Immune response to influenza vaccination in children with renal disease

Characteristics of Peripheral and Peritoneal White Blood Cells in Children with Chronic Renal Failure, Dialyzed or Not

Objective

To explore further the mechanisms leading to immune deficiency in chronic renal failure and the role of dialysis treatment in these mechanisms.

Design

Cross-sectional and longitudinal analysis.

Patients

We studied 39 children treated with peritoneal dialysis (PD), 23 children treated with hemodialysis (HD), 33 children not yet dialyzed [chronic renal failure (CRF)], and 27 healthy children. Peritoneal cells were also obtained from PD children for analysis.

Methods

White blood cells (WBCs) were isolated from blood and peritoneal dialysis effluent by centrifugation. The number of CD2+, CD4+, and CD8+T cells, B cells, and natural killer cells were measured by flow cytometry.

Results

The total peripheral blood lymphocyte count was lower in PD children (2.6 x 109/L), HD children (2.1 x 109/L), and CRF children (2.0 x 109/L) compared with healthy children (3.1 x 109/L, p < 0.05). The B lymphocyte count was also lower in PD children (0.34x109/L), HD children (0.22 x 109/L), and CRF children (0.33 x 109/L) compared with healthy children (0.52 x 109/L, p < 0.01). Numbers of CD4+T cells were not different, but numbers of CD8+T cells were lower in PD children (0.56 x 109/L), HD children (0.63 x 109/L), and CRF children (0.53 x 109/L) compared with healthy children (0.77 x 109/L, p < 0.05). The count of natural killer cells was lower in PD children (0.21 x 109/L), HD children (0.17 x 109/L), and CRF children (0.18 x 109/L) compared with healthy children (0.50 x 109/L, p < 0.0001). The CD4/CD8 ratio of lymphocytes in peritoneal effluent was 0.8 versus 1.9 in peripheral blood ( p < 0.001). The CD2/CD19 ratio was not different. The cell subsets remained stable during the first year of PD treatment. The CD2/CD19 ratio in peritoneal effluent was higher in children with a peritonitis incidence ≥ 1 per year.

Conclusions

The reduced numbers of B lymphocytes, CD8+T cells, and natural killer cells found in CRF children, dialyzed or not, may favor the frequent occurrence of infections.

Vaccinations in pediatric kidney transplant recipients

Pediatric kidney transplant (KT) candidates should be fully immunized according to routine childhood schedules using age-appropriate guidelines. Unfortunately, vaccination rates in KT candidates remain suboptimal. With the exception of influenza vaccine, vaccination after transplantation should be delayed 3-6 months to maximize immunogenicity. While most vaccinations in the KT recipient are administered by primary care physicians, there are specific schedule alterations in the cases of influenza, hepatitis B, pneumococcal, and meningococcal vaccinations; consequently, these vaccines are usually administered by transplant physicians. This article will focus on those deviations from the normal vaccine schedule important in the care of pediatric KT recipients. The article will also review human papillomavirus vaccine due to its special importance in cancer prevention. Live vaccines are generally contraindicated in KT recipients. However, we present a brief review of live vaccines in organ transplant recipients, as there is evidence that certain live virus vaccines may be safe and effective in select groups. Lastly, we review vaccination of pediatric KT recipients prior to international travel.

Nephrologists need to play a key role in improving annual influenza vaccination rates in children with kidney disease

AIM

This study investigated the under-researched area of annual influenza vaccination rates in children with chronic kidney disease and identified reasons for nonimmunisation.

METHODS

A prospective cross-sectional study was conducted in the nephrology clinic and dialysis unit of a tertiary paediatric medical centre from August to October 2011 and September to October 2012. Parents were asked to complete a questionnaire on their child's immunisation against influenza.

