Complete Seroconversion by Low-Dose Intradermal Injection of Recombinant Hepatitis B Vaccine in Hemodialysis Patients

Abstract

The present study was undertaken to find out if the seroconversion rate of hemodialysis (HD) patients was enhanced by the intradermal (i.d.) inoculation of recombinant hepatitis B (HB) vaccine. Thirty-five HBs-Ag, HBs-Ab and HBc-Ag, HBc-Ab negative HD patients were divided into three groups: 14 patients in group I received 5 μg HBs Ag i.d. every 2 weeks, 13 patients in group II were given 2.5 μg HBs vaccine i.d. every 2 weeks, 5 times, then every week. The remaining 8 patients in group III were immunised with 10 μg HBs Ag every 4 weeks 5 times intramuscularly (i.m.), then 5 μg i.d., every 2 weeks until complete seroconversion. Antibody response to i.m. injection was poor and only 37.5% of patients developed anti-HBs at a titer of 10 mlU/ml or more at 16 weeks after the start of immunisation. However, this poor response was improved by i.d. injection. The time of seroconversion was significantly earlier and the rate of response was higher in group I. The poor response in group II was markedly improved by doubling the inoculation rate. Overall, 100% of seroconversion was finally obtained by multiple i.d. immunisation. However, the anti-HBs titers were lower in all patients and declined in some patients after the immunisation was stopped. The last seroconverted patient in each group lost protective antibody levels at the 39th week. These patients became antibody positive again at the 52nd week with a booster dose. We feel that the i.d. route remains a useful and cheapter method of obtaining prophylaxis against HBs in high-risk HD patients but it would seem to be prudent to monitor these patients serially to assess the persistence of anti-HBs in the serum.

Expectation of Impaired Response to Recombinant Hepatitis B Vaccination

“…Yet, they differ for primitive renal desease and clinical patholo gy related to their immune function, as for sensitivity to antiviral vaccination [1][2][3][4]. We suggested that they must not be regarded as a homogeneous group in these aspects.…”

“…All were negative for infections and HBV markers of previous contact. Patients' renal pa thologies were: idiopathic CRF [4], primary CGN [3]…”

“…In order to increase the chances of response and to shorten its time, a number of schedules of vaccine administration and expensive immunotherapies have been suggested, prolonging trials for NR, with relative success [2,3]. Some good results have been recently obtained with mul tiple low-dose intradermal injection, with the drawbacks of local pain, staff engagement and short-life antibody titers [4], As NR show resistence to further immunization, we postulated that thay could be regarded as a separate set of patients and probably preselected by immune parameters. There is agreement about the main defect of T cell (Tc) immune response in uremia and recent interest about the role of monocytes on Tc activation, sensitivity and interleu kine production [5], Therefore, in our vaccination trial we searched for phe notypical features [Tc subsets, peripheral blood mononuc lear cells (PBMC) and IgG] that could help us to character ize NR patients.…”

Granulocyte-Macrophage Colony-Stimulating Factor as an Adjuvant to Hepatitis B Vaccination in Maintenance Hemodialysis Patients

“…Hence, it is important that patients with chronic renal failure be offered adequate protection against HBV when they enter a renal replacement therapy program. Because of the low seroconversion rate among chronic HD patients, multiple strategies have been used to enhance the immune response to HBV vaccination in these patients [12][13][14][15]. These include: doubling the vaccination dose (40 Ìg/dose in HD patients), use of intradermal versus intramuscular mode of injection [12,13], administration of the vaccine in the deltoid muscle, giving an additional booster dose, beginning the vaccination series before the patients reach end-stage renal disease, giving a booster dose (40 Ìg) when the antibody titer falls to !10 IU/ml, and finally, using various growth factors or adjuvants, e.g., recombinant human erythropoietin [13,14] and granulocyte-macrophage colony-stimulating factor (GM-CSF) [15].…”

A Successful Two-Step Integrated Protocol of Anti-HBV Vaccination in Chronic Uremia

“…The success rate of anti-HBV vaccination in chronic uremia has been limited by the depressed immune re sponse, detectable since the early phases of renal failure [1], Many authors have proposed several strategies to overcome this poor response [1][2][3][4], We report here our experience with a two-step integrated protocol of anti-HBV vaccination, combining in sequence the intramuscular and the intrader mal routes of administration.…”