delay vaccination once a seronegative patient is identified on the waiting list—vaccinate immediately to ensure adequate time for immune response before transplantation 1, 5
- Do not withhold vaccination from household contacts—their vaccination protects the immunosuppressed patient without posing significant risk 3