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How to Help Dialysis Patients Avoid Hospitalizations during Flu Season

Due to a weakened immune system, end stage kidney disease (ESKD) patients on dialysis are at higher risk for pneumonia and other conditions that require hospitalization. Influenza is one condition in particular that can be life threatening for ESKD patients. When it comes to reducing the risk for hospitalization or death, the efficacy of the influenza vaccine at usual dosages for ESKD patients is not certain; however, a study was conducted on the efficacy of using a higher dosage vaccine in this patient population. This blog post will report on the results of this study, as well as recommendations for kidney patients, including transplant recipients, during flu season.

Impaired Immunity in ESKD Patients

An influenza-like illness (ILI) may not be the direct cause of morbidity or mortality in ESKD patients, but it may contribute to other causes of hospitalization or death. For example, ESKD patients with ILI may experience acute inflammation, making them vulnerable to other infections or cardiovascular events. Thus, researchers recommend that all patients on dialysis receive the influenza vaccine.

2019-2020 Flu Season and Vaccination

While the exact timing and duration of flu seasons can vary, influenza activity often begins to increase in October and often peaks between December and February. However, activity can last as late as May. Although you may expect that flu activity has already peaked for the season in the United States, the worst may be yet to come. In fact, some predict 2019-2020 may be the most severe flu season in decades, particularly for children.

Therefore, it is important to not only encourage your patients to get vaccinated—if they have not done so already—but to recommend that they ask their family, friends and other close contacts to get vaccinated, as well. Promoting herd immunity can help protect patients with weakened immunity from flu transmission; this is especially crucial for transplant recipients.

Study on High-Dose Vaccine

Please note that although a high-dose inactivated vaccine is available this flu season, Fluzone® High‑Dose Influenza Vaccine is indicated only for those patients age 65 years or older.The standard dose of inactivated influenza vaccine is recommended annually for ESKD patients who are younger than 65 years.

Given that the efficacy of standard influenza vaccination in patients on dialysis is uncertain—that is, a substandard immune response or a lower seroprotection rate was observed in several studies of these patients compared with the age-matched general population—a study was conducted to determine whether a high-dose vaccine benefits patients on dialysis, including those younger than 65 years. This study compared the hospitalization and mortality rates in the 2015–2016 and 2016–2017 influenza seasons in dialysis patients who received high-dose trivalent vaccines versus standard-dose quadravalent vaccines. Results show that receipt of high-dose compared with standard dose influenza vaccine in 2016–2017 was associated with lower rates of hospitalization in patients on dialysis, although that was not seen in 2015–2016. No significant differences in death rates between the high-dose and standard-dose groups were seen in either influenza season. Considering the effect on hospitalizations rates, additional and more rigorous studies on the use of high-dose influenza vaccines in dialysis patients younger than 65 years is warranted.

Recommendations for Transplant Patients

The Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group recommends that kidney transplant recipients receive age-appropriate inactivated vaccinations as recommended for general population. Kidney transplant recipients should not receive live vaccines. If a patient has received a live vaccine, the transplant should be delayed by at least 4 weeks since the time of administration. Although it may be best to wait until after the first 3 to 6 months following kidney transplantation—the period of intense immunosuppression—before vaccination, an inactivated influenza vaccine can be administered as early as 1 month after kidney transplant, if needed, prior to the start of peak flu activity. As with live vaccines, the use of intranasal flu vaccine is contraindicated in transplant recipients.

In general, kidney patients—regardless of vaccination receipt—should avoid contact with persons infected with the influenza virus. In addition to the influenza vaccine, giving simple reminders to your patients before and during flu season can help keep them healthy and out of the hospital.

Managing Editor