Hepatitis B vaccination in Haemodialysis Patients: The Impact of Local Endemicity

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1 1 Hepatitis B vaccination in Haemodialysis Patients: The Impact of Local Endemicity Dr. Salwa Ibrahim, MD MRCP Assistant Professor of Nephrology Cairo University, Egypt Patients on hemodialysis therapy are at a relatively high risk of exposure to hepatitis-b virus (HBV) infection (1). Dialysis staff can transfer the virus to patients from contaminated surfaces via their hands or through use of contaminated equipment and supplies (2). Hepatitis B Virus HBV infection is a major public health problem in the Middle East; the majority of its countries have an intermediate or high endemicity of HBV infection, including Egypt (3). Hepatitis-B vaccination has been recommended by the centers for Disease Control and prevention (CDC) for all susceptible hemodialysis patients since it became available in

2 2 1982, but the seroconversion rates are much lower in the patient population with end-stage renal disease (ESRD) (4). Seroconversion (anti-hbs >10 IU/l) was found in % of hemodialysis patients three months after vaccine administration, but an adequate response (anti-hbs >100 IU/l) was observed only in 53.5% in one series (5). Beside lower response rates, hepatitis-b vaccine immunogenicity is often transient, and booster doses are necessary to maintain protection against HBV (5). Reasons for poor response include malnutrition, uraemia, older age and the immunocompromised state of patients with chronic kidney disease (6). Factors that have been associated with good response to HBV vaccination include young age (<40 years) (7) good nutritional status (8) and adequacy of dialysis (9). However, others have shown that neither age,

3 3 serum albumin, nor dialysis adequacy had an effect on HBsAb levels (10). On the other hand, duration of dialysis (4) haemoglobin and parathyroid hormone levels and hepatitis-c virus (HCV) infection did not significantly influence antibody responses to hepatitis-b immunization (6). Hepatitis B vaccine limitations Limited Efficacy Transient Immunogenicity HBsAb levels are not affected by different clinical and laboratory parameters including age, serum albumin, dialysis adequacy in some studies In order to identify the efficacy of hepatitis B vaccination in our region as well as factors that affect antibody response, we monitored HBsAb titres after primary vaccination (4 doses; Engerix B, 40 ug i.m at 0,1,3,6 months) in 29 seronegative hemodialysis (HD) patients (11). Their mean age was 45.55±10.94 years, and the hemodialysis duration ranged from one to twenty one years. In addition, we assessed Kt/V for all cases on 3 different occasions beside the estimation of predialysis serum albumin, serum ferritin, C-reactive protein (CRP), transferrin saturation ratio (TS) and subjective global assessment (SGA). Table 1 showed main characteristics of the study group.

4 4 Table 1. Patient demographic characteristics Parameter Age (year) Duration of Haemodialysis (year) URR% Kt/V Serum Albumin (g/dl) Haemoglobin level (g/dl) BMI SGA CRP (mg/l) Ferritin (ug/l) Transferrin Saturation (TST)% Mean+SD Ibrahim S, El-Din S, Bazzal I. J Natl Med Assoc, 2006 Our results showed that one patient (3.44%) was non responder (HBsAb <10 IU/1) after the completion of vaccination. Two patients (6.89%) were weak responders (10-100IU/1). Strikingly 26 patients (89.65%) showed good antibody response (>100 IU/1). Moreover, 15 patients (51.72%) demonstrated good antibody response after the first dose that was maintained on subsequent evaluation (Figure 1). Fig.1 Response rates to vaccination 70 Response rate to HB vaccination 65.51% 65.51% % % 3.44% 6.89% 3.44% 24.13% 0 Nonresponders poor responders good responders high responders Ibrahim S, El-Din S, Bazzal I. J Natl Med Assoc, 2006

5 5 HBsAb titres showed no significant correlation with age, duration of HD therapy, serum albumin, CRP, TS level or SGA scores (p>0.05). Responders to primary vaccination had significantly higher levels of URR % and Kt/V compared to nonresponders ( % and vs % and respectively, P <0.05) (Table 2). However, this association did not reach statistical significance on linear regression analysis (P>0.05). Table 2. Patient variables of responders and nonresponders to primary vaccination Parameter Responders (n=27) Nonresponders (n=2) P value Age Duration of HD therapy URR% Kt/V CRP (mg/l) TST % Ferritin (ug/l) Albumin (g/dl) HB (g/dl) BMI SGA Anti-HBs level (m IU/ml) < Our study showed for the first time a very high response to hepatitis B vaccination among HD patients that neither correlates with nutritional status nor systemic inflammation. Previous studies in hemodialysis patients had shown a variable hepatitis B vaccination response rate ranged from 47 to 73% (3,4,5). Our results might be attributed to the endemic nature of hepatitis B infection in our study region. Similar good response to hepatitis B vaccination in haemodialysis patients had also been observed in areas with intermediate endemicity (2-8% prevalence)

6 6 of hepatitis B virus like Brazil that approached 89.5 % in one study (12,13). The prevalence of HBsAg ranged from 3% to 11% in Egypt (14, 15). Studies in Egypt suggest that perinatal transmission is relatively high, HBsAg was found in 8% of pregnant mothers and 17% of their infants in one study (16). Other factors found to be associated with HBV infection and carrier status in the Middle East are family size, socioeconomic status, previous blood transfusion, surgery and maternal history of schistosomal infection (16). Conclusions This was a preliminary study showing a very high response to hepatitis B vaccination among HD patients that neither correlated with systemic inflammation nor nutritional status. Our results might be attributed to the endemic nature of hepatitis B infection in our study region. Further studies are needed to determine the most cost-effective vaccine dosing regimen for dialysis patients in the study region. References 1. Cheng CH, Huang CC, Leu ML, Chiang CY, Wu MS, Lai PC. Hepatitis B vaccine in haemodialysis patients with hepatitis C infection. Vaccine, 1997; 15(12-13): CDC. Outbreaks of Hepatitis B Virus infection Among Haemodialysis Patients- California, Nebraska, and Texas, MMWR 1996; 45: Navarro JF, Teruel JL, Mateos ML, Marcen R, Ortuno J. Antibody level after hepatitis B vaccination in haemodialysis patients: influence of hepatitis C virus infection. Am J Nephrol. 1996; 16 (2):95-97.

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