Pediatric Nephrology

, Volume 31, Issue 9, pp 1437–1448 | Cite as

Vaccinations in children on immunosuppressive medications for renal disease

  • Sushmita Banerjee
  • Pathum Vindana Dissanayake
  • Asiri Samantha Abeyagunawardena
Educational Review

Abstract

Renal diseases are often treated with immunosuppressive medications, placing patients at risk of infections, some of which are vaccine-preventable. However, in such patients vaccinations may be delayed or disregarded due to complications of the underlying disease process and challenges in its management. The decision to administer vaccines to immunosuppressed children is a risk–benefit balance as such children may have a qualitatively diminished immunological response or develop diseases caused by the vaccine pathogen. Vaccination may cause a flare-up of disease activity or provocation of graft rejection in renal transplant recipients. Moreover, it cannot be assumed that a given antibody level provides the same protection in immunosupressed children as in healthy ones. We have evaluated the safety and efficacy of licensed vaccines in children on immunosuppressive therapy and in renal transplant recipients. The limited evidence available suggests that vaccines are most effective if given early, ideally before the requirement for immunosuppressive therapy, which may require administration of accelerated vaccine courses. Once treatment with immunosuppressive drugs is started, inactivated vaccines are usually considered to be safe when the disease is quiescent, but supplemental doses may be required. In the majority of cases, live vaccines are to be avoided. All vaccines are generally contraindicated within 3–6 months of a renal transplant.

Keywords

Vaccination Immunosuppresed children Infections Renal disease Renal transplantation 

