A prospective study of hepatitis B vaccination - a comparison of responders versus nonresponders

Herein we present one of the largest single-center reports of the response of hemodialysis patients to a two-vaccine hepatitis B virus vaccination protocol in a European dialysis population. A hepatitis B recombinant DNA vaccine, HBvaxPRO, was given at a dose of 40 µg intramuscularly using a four-dose schedule at 0, 1, 2, and 12 months. Responses were (1) a titer >100 mIU/mL = patient immune, (2) a titer level 10-99 mIU/mL = give a booster dose and recheck level 2 months later, and (3) 0 ≤ 10 mIU/mL = repeat vaccination course using a different vaccine, Engerix-B. We compared responder groups in terms of titer levels for each vaccine and variables including age, gender, serum albumin, parathyroid hormone (PTH), calcium, phosphate, hemoglobin, years on dialysis, and type of dialysis access. Of the 176 patients who received the first vaccine course, 71 patients achieved immunity, that is, 40% uptake for the first vaccine. Of the 105 who failed, 72 received the second vaccine with 46 responders, that is, 64% uptake for the second vaccine. Overall, 143 of the 176 patients who entered the vaccination program completed the protocol with 117 achieving immunity, representing an 82% success rate. The only variable overall to show significance in achieving seroconversion was serum albumin (p = 0.03). Using a two-vaccine protocol, hepatitis B vaccination response was high in our population of end-stage renal disease patients.

Variability of hepatitis B testing in British Columbian ESRD patients: the case to focus on implementation of guidelines

BACKGROUND

Hepatitis B virus (HBV) immunization protocols are routinely followed in dialysis units. Recommendations for retesting and booster dose administration are variable and less well known.

DESIGN

Quality improvement report.

SETTING & PARTICIPANTS

Provincial dialysis cohort in all 5 regional centers in British Columbia (n = 1,055).

QUALITY IMPROVEMENT PLAN

(1) Describe the variations in HBV testing practice patterns between centers and modalities of dialysis, (2) propose an evidence-based protocol for HBV follow-up testing, and (3) compare the current practice for HBV follow-up testing with the protocol.

MEASURES

(1) Number of HBV tests performed based on geographic center and dialysis modality; (2) tabulation of local, national, and international guidelines to determine concordance and develop British Columbian protocol, and (3) percentage of patients who received recommended HBV testing based on protocol.

RESULTS

(1) Significant variation noted in HBV testing frequency among the 5 regional centers and between hemodialysis and peritoneal dialysis patients (P < 0.001); (2) current available guidelines generally are concordant, but vary in regard to frequency of follow-up testing; and (3) comparing recommended testing frequency with actual testing, 50% of patients were tested as recommended; 13%, less than recommended; and 37%, more than recommended. Hemodialysis patients often were tested more than recommended (hemodialysis, 47% versus peritoneal dialysis, 16%; P < 0.01). Patients with current or past HBV infection were tested more than recommended (P < 0.01). All variability remained significant when adjusted for age, sex, and dialysis therapy duration in a multivariate model.

LIMITATIONS

The cohort was ascertained from laboratory data; therefore, information for vaccination and booster dose administration was not available.

CONCLUSION

In a cohort of dialysis patients initially screened for hepatitis B, 50% of patients are being appropriately monitored with retesting compared with an evidence-based protocol. Patients with known HBV infection and hemodialysis patients are being tested more than recommended. Adherence to a protocol for retesting would ensure appropriate follow-up and reduce unnecessary retesting, potentially leading to significant cost savings.