Would you administer the Shingrix (recombinant zoster vaccine) to a patient with a history of resolved herpes zoster (shingles) and comorbid end-stage renal disease (ESRD)?

Shingrix Vaccination in ESRD Patients with Resolved Shingles

Yes, you should absolutely administer Shingrix (recombinant zoster vaccine) to this patient with resolved herpes zoster and end-stage renal disease. Both the history of prior shingles and the presence of ESRD are strong indications for vaccination, not contraindications.

Primary Recommendation

Administer the full 2-dose Shingrix series (doses separated by 2-6 months) regardless of the prior shingles episode. 1 The recombinant vaccine is specifically recommended for ESRD patients and is safe in immunocompromised populations, unlike the older live-attenuated vaccine. 2, 3

Why This Patient Needs Vaccination

Prior Shingles Does Not Provide Protection

• Having had shingles once does not confer reliable immunity against future episodes—the 10-year cumulative recurrence risk is 10.3%. 1
• Natural immunity from a prior episode is insufficient, and vaccination significantly reduces recurrence risk with 70.1% real-world effectiveness for the two-dose series. 1
• Wait at least 2 months after acute symptoms have resolved before administering the first dose. 1

ESRD Significantly Increases Risk

• ESRD patients face substantially elevated risk of herpes zoster due to uremia-induced immune dysfunction, regular dialysis exposure to high-transmission environments, and multiple comorbidities. 4
• Mortality risk is markedly increased in ESRD patients who develop shingles—51% of hospitalized ESRD patients with zoster died within 2 years (mean time to death 8.1 months). 5
• The live-attenuated vaccine demonstrated 51% effectiveness in reducing HZ incidence in ESRD patients aged ≥60 years (adjusted HR 0.49), and the recombinant vaccine is expected to perform even better. 6

Vaccine Selection and Safety

Shingrix is the Only Appropriate Choice

• Use only the recombinant zoster vaccine (Shingrix/RZV)—never the live-attenuated Zostavax in ESRD patients. 7, 2
• Shingrix is non-live and specifically approved for immunocompromised adults, making it safe for ESRD patients regardless of dialysis modality (hemodialysis or peritoneal dialysis). 4, 2
• The recombinant vaccine demonstrates 97.2% efficacy in adults aged ≥50 years with protection persisting for at least 8 years. 1, 2

Expected Immune Response in ESRD

• ESRD patients develop seroconversion following vaccination but achieve less robust and potentially less durable antibody responses compared to healthy individuals. 4
• The immune response depends on vaccine type, time since ESRD onset, age, BMI, and nutritional status (serum albumin and iron levels). 4
• Despite suboptimal responses, the vaccine remains protective—a phase I trial in ESRD patients showed a significant 2.1-fold rise in anti-VZV antibody titers at 5 weeks post-vaccination, consistent with protective responses seen in adults >50 years. 8

Practical Implementation

Dosing Schedule

• Administer the first dose immediately (assuming acute shingles symptoms resolved ≥2 months ago). 1
• Give the second dose 2-6 months after the first dose (minimum interval 4 weeks). 1
• Consider a third or booster dose in the future, as several studies suggest ESRD patients may benefit from additional doses to achieve optimal antibody response. 4

Timing Considerations

• Vaccinate early in the course of ESRD when possible, as earlier vaccination (within 2 years of dialysis initiation) may provide greater protection. 6
• Do not delay vaccination—there is no maximum interval after a prior shingles episode, and waiting leaves the patient vulnerable. 1
• If the patient is on immunosuppressive therapy for autoimmune kidney disease (e.g., rituximab, high-dose steroids), adjust timing according to specific medication guidelines. 4

Important Caveats

Immunosuppressive Medications

• For patients on anti-CD20 therapy (rituximab), wait at least 6 months after the last dose before vaccinating, then delay the next rituximab dose by at least 4 weeks post-vaccination. 9
• For patients on steroids, taper to <20 mg prednisone daily before vaccination if the underlying autoimmune disease is not active. 4
• If autoimmune kidney disease is active, prioritize immunosuppressive therapy over vaccination, though disease activation after vaccination is rare. 4

Safety Profile

• Injection-site reactions (pain, redness, swelling) occur in 9.5% of recipients (grade 3 reactions) versus 0.4% with placebo. 1
• Systemic symptoms (myalgia, fatigue) occur in 11.4% versus 2.4% with placebo, but most resolve within 4 days. 1
• No serious safety concerns have been identified in large clinical trials, with similar rates of serious adverse events between vaccine and placebo groups. 1

Monitoring

• The vaccine was safe and well-tolerated in ESRD patients awaiting transplant, with no cases of herpes zoster, rash illness, changes in donor-specific antibody, or rejection episodes during follow-up. 8
• No specific post-vaccination monitoring is required beyond standard observation for adverse reactions. 8