RESULTS

Of the 217 children studied, 45.6% were vaccinated against influenza. The major reason for nonimmunisation was because the parents had not received the necessary information from the primary physician or treating nephrologist. The nonvaccinated children were significantly more likely to be less than two years old and female and to have parents who did not believe in the benefits of vaccination (p < 0.05). Of the parents who did not vaccinate their child, 38% claimed they would have done so if the vaccine had been offered in the nephrology clinic.

CONCLUSION

Children with kidney disease had a higher annual influenza vaccination rate than the general population, but it was still suboptimal. Nephrologists should be alerted to the need to provide parents with information on influenza vaccinations and they should be available in nephrology clinics.

2013 IDSA clinical practice guideline for vaccination of the immunocompromised host

An international panel of experts prepared an evidenced-based guideline for vaccination of immunocompromised adults and children. These guidelines are intended for use by primary care and subspecialty providers who care for immunocompromised patients. Evidence was often limited. Areas that warrant future investigation are highlighted.

Vaccination of immunocompromised patients

Vaccination of immunocompromised patients is challenging both regarding efficacy and safety. True efficacy data are lacking so existing recommendations are based on immune responses and safety data. Inactivated vaccines can generally be used without risk but the patients who are most at risk for infectious morbidity and mortality as a result of their severely immunosuppressed state are also those least likely to respond to vaccination. However, vaccination against pneumococci, Haemophilus influenzae and influenza are generally recommended. Live vaccines must be used with care because the risk for vaccine-associated disease exists.

Serologic vaccination response after solid organ transplantation: a systematic review

BACKGROUND

Infectious diseases after solid organ transplantation (SOT) are one of the major complications in transplantation medicine. Vaccination-based prevention is desirable, but data on the response to active vaccination after SOT are conflicting.

METHODS

In this systematic review, we identify the serologic response rate of SOT recipients to post-transplantation vaccination against tetanus, diphtheria, polio, hepatitis A and B, influenza, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitides, tick-borne encephalitis, rabies, varicella, mumps, measles, and rubella.

RESULTS

Of the 2478 papers initially identified, 72 were included in the final review. The most important findings are that (1) most clinical trials conducted and published over more than 30 years have all been small and highly heterogeneous regarding trial design, patient cohorts selected, patient inclusion criteria, dosing and vaccination schemes, follow up periods and outcomes assessed, (2) the individual vaccines investigated have been studied predominately only in one group of SOT recipients, i.e. tetanus, diphtheria and polio in RTX recipients, hepatitis A exclusively in adult LTX recipients and mumps, measles and rubella in paediatric LTX recipients, (3) SOT recipients mount an immune response which is for most vaccines lower than in healthy controls. The degree to which this response is impaired varies with the type of vaccine, age and organ transplanted and (4) for some vaccines antibodies decline rapidly.

CONCLUSION

Vaccine-based prevention of infectious diseases is far from satisfactory in SOT recipients. Despite the large number of vaccination studies preformed over the past decades, knowledge on vaccination response is still limited. Even though the protection, which can be achieved in SOT recipients through vaccination, appears encouraging on the basis of available data, current vaccination guidelines and recommendations for post-SOT recipients remain poorly supported by evidence. There is an urgent need to conduct appropriately powered vaccination trials in well-defined SOT recipient cohorts.

Immunizations in children with chronic kidney disease

Children with chronic kidney disease (CKD) are at increased risk for vaccine-preventable diseases. These patients may have a reduced response to and/or reduced duration of antibody after immunization and therefore monitoring of antibody levels or titers is indicated for some vaccines. In addition, pediatric CKD patients require immunizations not routinely provided to healthy children. Unfortunately, studies in pediatric CKD patients, including those on dialysis and awaiting kidney transplantation, have demonstrated sub-optimal immunization rates. In order to minimize the risk for vaccine-preventable disease in pediatric CKD patients, it is imperative that all who care for these patients remain abreast of the recommended childhood immunization schedule, as well as alterations to this schedule required for children with CKD, including end-stage kidney disease. This article reviews recent changes to the recommended childhood immunization schedule and alterations and additions to this schedule recommended for children with CKD. Where available, data on antibody response to immunizations in children with CKD are presented.