References

  1. 1.
    Esposito S, Mastrolia MV, Prada E, Pietrasanta C, Principi N (2014) Vaccine administration in children with chronic kidney disease. Vaccine 32:6601–6606CrossRefPubMedGoogle Scholar
  2. 2.
    Laube GF, Berger C, Goetschel P, Leumann E, Neuhaus TJ (2002) Immunization in children with chronic renal failure. Pediatr Nephrol 17:638–642CrossRefPubMedGoogle Scholar
  3. 3.
    Neu AM, Lederman HM, Warady BA, Fivush BA (1996) Hemophilus influenzae type b immunization in infants on peritoneal dialysis. Pediatric Peritoneal Dialysis Study Consortium. Pediatr Nephrol 10:84–85CrossRefPubMedGoogle Scholar
  4. 4.
    Neu AM, Warady BA, Furth SL, Lederman HM, Fivush BA (1997) Antibody levels to diphtheria, tetanus, and rubella in infants vaccinated while on PD: a Study of the Pediatric Peritoneal Dialysis Study Consortium. Adv Perit Dial 13:297–299PubMedGoogle Scholar
  5. 5.
    Modarresi M, Gheissari A, Sattari (2013) Protective status of end-stage renal disease children against tetanus and diphtheria vaccination. Int J Prev Med 4:420–424PubMedPubMedCentralGoogle Scholar
  6. 6.
    Prelog M, Pohl M, Ermisch B, Fuchshuber A, Huzly D, Jungraithmayr T, Forster J, Zimmerhackl LB (2007) Demand for evaluation of vaccination antibody titers in children considered for renal transplantation. Pediatr Transplant 11:73–76CrossRefPubMedGoogle Scholar
  7. 7.
    Genc G, Ozkaya O, Aygun C, Yakupoglu YK, Nalcacioglu H (2012) Vaccination status of children considered for renal transplants: missed opportunities for vaccine preventable diseases. Exp Clin Transplant 10:314–318CrossRefPubMedGoogle Scholar
  8. 8.
    Neu AM (2012) Immunizations in children with chronic kidney disease. Pediatr Nephrol 27:1257–1263CrossRefPubMedGoogle Scholar
  9. 9.
    U.S. Centers for Disease Control and Prevention (CDC) (2012) Recommendations of the advisory committee on immunization practices. Guidelines for vaccinating kidney dialysis patients and patients with chronic kidney disease. Available at: http://www.cdc.gov/vaccines/pubs/downloads/dialysis-guide-2012.pdf
  10. 10.
    U.S. Centers for Disease Control and Prevention (2010) Global routine vaccination coverage. Morb Mortal Wkly 59:1367–1371Google Scholar
  11. 11.
    World Health Organization (WHO) (2015) Recommendations for routine immunization. Available at: http://www.who.int/immunization/policy/immunization_tables/en
  12. 12.
    American Academy of Pediatrics (2015) Recommended immunization schedule for persons aged 0 through 18 years. Available at: http://www2.aap.org/immunization/izschedule.html
  13. 13.
    National Health Service UK (2014) Vaccination schedule. Available at: http://www.nhs.uk/conditions/vaccinations/pages/vaccination-schedule-age-checklist.aspx
  14. 14.
    Indian Academy of Pediatrics (2014) Immunization timetable. Available at: http://www.iapindia.org/page.php?id=129
  15. 15.
    Siegrist CA (2008) Vaccine immunology. In: Plotkin SA, Orenstein WA, Offit PA (eds) Vaccines, 5th edn. Available at: http://www.who.int/immunization/documents/Elsevier_Vaccine_immunology.pdf
  16. 16.
    Clem AS (2011) Fundamentals of vaccine immunology. J Glob Infect Dis 3:73–78CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Wei CC, Yu IW, Lin HW, Tsai AC (2012) Occurrence of infection among children with nephrotic syndrome during hospitalizations. Nephrology 17:681–688CrossRefPubMedGoogle Scholar
  18. 18.
    Chatham WW, Kimberly RP (2001) Treatment of lupus with corticosteroids. Lupus 10:140–147CrossRefPubMedGoogle Scholar
  19. 19.
    Rhen T, Cidlowski JA (2005) Anti-inflammatory action of glucocorticoids—new mechanisms for old drugs. N Engl J Med 353:1711–1723CrossRefPubMedGoogle Scholar
  20. 20.
    Pereira Wde F, Brito-Melo GE, Guimarães FT, Carvalho TG, Mateo EC, Simões e Silva AC (2014) The role of the immune system in idiopathic nephrotic syndrome: a review of clinical and experimental studies. Inflamm Res 63:1–12CrossRefPubMedGoogle Scholar
  21. 21.
