What is the recommended vaccination schedule for adults with chronic kidney disease, including those on dialysis or being evaluated for kidney transplantation?

Vaccination in Chronic Kidney Disease

All adults with CKD should receive annual influenza vaccination, pneumococcal vaccination (especially with eGFR <30 mL/min/1.73 m²), and hepatitis B vaccination with high-dose regimens for those at high risk of progression, with mandatory post-vaccination antibody testing for hepatitis B to confirm adequate protection. 1

Core Vaccination Recommendations by Disease Stage

All CKD Patients (Any Stage)

• Annual influenza vaccination is mandatory for all adults with CKD using inactivated or recombinant formulations; live attenuated influenza vaccine is absolutely contraindicated. 1
• Vaccinate as early as possible in the CKD course, ideally before dialysis initiation, as patients achieve significantly higher seroprotection rates with preserved kidney function. 2
• Standard age-appropriate dosing is sufficient for influenza vaccine—no special high-dose formulation is required for CKD patients. 2

Advanced CKD (eGFR <30 mL/min/1.73 m² or GFR Categories G4-G5)

Pneumococcal Vaccination

• All patients with eGFR <30 mL/min/1.73 m² must receive both PCV13 and PPSV23 in a sequential schedule. 1
• If PCV13 is given first, administer PPSV23 at least 8 weeks later. 1, 2
• If PPSV23 is given first, administer PCV13 one year later. 1, 2
• Revaccinate with PPSV23 every 5 years after the initial PPSV23 dose. 1
• High-risk patients (nephrotic syndrome, diabetes, immunosuppression) require pneumococcal vaccination regardless of eGFR level. 1

Hepatitis B Vaccination

• All adults at high risk of CKD progression with eGFR <30 mL/min/1.73 m² must be immunized against hepatitis B with response confirmed by serological testing. 1
• Use high-dose regimens: Recombivax HB 40 µg at months 0,1, and 6 OR Engerix-B 40 µg at months 0,1,2, and 6. 1, 2, 3
• Mandatory post-vaccination testing: Check anti-HBs titers 1-2 months after completing the series; adequate response is defined as ≥10 mIU/mL. 1, 2, 3
• If the initial series fails (anti-HBs <10 mIU/mL), administer a complete second high-dose series; no additional doses beyond the second series have demonstrated benefit. 1, 2

Dialysis-Dependent Patients

Hepatitis B (Critical Priority)

• Dialysis patients require the highest dose regimen: Recombivax HB 40 µg at 0,1, and 6 months OR Engerix-B 40 µg at 0,1,2, and 6 months. 1, 2, 3
• Annual anti-HBs monitoring is mandatory for all dialysis patients; administer a booster dose if titer falls below 10 mIU/mL. 2, 3
• Seroconversion rates are only 50-67% in dialysis patients compared to >95% in healthy adults, making post-vaccination testing absolutely essential. 3

Pneumococcal Vaccination

• Dialysis patients should receive both PCV13 and PPSV23 using the same sequential schedule as advanced CKD patients. 1, 2
• Administer a second dose of PPSV23 five years after the first PPSV23 dose. 1, 2

Herpes Zoster

• Dialysis-dependent patients ≥50 years should receive recombinant zoster vaccine (RZV, Shingrix) in a two-dose series given 2-6 months apart. 1, 2
• RZV is the preferred vaccine; live zoster vaccine (Zostavax) is absolutely contraindicated. 1, 2

Pre-Dialysis CKD Patients

• For hepatitis B vaccination in pre-dialysis adults with eGFR <30 mL/min/1.73 m², use standard adult doses: Recombivax HB 10 µg or Engerix-B 20 µg at months 0,1, and 6. 2, 3
• Vaccinating at pre-dialysis stages (eGFR >15 mL/min/1.73 m²) yields higher short-term seroprotection (63-100%) than in dialysis patients (50-89.3%). 4

Live Vaccine Contraindications

• Live vaccines are absolutely contraindicated in dialysis patients and those on significant immunosuppression. 1, 2
• This includes live attenuated influenza vaccine (LAIV) and live zoster vaccine (ZVL). 1, 2
• Consideration of any live vaccine must include assessment of the patient's immune status and should follow official governmental recommendations. 1

Pediatric CKD Patients

• Pediatric immunization schedules should follow official international and regional recommendations for children with CKD. 1
• For hepatitis B in pediatric CKD patients (<20 years), use Recombivax HB 5 µg or Engerix-B 10 µg at months 0,1, and 6. 2, 3

Common Pitfalls to Avoid

• Do not use standard adult hepatitis B doses (20 µg) in dialysis patients—this results in inadequate immune response; always use 40 µg doses. 3
• Do not skip post-vaccination antibody testing for hepatitis B—failing to check titers may leave patients unprotected despite completing the series. 2, 3
• Do not delay pneumococcal vaccination—infection risk is highest within the first six months after CKD diagnosis, particularly when serum albumin is low. 5
• Do not forget annual anti-HBs monitoring in dialysis patients—antibody levels decline rapidly in this population, requiring regular surveillance and booster doses. 2, 3
• Emphasize vaccination to primary care providers, as they typically administer routine immunizations and facilitate tracking and revaccination. 1

Additional Considerations

• Healthcare workers in dialysis units must be vaccinated annually against influenza to protect vulnerable patients. 1
• For transplant candidates, prioritize hepatitis B vaccination in those most likely to require future dialysis or renal transplantation based on fiscal responsibility and risk-benefit analysis. 1
• CKD patients are at increased risk of acute kidney injury (AKI), and vaccination strategies should be coordinated with overall AKI prevention efforts. 1