Cybele Ghossein @cybeleg1
Cybele Ghossein is Professor of Medicine at the Feinberg School of Medicine at Northwestern University. She serves as Associate Chief for Clinical Operations in the Nephrology division and Vice-Chair of Academic and Faculty Affairs in the Department of Medicine. Her clinical interests include the management of CKD, especially in patients transitioning from the pediatric to the adult health care setting as well as the care of patients with scleroderma renal disease.
Competitors for the Vaccines Region
A few weeks ago, while on the critical care nephrology service, there were four patients with end-stage kidney disease (ESKD) admitted with pneumonia to the ICU. They were treated with antibiotics, received dialysis, and eventually discharged after a week-long admission to the hospital. Once discharged, patients with ESKD experience an increased mortality risk for the next 6 months.
Pneumonia is the second most common infectious disease in patients receiving maintenance hemodialysis and leads to significant morbidity and mortality. There are many reasons for this, not the least of which is the immune dysfunction that occurs in the uremic milieu which unfortunately can’t be modified. However, what may be modified is our efforts at prevention.
As nephrologists caring for patients with chronic kidney disease (CKD), there are many things that we need to address during routine follow-up appointments: hypertension, volume assessment, anemia, bone mineral metabolism, and dietary education just to name a few. Given that infections are among the leading causes of death in patients with CKD and ESKD, infection prevention should be an important part of routine care of all of our patients. The cornerstone of infection prevention is vaccination.
The Vaccines Region of NephMadness 2020 highlights the importance of the influenza and the pneumococcal vaccines in patients with ESKD. I don’t know which teams will be advancing to the next round of NephMadness but here are few things that I do know.
The eradication of the hepatitis B virus in dialysis units is evidence of the power of vaccination and improved infection control. We know it can be done. Now the focus needs to shift to other preventable infectious diseases.
Pneumococcal pneumonia is the leading cause of bacterial pneumonia. Two vaccines are available for pneumococcal disease and yet the rate of vaccination in our vulnerable population is just around 68% for pneumovax and under 10% for 13 valent pneumococcal conjugate vaccine (PCV13). Rates for revaccination and monitoring of immune response are unknown.
For seasonal influenza, we do a bit better with a vaccination rate of around 70%. For our vulnerable population, however, it should be 100%, especially given the fact that immunization is associated with lower rate of hospitalization, ICU stays, and death. We should also consider using the high-dose influenza immunization to improve immune response.
Some naysayers will argue that the reason for the lack of universal vaccination is that the immune response rate in this population is so low. That is not an argument to avoid vaccination but rather to vaccinate earlier in the development of CKD and to consider seroconversion monitoring like what is done with hepatitis B vaccination. This also brings to light the urgent need for more research around the improving immunogenicity in our patient population.
Other naysayers may suggest that immunizations should be provided by primary care physicians. I would argue that just like the management of hypertension, this is a shared responsibility. Nephrologists need to be more proactive with vaccinations. Let’s do better!
It is time to bring more awareness to the importance of vaccinations as part of our early action plan with patients with CKD. We won’t eradicate pulmonary infectious diseases, but hopefully we will make some improvement in our patients’ lives. I’m cheering for one of the teams in the Vaccines Region to win it all in NephMadness 2020 and you should as well.
– Guest Post written by Cybele Ghossein @cybeleg1
As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.