Influenza vaccination for immunocompromised patients: systematic review and meta-analysis from a public health policy perspective

BACKGROUND

Immunocompromised patients are vulnerable to severe or complicated influenza infection. Vaccination is widely recommended for this group. This systematic review and meta-analysis assesses influenza vaccination for immunocompromised patients in terms of preventing influenza-like illness and laboratory confirmed influenza, serological response and adverse events.

METHODOLOGY/PRINCIPAL FINDINGS

Electronic databases and grey literature were searched and records were screened against eligibility criteria. Data extraction and risk of bias assessments were performed in duplicate. Results were synthesised narratively and meta-analyses were conducted where feasible. Heterogeneity was assessed using I(2) and publication bias was assessed using Begg's funnel plot and Egger's regression test. Many of the 209 eligible studies included an unclear or high risk of bias. Meta-analyses showed a significant effect of preventing influenza-like illness (odds ratio [OR]=0.23; 95% confidence interval [CI]=0.16-0.34; p<0.001) and laboratory confirmed influenza infection (OR=0.15; 95% CI=0.03-0.63; p=0.01) through vaccinating immunocompromised patie nts compared to placebo or unvaccinated controls. We found no difference in the odds of influenza-like illness compared to vaccinated immunocompetent controls. The pooled odds of seroconversion were lower in vaccinated patients compared to immunocompetent controls for seasonal influenza A(H1N1), A(H3N2) and B. A similar trend was identified for seroprotection. Meta-analyses of seroconversion showed higher odds in vaccinated patients compared to placebo or unvaccinated controls, although this reached significance for influenza B only. Publication bias was not detected and narrative synthesis supported our findings. No consistent evidence of safety concerns was identified.

CONCLUSIONS/SIGNIFICANCE

Infection prevention and control strategies should recommend vaccinating immunocompromised patients. Potential for bias and confounding and the presence of heterogeneity mean the evidence reviewed is generally weak, although the directions of effects are consistent. Areas for further research are identified.

Influenza vaccine after pediatric kidney transplant: a Midwest Pediatric Nephrology Consortium study

The main aim of this study was to compare the response to trivalent inactivated influenza vaccine in children who received a kidney transplant and were on steroid-free versus steroid-based immunosuppression. Groups: 1. Kidney transplant recipients on steroid-free immunosuppression (n=27); 2. Kidney transplant recipients on steroid-based immunosuppression (n=39); 3. Healthy controls (n=21). Hemagglutination inhibition titers against 2007-2008 A/H1N1 and A/H3N2 and B strains were measured before and 8 weeks postvaccination. Postvaccination geometric mean titers to A/H1N1 were significantly lower among both transplant groups than controls (p=0.025 and 0.015, respectively). Postvaccination titers to H3N2 and B strains were not statistically different between groups. Proportions of participants developing seroprotection were not different among groups. Both kidney transplant groups seroconverted less than controls for A/H1N1 (p=0.0002) and were no different from controls for B. For A/H3N2, the steroid-free group had the weakest seroconversion (p=0.008), possibly due to mycophenolate-enhanced exposure and a younger age. Overall, children after kidney transplantation demonstrated a good serologic response to the inactivated influenza vaccine although somewhat lower than controls. Steroid-free immunosuppression did not seem to present an advantage in antibody response. Data on inactivated influenza vaccine safety and efficacy was collected and demonstrated absence of acute rejection or laboratory-proven influenza for 6 months postvaccination.

Immunization issues before and after solid organ transplantation in children

Solid-organ transplant recipients are at risk from various infectious diseases, many of which can be prevented by immunizations that could reduce morbidity and mortality. However, it is not uncommon for children requiring transplantation to have received inadequate or no immunizations pre-transplant. Every effort should be made to immunize transplant candidates early in the course of their disease according to recommended schedules prior to transplantation. It is also important to immunize their household contacts and healthcare workers. In this review, we summarize the major immunization issues for children undergoing transplantation, the data currently available on immunization safety and efficacy, and suggest immunization practices to reduce vaccine-preventable disease. There is a real need for a standardized approach to the administration and evaluation of immunizations in this group of patients.

