For an adult with chronic kidney disease (including dialysis or transplant candidates), what is the recommended schedule for PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) vaccinations in the 19‑64 age group and in adults ≥65 years?

Pneumococcal Vaccination for Adults with Chronic Kidney Disease

Direct Answer

For adults with chronic kidney disease (CKD), including dialysis or transplant candidates, administer PCV20 as a single dose—this is now the preferred approach that completes the pneumococcal vaccination series regardless of age (19-64 or ≥65 years). 1, 2, 3

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Vaccination Schedule by Age and Prior Vaccination Status

Adults 19-64 Years with CKD (Never Vaccinated)

• Administer one dose of PCV20 alone 1, 2, 3
• This completes the pneumococcal vaccination series with no additional doses needed 1, 3
• Alternative (if PCV20 unavailable): PCV15 followed by PPSV23 at ≥8 weeks (not ≥1 year, because CKD is an immunocompromising condition) 1, 2

Adults ≥65 Years with CKD (Never Vaccinated)

• Administer one dose of PCV20 alone 1, 2, 3
• This is the preferred single-dose option that provides comprehensive serotype coverage 1, 3
• Alternative: PCV15 followed by PPSV23 at ≥1 year later 1, 2

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If Previously Vaccinated: What to Do Next

Previously Received PPSV23 Only

• Administer PCV20 at least 1 year after the last PPSV23 dose 1, 3
• This applies to both age groups (19-64 and ≥65 years) 1, 3
• After PCV20, the series is complete—no additional pneumococcal vaccines needed 1, 3

Previously Received PCV13 Only

• Administer PCV20 at least 1 year after the PCV13 dose 1, 3
• For immunocompromised CKD patients, the interval remains ≥1 year (not shortened to 8 weeks) 1, 3
• After PCV20, the series is complete 1, 3

Previously Received Both PCV13 and PPSV23

• If PPSV23 was given before age 65: Administer PCV20 at least 5 years after the last pneumococcal vaccine dose 1, 3
• If PPSV23 was given at age ≥65: PCV20 may be considered through shared clinical decision-making, but only if ≥5 years have passed since the last dose 1, 3
• This is optional, not routinely recommended 1

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Critical Timing Rules for CKD Patients

Why CKD Patients Get Shorter Intervals

• CKD (including dialysis and transplant candidates) is classified as an immunocompromising condition 1, 2
• When using the PCV15 + PPSV23 series, the interval between vaccines is ≥8 weeks (not ≥1 year) 1, 2
• This shorter interval reflects the greater urgency for protection in patients at higher risk for invasive pneumococcal disease 1

Minimum Intervals Summary

• PCV20 after PPSV23: ≥1 year 1, 3
• PCV20 after PCV13: ≥1 year 1, 3
• PCV15 followed by PPSV23 (in CKD patients): ≥8 weeks 1, 2
• PCV20 after both PCV13 + PPSV23: ≥5 years 1, 3

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Special Considerations for Transplant Candidates

Pre-Transplant Vaccination

• Complete pneumococcal vaccination at least 2 weeks before transplant surgery or initiation of immunosuppressive therapy 1
• Use PCV20 as a single dose for simplicity and comprehensive coverage 1, 3

Post-Transplant Vaccination

• For kidney transplant recipients who were not vaccinated pre-transplant, sequential vaccination with PCV13 followed by PPSV23 has been shown to produce significant antibody responses 4
• However, current guidelines now favor PCV20 alone, which provides broader serotype coverage and eliminates the need for sequential dosing 1, 3, 5

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Why PCV20 is Preferred Over the Old PCV13 + PPSV23 Approach

Advantages of PCV20

• Broader serotype coverage: PCV20 covers 20 serotypes vs. 13 in PCV13 1, 3
• Single-dose simplicity: Eliminates the need for patients to return for a second dose 1, 3
• Superior immunologic response: Conjugate vaccines induce T-cell dependent responses and immunologic memory, unlike PPSV23 3, 6
• No hyporesponsiveness: Initial vaccination with PPSV23 results in lower responses to subsequent PPSV23, whereas PCV13 priming leads to robust recall responses 6

Evolution of Guidelines

• Before 2019: All adults ≥65 years received both PCV13 and PPSV23 1
• 2019: Routine PCV13 was no longer recommended for all adults ≥65 years 1
• 2024: PCV20 (and PCV21) became the preferred options, replacing the PCV13 + PPSV23 sequence 1, 5

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Common Pitfalls to Avoid

Do NOT:

• Coadminister PCV and PPSV23 on the same day—this reduces immune response and wastes the vaccine 1
• Give multiple PPSV23 boosters beyond what is recommended—there is insufficient evidence for safety with three or more doses 1
• Wait for complete medical records—use verbal history and proceed with vaccination if indicated 1
• Add PPSV23 after PCV20—once PCV20 is given, the series is complete 1, 3

Critical Timing Errors:

• Do not give PCV20 less than 1 year after prior PCV13 or PPSV23—the minimum 1-year interval must be observed for optimal response 1, 3
• Do not give PCV20 less than 5 years after both PCV13 + PPSV23—this violates ACIP recommendations 1, 3

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Maximum Lifetime PPSV23 Doses

• Immunocompetent adults: Maximum 1-2 doses total 1
• Immunocompromised adults (including CKD): Maximum 2-3 doses total 1
• No additional PPSV23 doses after the dose given at age ≥65 years 1

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When to Reassess at Age 65

• If the patient received PCV20 before age 65: No additional pneumococcal vaccines are typically needed at age 65 1, 3
• If the patient received only PPSV23 before age 65: Administer PCV20 at age ≥65 if at least 1 year has passed since the last PPSV23 dose 1, 3
• If the patient received PPSV23 before age 65 and is now ≥65: A second dose of PPSV23 is recommended if at least 5 years have passed since the first dose (but only if PCV20 is not being used) 1

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Bottom Line Algorithm for CKD Patients

1. Check vaccination history 1
2. If never vaccinated: Give PCV20 now (completes series) 1, 3
3. If PPSV23 only: Give PCV20 if ≥1 year since last PPSV23 (completes series) 1, 3
4. If PCV13 only: Give PCV20 if ≥1 year since PCV13 (completes series) 1, 3
5. If both PCV13 + PPSV23: Give PCV20 if ≥5 years since last dose (optional, shared decision-making) 1, 3
6. Document completion of series—no further pneumococcal vaccines needed 1, 3