    Han JW, Lee KY, Hwang JY, Koh DK, Lee JS (2010) Antibody status in children with steroid-sensitive nephrotic syndrome. Yonsei Med J 51:239–243CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Mantan M, Pandharikar N, Yadav S, Chakravarti A, Sethi GR (2013) Seroprotection for hepatitis B in children with nephrotic syndrome. Pediatr Nephrol 28:2125–2130CrossRefPubMedGoogle Scholar
  23. 23.
    Yildiz N, Sever L, Kasapçopur Ö, Çullu F, Arısoy N, Çalışkan S (2013) Hepatitis B virus vaccination in children with steroid sensitive nephrotic syndrome: immunogenicity and safety? Vaccine 31:3309–3312CrossRefPubMedGoogle Scholar
  24. 24.
    La Manna A, Polito C, Foglia AC, Di Toro A, Cafaro MR, Del Gado R (1992) Reduced response to hepatitis B virus vaccination in boys with steroid-sensitive nephrotic syndrome. Pediatr Nephrol 6:251–253CrossRefPubMedGoogle Scholar
  25. 25.
    Gorensek MJ, Lebel MH, Nelson JD (1988) Peritonitis in children with nephrotic syndrome. Pediatrics 81:849–856PubMedGoogle Scholar
  26. 26.
    Wilkes JC, Nelson JD, Worthen HG, Morris M, Hogg RJ (1982) Response to pneumococcal vaccination in children with nephrotic syndrome. Am J Kidney Dis 2:43–46CrossRefPubMedGoogle Scholar
  27. 27.
    Güven AG, Akman S, Bahat E, Senyurt M, Yüzbey S, Uguz A, Yegin O (2004) Rapid decline of anti-pneumococcal antibody levels in nephrotic children. Pediatr Nephrol 19:61–65CrossRefPubMedGoogle Scholar
  28. 28.
    Spika JS, Halsey NA, Le CT, Fish AJ, Lum GM, Lauer BA, Schiffman G, Giebink GS (1986) Decline of vaccine-induced anti pneumococcal antibody in children with nephrotic syndrome. Am J Kidney Dis 7:466–470CrossRefPubMedGoogle Scholar
  29. 29.
    Tejani A, Fikrig S, Schiffman G, Gurumurthy K (1984) Persistence of protective pneumococcal antibody following vaccination in patients with the nephrotic syndrome. Am J Nephrol 4:32–37CrossRefPubMedGoogle Scholar
  30. 30.
    Aoun B, Wannous H, Azéma C, Ulinski T (2010) Polysaccharide pneumococcal vaccination of nephrotic children at disease onset-long-term data. Pediatr Nephrol 25:1773–1774CrossRefPubMedGoogle Scholar
  31. 31.
    Ulinski T, Leroy S, Dubrel M, Danon S, Bensman A (2008) High serological response to pneumococcal vaccine in nephrotic children at disease onset on high-dose prednisone. Pediatr Nephrol 23:1107–1113CrossRefPubMedGoogle Scholar
  32. 32.
    Liakou CD, Askiti V, Mitsioni A, Stefanidis CJ, Theodoridou MC, Spoulou VI (2011) Safety, immunogenicity and kinetics of immune response to 7-valent pneumococcal conjugate vaccine in children with idiopathic nephrotic syndrome. Vaccine 29:6834–6837CrossRefPubMedGoogle Scholar
  33. 33.
    Liakou CD, Askiti V, Mitsioni A, Stefanidis CJ, Theodoridou MC, Spoulou VI (2014) Safety and immunogenicity of booster immunization with 7-valent pneumococcal conjugate vaccine in children with idiopathic nephrotic syndrome. Vaccine 32:1394–1397CrossRefPubMedGoogle Scholar
  34. 34.
    Poyrazoğlu HM, Düşünsel R, Gündüz Z, Patiroğlu T, Köklü S (2004) Antibody response to influenza A vaccination in children with nephrotic syndrome. Pediatr Nephrol 19:57–60CrossRefPubMedGoogle Scholar
  35. 35.
    Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, Bousvaros A, DhanireddyS SL, Keyserling H, Kang I (2014) Infectious Diseases Society of America. IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 58:309–318CrossRefPubMedGoogle Scholar
  36. 36.
    Furth SL, Arbus GS, Hogg R, Tarver J, Chan C, Fivush BA, Southwest Pediatric Nephrology Study Group (2003) Varicella vaccination in children with nephrotic syndrome: a report of the Southwest Pediatric Nephrology Study Group. J Pediatr 142:145–148CrossRefPubMedGoogle Scholar
  37. 37.
    Alpay H, Yildiz N, Onar A, Temizer H, Ozçay S (2002) Varicella vaccination in children with steroid-sensitive nephrotic syndrome. Pediatr Nephrol 17:181–183CrossRefPubMedGoogle Scholar
  38. 38.
    Fernandes P, Jorge S, Lopes JA (2010) Relapse of nephrotic syndrome following the use of 2009 pandemic influenza A (H1N1) vaccine. Am J Kidney Dis 56:185–186CrossRefPubMedGoogle Scholar
  39. 39.
    Ahuja AS, Wright M (1989) MMR and the nephrotic syndrome. BMJ 299:796CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Lyn CY, Hsu HC (1986) Histopathological and immunological studies in spontaneous remission of nephrotic syndrome after intercurrent nephrotic syndrome. Nephron 42:110–115CrossRefGoogle Scholar
