What is the recommended vaccination schedule for adults with chronic kidney disease or on dialysis, including hepatitis B, influenza, pneumococcal, tetanus‑diphtheria‑pertussis, COVID‑19, hepatitis A, and recombinant zoster vaccines, and how should non‑responders to hepatitis B vaccination be managed?

Immunization in CKD/Dialysis Patients

Hepatitis B Vaccination

All CKD patients should receive high-dose hepatitis B vaccination (40 μg) as early as possible in their disease course, ideally before dialysis initiation, with mandatory post-vaccination antibody testing and annual monitoring for dialysis patients. 1, 2

Dosing Schedules

• Dialysis-dependent patients: Recombivax HB 40 μg at 0,1, and 6 months OR Engerix-B 40 μg at 0,1,2, and 6 months 1, 2
• Pre-dialysis patients (eGFR <30 mL/min/1.73 m²): Recombivax HB 10 μg at 0,1, and 6 months OR Engerix-B 20 μg at 0,1, and 6 months 1, 2
• Pediatric patients (<20 years): Recombivax HB 5 μg at 0,1, and 6 months OR Engerix-B 10 μg at 0,1, and 6 months 1, 2

Post-Vaccination Monitoring

• Check anti-HBs titers 1-2 months after completing the vaccination series 1, 2
• Adequate response is defined as anti-HBs ≥10 mIU/mL 1, 2
• For dialysis patients, monitor anti-HBs levels annually 1, 2
• Administer booster dose if anti-HBs falls below 10 mIU/mL 1, 2

Management of Non-Responders

• If initial series fails (anti-HBs <10 mIU/mL), administer a complete second series using the same high-dose regimen 1, 2
• For patients who fail to respond to the second series, no additional doses have proven beneficial 1
• Response rate to revaccination is 25-50% for a single additional dose and 44-100% for a complete 3-dose series 2

Critical Pitfall

Using standard adult doses (20 μg) in dialysis patients instead of the recommended 40 μg results in inadequate immune response—this is the most common error in practice. 2

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Influenza Vaccination

All CKD and dialysis patients should receive annual inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV), with live attenuated vaccines contraindicated. 1, 3

Administration Details

• Use standard age-appropriate dosing—no higher doses specifically required for CKD patients 3
• Administer annually before influenza season begins, ideally in early fall 3
• Live attenuated influenza vaccine (LAIV) is absolutely contraindicated in dialysis patients 1
• No preference between standard quadrivalent and high-dose trivalent inactivated vaccines 1

Additional Protective Measures

• Vaccinate all household members and close contacts of dialysis patients 3
• All healthcare workers in dialysis units must receive annual influenza vaccination 1, 3

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Pneumococcal Vaccination

All dialysis patients and CKD patients with eGFR <30 mL/min/1.73 m² should receive both PCV13 and PPSV23 in sequence, with specific timing between doses. 1

Sequential Vaccination Protocol

• If PCV13 is given first: administer PPSV23 at least 8 weeks later 1
• If PPSV23 is given first: administer PCV13 one year later 1
• Administer a second dose of PPSV23 five years after the first PPSV23 dose 1

Additional Indications

• CKD patients with nephrotic syndrome, diabetes, or receiving immunosuppression should receive pneumococcal vaccination regardless of eGFR 1
• Revaccination is recommended within 5 years for all CKD patients who have received pneumococcal vaccination 1

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Recombinant Zoster Vaccine (Shingrix)

All dialysis-dependent patients aged ≥50 years should receive 2 doses of recombinant zoster vaccine (RZV/Shingrix) 2-6 months apart, as this is preferred over the live zoster vaccine which is contraindicated. 1

Key Points

• RZV (Shingrix) is the preferred vaccine over live zoster vaccine (ZVL/Zostavax) 1
• Recommended for immunocompetent adults ≥50 years, including dialysis patients 1
• Two-dose series: administer second dose 2-6 months after the first 1

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Tetanus-Diphtheria-Pertussis (Tdap)

CKD and dialysis patients should follow standard adult Tdap recommendations, though response rates may be lower than in the general population. 1

Evidence on Response

• Five years after Td booster in hemodialysis patients: 71% had protective tetanus antibodies, but only 32% had protective diphtheria antibodies 1
• Fewer than 50% of CKD patients have baseline protective tetanus titers 1
• Follow standard adult recommendations despite lower efficacy 1

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Hepatitis A Vaccination

Hepatitis A vaccination is recommended for CKD patients with chronic liver disease (including hepatitis B or C) or those who are candidates for renal transplantation. 1

Specific Indications

• Patients with chronic liver disease including chronic hepatitis B or hepatitis C 1
• Illicit drug users 1
• Men who have sex with men 1
• Candidates for renal transplantation 1

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COVID-19 Vaccination

While not explicitly detailed in the provided guidelines (which predate widespread COVID-19 vaccination), current practice follows similar principles: CKD and dialysis patients should receive COVID-19 vaccination per current CDC/ACIP recommendations, with consideration for additional doses given their immunocompromised status.

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General Principles for Vaccination in CKD

Timing Considerations

Vaccinate as early as possible in CKD progression—patients are more likely to respond before dialysis initiation. 1, 2

• Higher eGFR correlates with better vaccine response 4
• Pre-dialysis vaccination (eGFR >15 mL/min/1.73 m²) yields seroprotection rates of 63-100% vs. 50-89.3% in dialysis patients 5

Live Vaccines

Live vaccines are generally contraindicated in dialysis patients and should be avoided. 1

• Specific contraindications: live attenuated influenza vaccine, live zoster vaccine (Zostavax) 1
• CKD and hemodialysis alone do not cause sufficient immunosuppression to contraindicate live vaccines unless patients are on immunosuppressive therapy 6

Monitoring Strategy

Post-vaccination serological testing is essential for hepatitis B but not routinely performed for other vaccines in CKD patients. 1, 2