Immunizations in Renal Transplant Candidates and Patients: Busting Barriers

Many individuals who have end-stage renal disease (ESRD) fail to receive the vaccinations that they need. Causes for failure to be vaccinated include public perception, lack of access, financial barriers, fear of allograft rejection, and knowledge gaps among patients. In clinical practice, health care providers often do not adhere to recommendations for vaccines covered by numerous guidelines. Renal transplant candidates and recipients who contract vaccine-preventable disease are at increased risk for morbidity and mortality.

The journal Transplant Infectious Disease has published a summary of barriers to vaccination in renal transplant recipients.

The authors, who were pharmacists, identified insurance coverage as the greatest barrier to vaccination. Roughly 7% of renal transplant candidates do not have insurance coverage while they wait for transplant, and the remainder are covered by a number of different programs. Up to half are covered by Medicare/Medicaid. Medicare part B covers only influenza, pneumococcal, hepatitis B, and vaccines directly related to treatment of an injury or direct exposure to a communicable disease. Patients covered by Medicare part D have variable coverage.

The authors identified the herpes zoster immunization as the most critical vaccination to be completed 3 to 4 weeks before transplant, as it is contraindicated after transplant. Here too, financial barriers are a concern, as is the patient's age.

If the kidney recipient is a child, clinicians may need to consider accelerated childhood vaccination schedules. This will require working with parents and addressing their misconceptions, fear, or confusion.

The authors referred to the American Society of Transplantations Transplant Infectious Disease Guidelines from 2013, the most up-to-date vaccine guideline for renal transplant candidates and recipients. Its key recommendation is to administer live vaccines before renal transplant, and to employ an accelerated schedule if necessary to ensure that all vaccines are completed before the transplantation occurs.

The authors noted that there is limited information available about vaccinations in the renal transplant patient and propose that more study is needed. They also indicated that health care providers may need to think outside the traditional immunization schedule box, and promote policies that afford renal transplant patients the greatest protection possible.

Reference

Maldonado AQ, Johnson D, Trofe-Clark J. Barriers to vaccination in renal transplant recipients. Transpl Infect Dis. 2017 Jul 17. doi: 10.1111/tid.12749. [Epub ahead of print]