  41. 41.
    Abeyagunawardena AS, Goldblatt D, Andrews N, Trompeter RS (2003) Risk of relapse after meningococcal C conjugate vaccine in nephrotic syndrome. Lancet 362:449–450CrossRefPubMedGoogle Scholar
  42. 42.
    Taylor B, Andrews N, Stowe J, Hamidi-Manesh L, Miller E (2007) No increased risk of relapse after meningococcal C conjugate vaccine in nephrotic syndrome. Arch Dis Child 92:887–889CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Kuruma KA, Borba EF, Lopes MH, de Carvalho JF, Bonfá E (2007) Safety and efficacy of hepatitis B vaccine in systemic lupus erythematosus. Lupus 16:350–354CrossRefPubMedGoogle Scholar
  44. 44.
    Kapturczak MH, Meier-Kriesche HU, Kaplan B (2004) Pharmacology of calcineurin antagonists. Transplant Proc 36:25–32CrossRefGoogle Scholar
  45. 45.
    Abulayha A, Bredan A, El Enshasy H, Daniels I (2014) Rituximab: modes of action, remaining dispute and future perspective. Future Oncol 10:2481–2492CrossRefPubMedGoogle Scholar
  46. 46.
    Spika JS, Halsey NA, Fish AJ, Lum GM, Lauer BA, Schiffman G, Giebink GS (1982) Serum antibody response to pneumococcal vaccine in children with nephrotic syndrome. Pediatrics 69:219–223PubMedGoogle Scholar
  47. 47.
    Kashef S, Ghazizadeh F, Derakhshan A, Farjadian S, Alyasin S (2008) Antigen-specific antibody response in juvenile-onset SLE patients following routine immunization with tetanus toxoid. Iran J Immunol 5:181–184PubMedGoogle Scholar
  48. 48.
    Battafarano DF, Battafarano NJ, Larsen L, Dyer PD, Older SA, Muehlbauer S, Hoyt A, Lima J, Goodman D, Lieberman M, Enzenauer RJ (1998) Antigen-specific antibody responses in lupus patients following immunization. Arthritis Rheum 41:1828–1834CrossRefPubMedGoogle Scholar
  49. 49.
    Aikawa NE, Trudes G, Campos LM, Pereira RM, Moraes JC, Ribeiro AC, Miraglia J, TimenetskyMdo C, Bonfa E, Silva C (2013) Immunogenicity and safety of two doses of a non-adjuvanted influenza A H1N1/2009 vaccine in young autoimmune rheumatic diseases patients. Lupus 22:1394–1398CrossRefPubMedGoogle Scholar
  50. 50.
    Eisenberg RA, Jawad AF, Boyer J, Maurer K, McDonald K, Prak ET, Sullivan KE (2013) Rituximab-treated patients have a poor response to influenza vaccination. J Clin Immunol 33:388–396CrossRefPubMedGoogle Scholar
  51. 51.
    Kapetanovic MC, Kristensen LE, Saxne T, Aktas T, Mörner A, Geborek P (2014) Impact of anti-rheumatic treatment on immunogenicity of pandemic H1N1 influenza vaccine in patients with arthritis. Arthritis Res Ther 16:R2. doi:10.1186/ar4427 CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Kersun LS, Reilly AF, Coffin SE, Sullivan KE (2013) Protecting pediatric oncology patients from influenza. Oncologist 18:204–211CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Leahy TR, Smith OP, Bacon CL, Storey L, Lynam P, Gavin PJ, Butler KM, O'Marcaigh A (2013) Does vaccine dose predict response to the monovalent pandemic H1N1 influenza a vaccine in children with acute lymphoblastic leukemia? A single-centre study. Pediatr Blood Cancer 60:1656–1661CrossRefPubMedGoogle Scholar
  54. 54.
    Verma A, Wade JJ (2006) Immunization issues before and after solid organ transplantation in children. Pediatr Transplant 10:536–548CrossRefPubMedGoogle Scholar
  55. 55.
    Danziger-Isakov L, Kumar D, and the AST Infectious Disease Community of Practice (2013) Vaccination in solid organ transplantation. Am J Transplant 13:311–317CrossRefPubMedGoogle Scholar
  56. 56.
    Ghio L, Pedrazzi C, Assael BM, Panuccio A, Foti M, Edefonti A (1997) Immunity to diphtheria and tetanus in a young population on a dialysis regimen or with a renal transplant. J Pediatr 130:987–989CrossRefPubMedGoogle Scholar
  57. 57.
    Hibberd PL, Rubin RH (1990) Approach to immunization in the immunosuppressed host. Infect Dis Clin North Am 4:123–142PubMedGoogle Scholar
  58. 58.
    Duca P, Del Pont JM, D'Agostino D (2001) Successful immune response to a recombinant hepatitis B vaccine in children after liver transplantation. J Pediatr Gastroenterol Nutr 32:168–170CrossRefPubMedGoogle Scholar
  59. 59.
