What is the hepatitis B vaccination regimen in chronic kidney disease?
MONITORING THE RESPONSE TO VACCINATION AND REVACCINATION
Testing after vaccination is recommended to determine response. Testing should be done 1 to 2 months after the last dose of the vaccination schedule.1–3 Anti-HBs levels 10 IU/mL and greater are considered protective.10
Revaccination with a full vaccination series is recommended for patients who do not develop adequate levels of protective antibodies after completion of the vaccination schedule.2 Reported response rates to revaccination have varied from 40% to 50% after 2 or 3 additional intramuscular doses of 40 µg, to 64% after 4 additional intramuscular doses of 10 µg.3 Serologic testing should be repeated after the last dose of the vaccination series, as serologic testing after only 1 or 2 additional doses appears to be no more cost-effective.2,3
To the best of our knowledge, no data exist to indicate that in nonresponders, further doses given after completion of 2 full vaccination schedules would induce an antibody response.
ANTIBODY PERSISTENCE AND BOOSTER DOSES
Antibody levels fall with time in patients on hemodialysis. Limited data suggest that in patients who respond to the primary vaccination series, antibodies remain detectable for 6 months in 80% to 100% (median 100%) of patients and for 12 months in 58% to 100% (median 70%) of patients.3 The need for booster doses should be assessed by annual monitoring.2,11 Booster doses should be given when the anti-HBs titer declines to below 10 IU/mL. Limited data indicate that nearly all such patients would respond to a booster dose.3
OTHER WAYS TO IMPROVE VACCINE RESPONSE
Other strategies to improve vaccine response, such as the addition of adjuvants or immunostimulants, have shown variable success.12 Intradermal HBV vaccination in patients on chronic hemodialysis has also been proposed. The efficacy of intradermal vaccination may be related to the dense network of immunologic dendritic cells within the dermis. After intradermal administration, the antigen is taken up by dendritic cells residing in the dermis, which mature and travel to the regional lymph node where further immunostimulation takes place.13
In a systematic review of four prospective trials with a total of 204 hemodialysis patients,13 a significantly higher proportion of patients achieved seroconversion with intradermal HBV vaccine administration than with intramuscular administration. The authors concluded that the intradermal route in primary nonresponders undergoing hemodialysis provides an effective alternative to the intramuscular route to protect against HBV infection in this highly susceptible population.
Additional well-designed, double-blinded, randomized trials are needed to establish clear guidelines on intradermal HBV vaccine dosing and vaccination schedules.
