What is the recommended use of Prevenar 20 (Pneumococcal conjugate vaccine) in a patient with Chronic Kidney Disease (CKD) stage 5 and impaired renal function?

Prevenar 20 in CKD Stage 5 Patients

Patients with CKD stage 5 should receive pneumococcal vaccination with either one dose of PCV20 (Prevenar 20) alone OR one dose of PCV15 followed by PPSV23 at least 8 weeks later, as they face a 3.7-fold increased risk of invasive pneumococcal disease compared to the general population. 1

Risk Profile in CKD Stage 5

• CKD stage 5 patients (GFR <15 mL/min or on dialysis) have significantly elevated risk for pneumococcal disease, with end-stage renal disease conferring 3.7 times the risk for invasive pneumococcal disease (IPD) compared to individuals without underlying conditions 1

• The altered immune system in ESRD patients results in both diminished vaccine response and rapid antibody decline, which is compounded by gradual removal of serum antibodies through dialysis 1

• The 2012 KDIGO clinical practice guideline specifically recommends pneumococcal vaccination for adults with stages 4 and 5 CKD 1

Vaccination Recommendations

Primary Vaccination Strategy

• Administer one dose of PCV20 alone as the preferred single-dose regimen for pneumococcal vaccine-naïve CKD stage 5 patients 1

• Alternative approach: Give PCV15 followed by PPSV23 at least 8 weeks later (rather than the standard ≥1 year interval) because immunocompromising conditions like ESRD benefit from shorter intervals 1

• The chronic renal failure indication is explicitly listed in the 2023 ACIP recommendations for both age groups 19-64 years and ≥65 years 1

Timing Considerations

• For immunocompromising conditions including ESRD, shorter intervals between PCV15 and PPSV23 (≥8 weeks rather than ≥1 year) are beneficial 1

• These vaccine doses do not need to be repeated at age ≥65 years if administered at age <65 years 1

Important Clinical Nuances

Vaccine Response Limitations

• CKD patients demonstrate significantly lower immune response to PPSV23 compared to healthy adults, with some studies showing only 68% maintaining adequate response at 6 months and 48% at 1 year 1, 2

• Antibody concentrations decline more rapidly in dialysis patients (within 3-5 years) compared to healthy individuals, associated with impaired adaptive immunity and antibody removal through dialysis 1

• Approximately 21% of CKD patients are hypo-responders to pneumococcal polysaccharide vaccines, failing to mount adequate antibody response and remaining at significant risk for infection 3

PCV13 Evidence in CKD (Relevant to PCV20)

• PCV13 induces functionally active pneumococcal antibodies in severe CKD patients, with opsonophagocytic activity demonstrating fold increases ranging from 2.4 to 24.6 for different serotypes 4

• Previous PPSV23 immunization negatively impacts subsequent PCV13 response, with significantly lower fold increases in antibody concentrations and reduced class-switched memory B cells lasting at least one year post-immunization 4, 5, 6

• PPV23-naïve CKD patients show superior response to PCV13 compared to previously PPV23-immunized patients, with fold increases ranging from 4.3 to 67.0 for different serotypes 4

Common Pitfalls to Avoid

• Do not delay vaccination in CKD stage 5 patients - they are at highest risk and should be prioritized for immunization 1, 7

• Do not use PPSV23 as the initial vaccine - conjugate vaccines (PCV15 or PCV20) should be given first due to superior immunogenicity in immunocompromised populations 1

• Do not assume adequate long-term protection - antibody levels decline rapidly in dialysis patients, and monitoring may be warranted 1, 2

• Do not give PPSV23 before a conjugate vaccine - this creates hyporesponsiveness to subsequent conjugate vaccine administration that can last over one year 4, 5, 6

• Do not wait until age 65 to vaccinate - CKD stage 5 is an indication for vaccination regardless of age, and doses given before age 65 do not need repeating 1

Practical Implementation

• Administer PCV20 as a single intramuscular injection in the deltoid muscle 1

• If using the PCV15/PPSV23 sequence, ensure at least 8 weeks between doses for this immunocompromised population 1

• Document vaccination status carefully as these patients may transition between dialysis modalities or receive transplantation 7

• Consider earlier revaccination intervals given the rapid antibody decline in dialysis patients, though specific guidelines for PCV20 revaccination are still evolving 1, 2