    Eckerle I, Rosenberger KD, Zwahlen M, Junghanss T (2013) Serologic vaccination response after solid organ transplantation: a systematic review. PLoS One 8:e56974CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Lin PL, Michaels MG, Green M, Mazariegos GV, Webber SA, Lawrence KS, Iurlano K, Greenberg DP (2005) Safety and immunogenicity of the American Academy of Pediatrics—recommended sequential pneumococccal conjugate and polysaccharide vaccine schedule in pediatric solid organ transplant recipients. Pediatrics 116:160–167CrossRefPubMedGoogle Scholar
  61. 61.
    Scharpe J, Evenepoel P, Maes B, Bammens B, Claes K, Osterhaus AD, Vanrenterghem Y, Peetermans WE (2008) Influenza vaccination is efficacious and safe in renal transplant recipients. Am J Transplant 8:332–337CrossRefPubMedGoogle Scholar
  62. 62.
    Kumar D, Blumberg EA, Danziger-Isakov L, Kotton CN, Halasa NB, Ison MG, Avery RK, Green M, Allen UD, Edwards KM, Miller G, Michaels MG, AST Infectious Diseases Community of Practice (2011) Influenza vaccination in the organ transplant recipient : review and summary recommendations. Am J Transplant 11:2020–2030CrossRefPubMedGoogle Scholar
  63. 63.
    Furth SL, Hogg RJ, Tarver J, Moulton LH, Chan C, Fivush BA (2013) Varicella Vaccination in children with chronic renal failure. A report of the Southwest Pediatric Nephrology Study Group. Pediatr Nephrol 18:33–38CrossRefGoogle Scholar
  64. 64.
    Broyer M, Tete MJ, Guest G, Gagnadoux MF, Rouzioux C (1997) Varicella and zoster after kidney transplantation: long term results after vaccination. Pediatrics 99:35–39CrossRefPubMedGoogle Scholar
  65. 65.
    Warmington L, Lee BE, Robinson JL (2005) Loss of antibodies to measles and varicella following solid organ transplantation in children. Pediatr Transplant 9:311–314CrossRefPubMedGoogle Scholar
  66. 66.
    Zamora I, Simon JM, Da Silva ME, Piqueras AI (1994) Attenuated varicella vaccine in children with renal transplants. Pediatr Nephrol 8:190–192CrossRefPubMedGoogle Scholar
  67. 67.
    Rand EB, Mccarthy CA, Whittington PF (1993) Measles vaccination after orthoptic liver transplantation. J Pediatr 1123:87–89CrossRefGoogle Scholar
  68. 68.
    Lu Y, Bousvaros A (2010) Varicella vaccination in children with inflammatory bowel disease receiving immunosuppressive therapy. J Pediatr Gastroenterol Nutr 50:562–565PubMedPubMedCentralGoogle Scholar
  69. 69.
    Emir S, Büyükpamukçu M, Köseoğlu V, Hasçelik G, Akyüz C, Kutluk T, Varan A (2006) Varicella vaccination in children with lymphoma and solid tumours. Postgrad Med J 82:760–762CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Mirsaeidi M, Schraufnagel DE (2014) Pneumococcal vaccines: understanding centers for disease control and prevention recommendations. Ann Am Thorac Soc 11:980–985CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Campbell AL, Herold BC (2005) Immunization of pediatric solid organ transplantation candidates: Immunization in transplant candidates. Pediatr Transplant 9:625–661CrossRefGoogle Scholar
  72. 72.
    Lalvani A (2007) Diagnosing Tuberculosis infection in the 21st century: new tools to tackle an old enemy. Chest 131:1898–1906CrossRefPubMedGoogle Scholar
  73. 73.
    U.S. Food and Drug Administration. Recommendation on eculizumab (Soliris) use. http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM217725.pdf
  74. 74.
    Struijk GH, Bouts AHM, Rijkers GT, Kuin EAC, ten Berge IJM, Bemelman FJ (2013) Meningococcal sepsis complicating eculizumab therapy despite prior vaccination. Am J Transplant 13:819–820CrossRefPubMedGoogle Scholar
  75. 75.
    Diaz PS, Au D, Smith S, Amylon M, Link M, Arvin AM (1998) Lack of transmission of the live attenuated varicella vaccine virus to immunocompromised children after immunization of their siblings. Pediatrics 102:1483–1491CrossRefGoogle Scholar

Copyright information

© IPNA 2015

Authors and Affiliations

  • Sushmita Banerjee
    • 1
  • Pathum Vindana Dissanayake
    • 2
  • Asiri Samantha Abeyagunawardena
    • 2
  1. 1.Institute of Child HealthKolkataIndia
  2. 2.Department of Pediatrics, Faculty of MedicineUniversity of PeradeniyaPeradeniyaSri Lanka

Personalised recommendations