What vaccinations are recommended for patients with nephrotic syndrome, particularly those receiving corticosteroids or other immunosuppressive agents?

Special Vaccinations for Nephrotic Syndrome

All patients with nephrotic syndrome should receive influenza, pneumococcal, and varicella vaccines, with COVID-19 vaccination also strongly recommended. 1

Core Vaccination Recommendations

Inactivated Vaccines (Safe During Immunosuppression)

Pneumococcal Vaccination:

• Adults aged 19-64 years with nephrotic syndrome should receive either PCV20 as a single dose OR PCV15 followed by PPSV23 after ≥8 weeks 1
• Adults ≥65 years should receive PCV20 as a single dose OR PCV15 followed by PPSV23 1
• Revaccination with PPSV23 is indicated after 5 years for patients with nephrotic syndrome due to chronic renal failure 1
• Children should receive age-appropriate pneumococcal conjugate vaccine series 1

Influenza Vaccination:

• Annual influenza vaccination is recommended for all patients with nephrotic syndrome 1
• Household contacts should also receive annual influenza vaccination to minimize transmission risk 1

Hepatitis B Vaccination:

• Indicated for patients with chronic renal failure or those on hemodialysis 1
• Complete the standard 3-dose series at 0,1, and 6 months 1

COVID-19 Vaccination:

• All eligible and willing patients should be immunized against SARS-CoV-2 1

Live Vaccines (Timing-Dependent)

Critical Timing Restrictions:

Defer live vaccines (MMR, varicella, zoster) until:

• Prednisone dose is below 1 mg/kg daily (≤20 mg/day) OR 2 mg/kg on alternate days (≤40 mg on alternate days) 1
• Live vaccines are absolutely contraindicated in children receiving corticosteroid-sparing immunosuppressive agents (cyclophosphamide, rituximab, calcineurin inhibitors, mycophenolate) 1

Varicella Protection:

• Varicella vaccine should be given when immunosuppression criteria above are met 1
• For nonimmune children on immunosuppressive agents with close varicella exposure, administer varicella zoster immune globulin if available 1

Household Contact Vaccination Strategy

Immunize healthy household contacts with live vaccines to create a protective barrier, but:

• Avoid direct exposure of the immunosuppressed child to gastrointestinal, urinary, or respiratory secretions of vaccinated contacts for 3-6 weeks after vaccination 1
• This applies particularly to rotavirus vaccine in infant siblings 1

Special Considerations for Complement Inhibitor Use

Patients receiving complement inhibitors (eculizumab, ravulizumab) require enhanced vaccination against encapsulated organisms:

• Meningococcal vaccination (quadrivalent and serogroup B) is essential 1
• Ensure pneumococcal vaccination is up to date before initiating complement inhibitor therapy 1

Infection Prophylaxis Beyond Vaccination

Pneumocystis jirovecii Pneumonia (PJP) Prophylaxis:

• Use trimethoprim-sulfamethoxazole (or equivalent) when daily prednisone dose is ≥20 mg 1
• Also indicated with cyclophosphamide or rituximab therapy regardless of steroid dose 1

Common Pitfalls to Avoid

Do not assume all vaccines are contraindicated during treatment - inactivated vaccines remain safe and effective even during high-dose immunosuppression, though response may be reduced 2, 3

Do not delay pneumococcal vaccination - infection risk is highest within the first 6 months of diagnosis, particularly with serum albumin <2.9 g/dL 1

Do not give live vaccines to patients on any immunosuppressive agent beyond low-dose corticosteroids - this includes calcineurin inhibitors, rituximab, cyclophosphamide, and mycophenolate, even if steroid doses are low 1

Do not forget to screen for latent infections before immunosuppression - tuberculosis, hepatitis B and C, HIV, syphilis, and Strongyloides (in at-risk patients with eosinophilia) should be evaluated 1

Evidence Quality Note

While the benefit-risk ratio strongly favors vaccination in nephrotic syndrome, the theoretical concern about vaccine-triggered relapse has not been substantiated in clinical studies 2, 3. Research shows that IVIG, thymosin, and other immunomodulatory agents may reduce infection risk in children with nephrotic syndrome, though study quality is limited 4. Provider recommendation is the strongest predictor of vaccine adherence in this population 5.