What is the recommended pneumococcal vaccination schedule for adults with chronic kidney disease (including dialysis and transplant candidates), specifying timing of 13‑valent pneumococcal conjugate vaccine (PCV13) and 23‑valent pneumococcal polysaccharide vaccine (PPSV23) for ages 19‑64 and ≥65 and for those with prior PPSV23?

Pneumococcal Vaccination Schedule for Adults with Chronic Kidney Disease

Adults with CKD (including dialysis and transplant candidates) should receive pneumococcal vaccination as early in their disease course as possible, with a single dose of PCV20 as the preferred option for vaccine-naïve patients, or PCV15 followed by PPSV23 at a shortened 8-week interval for immunocompromised patients. 1

Ages 19–64 Years with CKD (Dialysis or Transplant Candidates)

Vaccine-Naïve or Unknown History

CKD qualifies as an immunocompromising condition, placing these patients in the high-risk category requiring aggressive vaccination schedules. 1

• Option A (Preferred): Administer a single dose of PCV20, which completes the pneumococcal series. 1
• Option B: Administer PCV15 followed by PPSV23 ≥8 weeks later (the shortened interval applies because CKD with dialysis or transplant candidacy is immunocompromising). 2, 1
• Re-evaluate vaccination status when the patient reaches age 65. 1

Prior PPSV23 Only

• Administer PCV20 or PCV15 ≥1 year after the last PPSV23 dose. 2, 1
• If PCV15 is given, no additional PPSV23 is needed. 2

Prior PCV13 Only

• Option A: Administer PPSV23 ≥8 weeks after PCV13 (shortened interval for immunocompromised patients). 1, 3
• A second PPSV23 dose is recommended 5 years after the first PPSV23 for immunocompromised patients whose first dose was before age 65. 2, 1
• Option B: Administer PCV20 ≥1 year after PCV13, which completes the series and eliminates the need for PPSV23. 1

Prior PCV13 + PPSV23

• Immunocompromised patients (including CKD with dialysis or transplant candidacy) may receive PCV20 ≥5 years after the last pneumococcal dose. 1
• Otherwise, no further vaccines are recommended until age 65. 1

Ages ≥65 Years with CKD

Vaccine-Naïve or Unknown History

• Preferred: Administer a single dose of PCV20, which completes the pneumococcal series for life. 2, 1
• Alternative: Administer PCV15 followed by PPSV23 ≥1 year later (standard interval for adults ≥65, even with CKD). 2, 1
• After completing the series at age ≥65, no additional pneumococcal vaccines are required. 2, 1

Prior PPSV23 Only

• Administer PCV20 ≥1 year after the last PPSV23 dose; this completes the series. 2, 1
• Alternative: Administer PCV15 ≥1 year after PPSV23; no further PPSV23 needed. 2, 1

Prior PCV13 Only

• Administer PCV20 ≥1 year after the PCV13 dose; series is complete. 2, 1
• Alternative: Administer PPSV23 ≥1 year after PCV13. 1

Prior PCV13 + PPSV23 (Both Received at ≥65)

• No additional pneumococcal vaccines are routinely recommended. 2, 1
• For immunocompromised patients, shared decision-making may allow PCV20 ≥5 years after the last pneumococcal dose. 2, 1

Critical Timing Intervals for CKD Patients

Scenario	Minimum Interval	Rationale
PCV → PPSV23 (CKD with dialysis/transplant candidacy)	≥8 weeks	Immunocompromising condition requires shorter interval [2,1,3]
PCV → PPSV23 (CKD without dialysis, age ≥65)	≥1 year	Standard interval for immunocompetent adults ≥65 [1]
PPSV23 → PCV (any CKD patient)	≥1 year	Universal interval regardless of immune status [2,1]
PCV13 → PCV20 (any CKD patient)	≥1 year	Standard interval for conjugate vaccine transition [1]
Two PPSV23 doses (first dose <65)	≥5 years	Applies to immunocompromised CKD patients [2,1]

Special Considerations for Transplant Candidates

Vaccination should be completed as early as possible in the CKD disease course, ideally before transplantation, because immune responses are superior in pre-transplant patients compared to post-transplant recipients. 3, 4

• Sequential vaccination with PCV13 followed by PPSV23 achieves higher antibody levels in kidney transplant recipients compared to PCV13 alone. 4
• The strongest serotype-specific responses occur against serotypes 9N and 14 after sequential vaccination. 4
• No patients in transplant vaccination studies developed pneumococcal pneumonia or vaccination-related allograft rejection during 12-month follow-up. 4

Common Pitfalls and Caveats

• Never co-administer PCV and PPSV23 on the same day—this reduces immune response and wastes vaccine. 2, 1
• The 8-week shortened interval between PCV and PPSV23 applies ONLY to immunocompromised patients (including CKD with dialysis or transplant candidacy); all others require ≥1 year. 2, 1, 3
• After a PPSV23 dose given at age ≥65, no further PPSV23 doses are indicated, even in immunocompromised patients. 2, 1
• Once PCV20 is administered, the pneumococcal series is complete; additional PPSV23 is not recommended. 2, 1
• Maximum lifetime PPSV23 doses: 2–3 for immunocompromised adults (including CKD with dialysis or transplant candidacy). 2, 1
• Use verbal vaccination history when records are unavailable; do not delay vaccination waiting for documentation. 2
• Vaccinate as early in the CKD disease course as possible—immune responses decline with worsening renal function and are poorest in dialysis patients. 3

Evidence Quality and Rationale

The 2023 ACIP guidelines 5, 1 represent the highest-quality evidence, with formal GRADE methodology and Evidence to Recommendation framework. These guidelines explicitly classify chronic renal failure as an immunocompromising condition requiring the shortened 8-week interval between PCV and PPSV23. 2, 1 Although clinical outcome data demonstrating reduced morbidity and mortality from pneumococcal vaccination in CKD are limited 3, epidemiological data show correlation between vaccination status and decreased total mortality in dialysis patients. 3 The 10-fold increased risk of pneumococcal disease in dialysis patients compared to the general population 3 justifies aggressive vaccination despite imperfect evidence of clinical efficacy.