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Chronic kidney disease (CKD), no matter what is the cause, has a profound effect on both innate and adaptive immune system. This is specially exaggerated in dialysis patients and amongst kidney transplant recipients, leads to an increased risk of infections. Besides being the second leading cause of death in patients with CKD, infections also increase the risk for cardiovascular events and lead to catastrophic healthcare expenditure secondary to invasive diseases and hospitalizations.
Along with improved sanitation, immunisation is humanity's greatest advances in preventing sickness and death from infectious diseases. Vaccines have helped eliminate or significantly reduce the burden of more than a dozen illnesses. Recognising that childhood is the best time to provide lifelong protection against infections, most countries have pout in place universal immunisation programs.
Specific recommendations are available for adults as well, but these are less well implemented. Various factors may account for these low rates, including financial disincentives.
Overall, prevention through vaccination remains the best strategy to minimise the adverse consequences associated with these infectious diseases in patients with CKD. Protection against hepatitis B infection is a great success story. However, vaccine efficacy his suboptimal in this population, secondary to the same deficiencies in the immune response that increase infection risk. Getting around this barrier needs innovative approaches, such as use of nonspecific adjuvant compounds to enhance host response. by targeting important cellular elements of the vaccine response.
We need more research in this area, to better understand how vaccination in populations at risk for developing CKD might benefit from earlier vaccination, and to expand repertoire of vaccines available against particularly troublesome pathogens, particularly MRSA, Group A streptococcus and other bacteria. Next-generation vaccines offer the possibility of sustained immunological memory, which can substantially prevent chronic viral disease.
In addition, we need to change behaviour so that nephrologists become sensitised to the notion of prevention rather than treating infection after they become apparent. Nephrologists need to be steadfast proponents of vaccination.
Current guidelines recommend immunisations for all patients with CKD regardless of the disease stage, but they are recommended during the early stages of progressive renal disease to increase the likelihood of vaccine-induced immunity.
This document is intended to help the Indian physician community who take care of patients with kidney disease make informed decisions about this often overlooked aspect of care.
The document has been prepared by leading nephrology academics and clinicians who have examined all aspects of vaccination, culled evidence from CKD population and where this was not available, from the general population.
As usual, this document is intended to inform practice, rather than provide specific guidance about every single patient. Practitioners are encouraged to implement the suggestions and recommendations keeping in mind the specific clinical context of the patient.