Immunization in children with chronic renal failure: a practical approach

The prevention of systemic viral and bacterial infections by effective vaccination represents an essential task of pediatric nephrologists caring for children with chronic renal failure (CRF) undergoing renal transplantation (RTPL) with life-long immunosuppression. This review addresses three issues: risk of vaccine-preventable diseases, safety, immunogenicity, and clinical efficacy of available vaccines, and implementation of immunization guidelines. Infections (including vaccine-preventable infections) represent the leading cause of morbidity and mortality in children on dialysis and after RTPL. Vaccination in children with CRF and after RTPL is safe and does not cause reactivation of an immune-related renal disease or rejection after RTPL. Children with CRF generally produce protective serum antibodies to primary vaccinations with killed or component vaccines and live virus vaccines; some children on dialysis and after RTPL may not respond optimally, requiring repeated vaccination. Proof of vaccine efficacy is absence of disease, which can only be confirmed in large cohort studies. A few observational studies provide evidence that vaccination has contributed significantly, at least in the western hemisphere, to the low prevalence of vaccine-preventable diseases among children with CRF. Close cooperation between the local pediatrician/practitioner and the pediatric nephrologist is essential for successful implementation of the vaccination schedule.

[Vaccinations and solid-organ transplantation: review and recommendations]

Pediatric solid-organ transplant recipients are at high risk for various infectious diseases. Many children are not fully vaccinated before transplantation. To reduce the risk of morbidity and mortality from vaccine-preventable disease, physicians treating pediatric solid-organ transplant recipients should monitor the immunization status of these patients. Consensus on the most appropriate immunization schedule for solid-organ transplant recipients is lacking. Therefore, we provide a review of the currently available data on immunization safety and efficacy and describe strategies to avoid vaccine-preventable diseases in pediatric solid-organ transplant recipients.

Infectious disease prophylaxis in renal transplant patients: a survey of US transplant centers

Definitive approaches to most infectious diseases following renal transplantation have not been established, leading to different approaches at different transplant centers. To study the extent of these differences, we conducted a survey of the practices surrounding specific infectious diseases at US renal transplant centers. A survey containing 103 questions covering viral, bacterial, mycobacterial and protozoal infections was developed. Surveys were sent to program directors at all U.S. renal transplant centers. Responses were received from 147 of 245 (60%) transplant centers and were proportionately represented all centers with respect to program size and geographical location. Pre-transplant donor and recipient screening for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV) and cytomegalovirus (CMV) is uniform, but great discrepancy exists in the testing for other agents. HCV seropositive donors are used in 49% of centers. HIV seropositivity remains a contraindication to transplantation, although 13% of centers indicated they have experience with such patients. Post-transplant, there is wide variety in approach to CMV and Pneumocystis carinii (PCP) prophylaxis. Similarly divergent practices affect post-transplant vaccinations, with 54% of centers routinely vaccinating all patients according to customary guidelines in non-transplant populations. In contrast, 22% of centers indicated they do not recommend vaccination in any patients. We believe an appreciation of the differences in approaches to post-transplant infectious complications may encourage individual centers to analyse the results of their own practices. Such analysis may assist in the design of studies to answer widespread and important questions regarding the care of patients following renal transplantation.

Vaccines for transplant recipients

Immune dysregulation and immunosuppression regimens impact on the ability of transplant recipients to respond to immunizations. The distinct challenges of immunizations to benefit stem cell transplant recipients and solid organ transplant recipients are discussed separately. Recommended vaccines for stem cell transplant recipients and solid organ transplant candidates are suggested. New approaches to consider to enhance immune responses of transplant recipients are discussed.

Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation

Many complications after renal transplantation can be prevented if they are detected early. Guidelines have been developed for the prevention of diseases in the general population, but there are no comprehensive guidelines for the prevention of diseases and complications after renal transplantation. Therefore, the Clinical Practice Guidelines Committee of the American Society of Transplantation developed these guidelines to help physicians and other health care workers provide optimal care for renal transplant recipients. The guidelines are also intended to indirectly help patients receive the access to care that they need to ensure long-term allograft survival, by attempting to systematically define what that care encompasses. The guidelines are applicable to all adult and pediatric renal transplant recipients, and they cover the outpatient screening for and prevention of diseases and complications that commonly occur after renal transplantation. They do not cover the diagnosis and treatment of diseases and complications after they become manifest, and they do not cover the pretransplant evaluation of renal transplant candidates. The guidelines are comprehensive, but they do not pretend to cover every aspect of care. As much as possible, the guidelines are evidence-based, and each recommendation has been given a subjective grade to indicate the strength of evidence that supports the recommendation. It is hoped that these guidelines will provide a framework for additional discussion and research that will improve the care of renal transplant recipients.

Antibody response to influenza immunization in two consecutive epidemic seasons in patients with renal diseases

The aim of this study was to assess antihemagglutinin and antineuraminidase antibody kinetics in 26 patients with renal diseases vaccinated against influenza in two consecutive epidemic seasons. Antibody responses were measured before immunization and 1, 3 and 6 months after immunization. Antihemagglutinin (HI) antibodies were determined by the hemagglutinin inhibition test and antineuraminidase (NI) antibody levels by the neuraminidase inhibition test. After vaccination HI and NI antibody titers significantly increased when compared with the pre-vaccination levels. Three months after vaccination the protection rates ranged from 50 to 61.5% in the 1995/96 season and 100% for all antigens in the 1996/97 season. Response rates ranged from 50 to 57.7% and 93.8 to 100% respectively. Significantly higher humoral response was recorded in the 1996/97 season than in the 1995/96 season. No serious adverse reactions were observed in the vaccinated patients and no symptoms of influenza or influenza-like infection were noted. In spite of some doubts about the safety and efficacy of influenza vaccination in patients from high-risk groups, the results of this study showed that many of them are able to produce HI antibodies in titers which are sufficient to protect against the influenza infection.

Immunizations for pediatric dialysis patients

Children maintained on chronic dialysis are at high risk for infection, and although the burden of vaccine-preventable disease in this population has not been fully documented, primary care of these patients should include careful compliance with the routine childhood immunization schedule. There have been considerable changes in this schedule in recent years, and an update is provided. In addition the supplemental vaccines for pneumococcal and influenza vaccines are discussed. Where available, data regarding vaccine response in children on dialysis are presented.

Humoral immune response to influenza vaccination in patients from high risk groups

Influenza is one of the most common respiratory diseases. Infections caused by this virus may be very serious and can lead to severe complications. So far, the most effective method of protection against influenza is annual vaccination. The Advisory Committee on Immunisation Practices recommends vaccination against influenza for some groups of people. Unfortunately, in spite of these clear indications, a large number of patients are not vaccinated. This article reviews the current scientific literature on immunological response to influenza vaccination in patients who are at especially high risk for serious post-influenza complications and for whom immunisation against this virus is strongly recommended. Results of studies carried out in Poland and other countries in elderly people, in patients with pulmonary diseases, renal diseases, diabetes mellitus, cancer and haemophilia, and in those with HIV infection are presented. In this review, we focus on the immune response to haemagglutinin. There are some discrepancies between the results of studies carried out by different authors in high risk groups of patients. Some investigations indicated poorer humoral response to influenza vaccine in these groups, while others showed responses comparable to those in healthy individuals. These differences may be explained by differences in types and stages of the chronic diseases, in the treatment and composition of influenza vaccines, and also patients' ages, vaccination history and prevaccination antibody titres. Influenza vaccines are well tolerated in high risk patients, and all adverse reactions are generally mild and similar to those observed in healthy people. Although, in some cases, immunological responses to influenza vaccination measured in the whole study group were poor, there were some individual patients who, after vaccination, developed antihaemaglutinin antibody titres which are considered to give protection against the infection or contribute to a milder course of the disease.

