Should patients with impaired renal function, including those with end-stage renal disease or undergoing dialysis, receive the influenza (flu) vaccine annually?

Influenza Vaccination in Renal Disease

All patients with chronic kidney disease, including those with end-stage renal disease on dialysis, should receive annual inactivated influenza vaccination. 1

Strength of Recommendation

The Canadian Society of Nephrology, endorsing KDIGO guidelines, provides a Grade 1B recommendation that all adults with CKD receive annual influenza vaccination unless contraindicated. 1 This recommendation applies across all stages of kidney disease, from early CKD through dialysis and transplantation. 1

Rationale for Vaccination

• Patients with ESRD face substantially higher morbidity and mortality from influenza compared to the general population due to their immunocompromised state, frequent healthcare exposure, and multiple comorbidities. 2, 3
• Influenza can trigger clinical deterioration in dialysis patients, including cardiovascular events and increased hospitalization rates. 2
• The vaccine is publicly funded in Canada for high-risk populations including individuals with renal disease, facilitating access through primary care providers. 1

Vaccine Selection and Administration

• Use only inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV) in patients with renal disease. 1, 4
• Live attenuated influenza vaccine (LAIV) is absolutely contraindicated in immunocompromised patients including those with ESRD. 1, 4, 5
• Standard age-appropriate dosing should be used—there is no recommendation for higher doses specifically for renal patients, unlike hepatitis B vaccination. 1, 5
• Administer annually before influenza season begins, ideally in early fall. 1, 3

Expected Immune Response

A critical caveat: immune response to influenza vaccine is significantly impaired in ESRD patients. 2, 6

• Seroconversion rates are lower than in healthy individuals, with variable immunogenicity depending on the degree of immunosuppression. 2, 6
• Despite reduced antibody response, vaccination still provides meaningful protection against severe disease outcomes in a significant proportion of patients. 2, 6
• One controversial study using natural experiment methodology found minimal vaccine effectiveness (0% for influenza-like illness, 2% for hospitalization, 0% for mortality) when comparing matched versus mismatched vaccine years. 7 However, this single study's methodology has limitations, and the consensus of guidelines remains strongly in favor of annual vaccination given the high risk of severe complications in unvaccinated patients. 1, 8

Evidence Quality and Clinical Decision

The quality of evidence for influenza vaccine effectiveness in ESRD is admittedly very low, with only observational studies available and significant risk of bias. 8 However, given the extremely high rates of health-endangering events in dialysis patients, even modest vaccine effectiveness justifies annual vaccination. 8 The potential benefits clearly outweigh the minimal risks, and vaccination remains the best available preventive strategy. 2, 8

Safety Profile

• All available studies confirm excellent safety and tolerability of inactivated influenza vaccines in ESRD patients. 2, 6
• No serious adverse events have been documented in this population. 2
• The vaccine does not accelerate kidney disease progression or cause dialysis-related complications. 2

Additional Protective Measures

• Vaccinate close contacts and household members of dialysis patients to create a protective barrier. 5
• Healthcare workers in dialysis units should receive annual influenza vaccination to prevent nosocomial transmission. 5
• Implement strict infection control in dialysis units during influenza season, including masking symptomatic patients and maintaining physical separation. 4

Special Populations

For kidney transplant recipients: Annual inactivated influenza vaccination is recommended, ideally administered at least 3 months post-transplant when immunosuppression is less intense, though vaccination can be given as early as 1 month post-transplant during high influenza activity. 5 Live vaccines remain contraindicated. 5

For pediatric CKD patients: Follow standard pediatric immunization schedules with inactivated vaccines according to international recommendations. 1

Common Pitfalls to Avoid

• Never use live attenuated influenza vaccine in any patient with renal disease or immunosuppression. 1, 4, 5
• Do not delay vaccination waiting for "optimal" timing—vaccinate as soon as vaccine becomes available each season. 3
• Do not assume vaccination provides complete protection—counsel patients that breakthrough infections can occur but are likely to be less severe. 2, 6
• Do not neglect vaccination of household contacts and caregivers, as this is a critical component of protecting vulnerable dialysis patients. 5