2. Type of transplant (i.e. autologous or allogenic, blood or haemopoetic stem cell).
Immunisation of renal dialysis patients and patients with chronic renal disease
3. Time interval since transplantation.
Patients with renal failure have an increased risk of infection with a variety of pathogens particularly hepatitis B and pneumococcus.
4. Receipt of immunosuppressive medications. 5. Presence of graft versus host disease. Although many will acquire donor's immunity, some will lose serological evidence of immunity. Therefore it is advisable to facilitate retention of donor immunity by antigenic stimulation soon after transplantation. Inactivated vaccines such as diphtheria, tetanus, pertussis, Hib, hepatitis A and B, IPV and pneumococcal and meningococcal vaccines are recommended immediately after transplantation. Persons with asplenia or functional asplenia This results from the following: 1. Surgical removal of the spleen in trauma, in Hodgkins disease, in treatment of haemolytic conditions such as hereditary spherocytosis and in idiopathic thrombocytopenic purpura. 2. Sickle cell disease (functional asplenia).
Hepatitis B vaccination is recommended for pre-end-stage renal disease before they become dialysis dependent. Patients with uraemia who were vaccinated before they required dialysis have been shown to have higher seroconversion rates and antibody titres. For patients undergoing haemodialysis, higher vaccine doses or increased number of doses are required. Clinically significant hepatitis B infection has been documented in patients who have not maintained anti-HBs concentrations equal to or greater than 10 mIU/mL. A booster dose should be administered when the level is less. (Please see Chapter 6) Pneumococcal vaccine – Patients with renal failure have an increased risk for pneumococcal infections. The efficacy of pneumococcal vaccination may be lower for some of these patients. Their antibody levels may be low. They may require repeat vaccinations or an increased dose of vaccine. Because secondary antibody responses are less affected than primary antibody responses, immunisation strategies should be formulated early in the course of progressive renal disease. This approach is particularly important if transplantation and immunosuppressive therapy are being considered.
3. Congenital asplenia. Such children have an increased risk of fulminant bacteremia and need immunisation with pneumococcal, Hib and meningococcal vaccines. When surgical splenectomy is planned, immunisation status for Hib, pneumococcus and meningococcus should be ascertained and the needed vaccines should be administered 2 weeks prior to splenectomy, if possible. If splenectomy is urgent, immediate administration of vaccines is recommended. Immunisation of HIV infected persons Please see Chapter 21. 163
DTaP, Hib, hepatitis A, Japanese encephalitis, MMR, meningococcal, polio (IPV), rabies, typhoid, varicella, yellow fever and inactivated influenza vaccines may be administered prior to commencement of dialysis, if indicated. Patients requiring repeated blood transfusions A large number of infections can be transmitted by blood transfusions. These include HIV, hepatitis B&C, syphilis, malaria, human T cell lymphotropic virus types 1&2, cytomegalovirus, Epstein Barr virus and parvovirus B19. Since immunisation is at present available only for hepatitis, donor blood screening is essential before blood transfusion. Nucleic acid amplification testing (NAT) identifies viral genes in the 164