Immunization of pediatric solid organ transplant candidates and recipients

Organ transplantation has evolved from an experimental procedure to an accepted treatment for otherwise irreversible or congenital disorders. The immunosuppression necessary to prevent rejection enhances the severity of many infectious diseases and may potentially attenuate the response to vaccines designed to prevent disease. In spite of the frequency and severity of infectious diseases in organ transplant recipients, many children are not fully vaccinated before transplantation. The safety and efficacy of many of the currently available vaccines for solid organ transplant recipients have not been evaluated. We review the currently available data on immunization safety and efficacy, discuss experimental vaccines, and outline strategies to avoid vaccine-preventable diseases in pediatric organ transplant recipients.

Vaccine recommendations for patients on chronic dialysis. The Advisory Committee on Immunization Practices and the American Academy of Pediatrics

Pediatric patients on dialysis should receive all the vaccines currently recommended by the ACIP and the AAP for healthy children, except the oral polio vaccine (34, 35). Adult patients should receive the hepatitis B vaccine series, pneumococcal vaccine, yearly influenza vaccinations, tetanus-diphtheria toxoids, and varicella vaccine, if they are susceptible (33, 48, 69). Vaccines are well tolerated by these patients (33), but higher doses and/or additional boosters may be required periodically to adequately protect dialysis patients from vaccine-preventable diseases (33, 36, 37, 82, 83). Following vaccination, antibody concentrations for hepatitis B vaccine should be measured annually and booster doses administered when antibody concentrations fall below protective levels (33, 38). Although both children and adults on dialysis may show an impaired and/or delayed immunologic response to certain antigens, particularly hepatitis B virus and S. pneumoniae, appropriate immunizations can significantly reduce the risk of serious complications from vaccine-preventable diseases (11, 84). Because the protection these vaccines provide may be incomplete or transient, infection control strategies at hospitals and other health care facilities should be implemented simultaneously. Health care providers are encouraged to assess each patients need for vaccinations individually and formulate immunization strategies early in the course of progressive renal disease, ideally before the patient requires dialysis.

Duration of immunity to diphtheria and tetanus in young kidney transplant patients

A considerable proportion of patients with renal transplant, evaluated many years after transplant, lack protective diphtheria antibody levels, despite primary immunization, but maintain immunity to tetanus. These patients respond to a diphtheria and tetanus booster but the duration of the response is uncertain. This study was undertaken to assess if protective antibodies evoked by primary immunization are lost quickly after transplantation, and whether the extent of the immune response to a booster influences the persistence of protective antibodies. We studied 15 patients (group 1) immediately after renal transplant and 35 patients with renal transplant for 6 +/- 4 yr who received a diphtheria and tetanus booster (group 2). Six patients (40%) of group 1 lost protective diphtheria antibodies a median time of 6.5 months after transplant. Thirty-three patients of group 2 responded to the booster with normal diphtheria antibody titers (> 1 IU/mL) in 22 cases and with low titers in 11. Four of the latter lacked immunity to diphtheria at 12 months follow-up. All patients with normal immunity maintained protective levels of diphtheria antibodies. The low responders had a creatinine clearance of 50 +/- 20 mL/min/1.73 m2. Tetanus immunity was maintained in almost all patients of both groups. In conclusion, renal transplant patients had an accelerated loss of diphtheria antibodies in the early post-transplant period. Response to a diphtheria booster identified a group at particular risk, namely the low responders, who may require frequent booster doses. This group had significantly poorer renal function than the normal responders.

Immunogenicity of influenza vaccine in patients with hemato-oncological disorders

The aim of this study was to measure the production of antihemagglutinin and antineuraminidase antibodies in patients with proliferative diseases of the hematopoietic or lymphatic system, immunized with influenza vaccine in the epidemic season 1995/96. Twenty patients between 22 and 84 years volunteered for vaccination and were vaccinated subcutaneously with a single dose of split trivalent influenza vaccine ("Fluarix", SmithKline Beecham) in autumn 1995 at the outpatients clinic, General Hospital, Toruń, Poland, where they were being treated with anti-cancer chemotherapy. The vaccine consisted of a 0.5 ml dose containing 15 microg hemagglutinin (HA) of each of the following strains: A/Singapore/6/86 (H1N1), A/Johannesburg/33/94 (H3N2) and B/Beijing/184/93. Neuraminidase activity amounted to 17.24x10(-3) U/ml. Antibody production was determined in sera collected before vaccination, 10 days and 28 days after vaccination by the hemagglutinin inhibition test (HI) and neuraminidase inhibition test (NI). Mean fold increase values after vaccination were statistically significant in patients undergoing cytostatic treatment. After 28 days mean fold increase of antihemagglutinin antibodies ranged from 7.9 to 25.2, while in the case of antineuraminidase antibodies these values were between 12.4 and 14.3. It is notable that no adverse reactions were observed after immunization and none of the patients was infected with influenza virus, in spite of the fact that there was a local epidemic in the Toruń region when the study was carried out. The results presented in this paper confirm the beneficial effect of influenza vaccination in high-risk groups of patients with proliferative diseases of the hematopoietic and lymphatic systems.

Management of end-stage renal disease in children

OBJECTIVE

To review the medical literature on management of end-stage renal disease (ESRD) and its complications in the pediatric patient.

DATA SOURCES AND STUDY SELECTION

MEDLINE searches (1970-1997) of the English-language literature. Clinical trials and reviews of drug therapy management were included, and bibliographies were reviewed for relevant articles.

DATA SYNTHESIS

Principles of renal replacement therapy in children have been expanded to include maintenance of fluid and electrolyte balance and to manage the complications of ESRD in children. Types of renal replacement and their complications are reviewed. Complications of ESRD are reviewed with emphasis on drug therapy management of anemia of chronic renal failure, growth retardation, and hypertension. A discussion of the use of vitamins and supplements to maintain bone and mineral homeostasis is provided, and specific recommendations for vaccination of children with ESRD are given.

CONCLUSIONS

Children with end-stage renal failure present a unique challenge to the pharmacist. Renal replacement therapy for children with ESRD involves some form of dialysis and an intensive medication regimen. Complications must be treated with appropriate drug therapy. Drug therapy must be monitored closely for dosage adjustment, clinical response, drug interactions, and toxicity. Patients and families must receive continuous education and follow-up to encourage compliance. The pharmacist must work closely with the healthcare team to optimize drug therapy and improve patient education and compliance.

Use of licensed vaccines for active immunization of the immunocompromised host

The latter part of the 20th century has witnessed an unprecedented rise in the number of individuals with impaired immunity. This is primarily attributable to the increased development and use of antineoplastic therapy for malignancies, organ and bone marrow transplantation, and the AIDS epidemic. Individuals with impaired immunity are often at increased risk for infections, and they can experience more severe and complicated courses of infection. The lack of therapy for a variety of viruses and the rise in antimicrobial resistance of many pathogens have focused attention on vaccination to prevent infectious diseases. The efficacy of most licensed vaccines has been established in immunocompetent hosts. However, there is also considerable experience with most vaccines in those with impaired immunity. We reviewed the use of licensed live, inactivated, and polysaccharide vaccines in this group, and several themes emerged: (i) most vaccines are less immunogenic in those with impaired immunity than in normal individuals; (ii) live vaccines are generally contraindicated in this group; and (iii) the efficacy of many commonly used vaccines has not been established in people with impaired immunity. This review suggests that for most vaccines there are little or no efficacy data in those with impaired immunity but their use in this patient group is generally safe.