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Preventive Care in End-Stage Renal Disease
Preventive care of dialysis patients encompasses general medical care issues as well as dialysis-specific issues that are detailed in preceding chapters. In this chapter, aspects of general medical preventive care are discussed as they apply to maintenance dialysis patients. The transplant status of a patient will affect some of these issues. For example, recommendations for cancer screening and immunizations will in part depend on the patient's transplant status, and when relevant, this will be noted. Specific patient recommendations for preventive care are based on the individual patient's prognosis and risk factors. The suggestions for dialysis patient preventive care that follow need to be individualized for specific patients by their nephrologists and dialysis care providers. Preventive care can be categorized into immunizations, infection prevention, screening, health care counseling, advance care planning (ACP), supportive care, and disease monitoring. Each of these is discussed in this chapter.
Immunizations
Table 62.1 lists the Centers for Disease Control and Prevention (CDC) recommendations for immunizations in dialysis patients based on age and transplant status. Although dialysis patients generally have a lower immunologic response and develop lower and less sustained antibody titers to immunizations, the CDC recommends vaccinating all dialysis patients. Despite less robust antibody responses, dialysis patients may be protected from infection, and vaccinating dialysis patients may reduce the risk for virus transmission in dialysis units. Altering immunization schedules and vaccine doses may, in some cases, improve the antibody response in dialysis patients. Dual vaccination (e.g., simultaneous tetanus and hepatitis B) has also been observed to improve antibody responses in dialysis patients. Live vaccines (varicella zoster, intranasal influenza, measles, mumps, rubella, yellow fever, bacillus Calmette-Guérin, and oral Salmonella typhi ) should not be administered to transplanted and immunosuppressed patients and thus should be given based on clinical circumstances.
Table 62.1
Recommended Adult Immunizations for Dialysis Patients
Based on Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule. http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf .
| Vaccine | Dosing and Information |
|---|---|
| Hepatitis B | 40 μg Recombivax HD on three-dose schedule or 40 μg Engerix-B on four-dose schedule |
| Hepatitis A | Only if another risk factor is present |
| Human papillomavirus | Female—two or three doses through age 26 years depending on age at initial dose Male—two or three doses through age 26 years depending on age at initial dose |
| Influenza | Age ≥ 19 years trivalent vaccine yearly |
| Measles, mumps, rubella | One or two doses if no immunity |
| Meningococcal | Only if another risk factor is present |
| Pneumococcal | Age ≥ 19 years, one dose PCV13 followed by one dose PPSV23 at least 8 weeks later; repeat PPSV23 in 5 years |
| Tetanus, diphtheria pertussis | One-time dose of Tdap (tetanus, diphtheria, and pertussis); then boost with Td (tetanus and diphtheria) every 10 years |
| Varicella zoster | Age ≥ 50 years two doses recombinant vaccine |
PCV13 , Pneumococcal conjugate vaccine; PPSV23 , pneumococcal polysaccharide vaccine.
Hepatitis B Vaccine
Table 62.1 summarizes the recommendations for vaccination. Because hepatitis B is transmitted via inoculation through exchange of blood products or body fluids and was responsible for infection outbreaks in dialysis units in the 1980s, hepatitis B vaccination is recommended for all dialysis patients, and monitoring for antibody protection is required. Only 34% to 88% of dialysis patients will develop immunity through vaccination, which is therefore suggested early in chronic kidney disease (CKD) to take advantage of a better-preserved immune response with less severe kidney disease. Vaccine manipulations (higher dose, extra doses, coadministration of immune modulators, or other vaccines) may improve the antibody response. Patients who do not respond to an initial vaccination series should have the series repeated once. Patients who lose antibody titers after an initial response to the vaccine should receive a booster dose. The precise timing of monitoring antibody titers is unclear.
Influenza and H1N1 Vaccine
Similar to the case with other vaccines, dialysis patients develop variable responses to influenza; 36% to 90% develop protective antibodies. Response to the H1N1 vaccine is similar, with 33% to 64% of dialysis patients developing antibodies. Older studies suggested that hospitalization and secondary pneumonia were more common among dialysis patients with influenza, leading to the recommendation that all dialysis patients receive yearly influenza vaccines. A more recent study suggested only a small benefit of influenza vaccination in dialysis patients but raised the issue of addressing vaccination strategies to maximize dialysis patient vaccine response (e.g., high-dose trivalent vaccine may be preferable in dialysis patients as it is in older adults; see Table 62.1 ). More recent studies comparing the high-dose influenza vaccine with standard-dose vaccine in dialysis patients found no significant difference in morbidity or mortality with the high-dose vaccine.
Tetanus, Pneumococcal, Human Papillomavirus, and Varicella Zoster Vaccines
There are few studies of antibody response to these vaccines in dialysis patients. Similar to other vaccines, the antibody response tends to be suboptimal and short-lived. The CDC continues to recommend routine vaccination of dialysis patients with these vaccines (see Table 62.1 ). If the patient was younger than 65 years of age upon initial pneumococcal vaccination, an additional dose should be given 5 years later. A tetanus, diphtheria, acellular pertussis vaccine became available in the United States in 2005 for those 11 to 64 years of age. A single booster vaccine dose is suggested for adults and is given 2 years or less after the initial vaccine in high-risk individuals. There is little information on the safety and efficacy of varicella zoster and human papillomavirus (HPV) vaccines in dialysis patients. Small studies suggest that girls with CKD developed antibodies to HPV vaccine, and thus, those less than 26 years of age should be vaccinated. The Shingrix vaccine is a recombinant vaccine (not a live vaccine like the older Zozstavax vaccine) and should be given to all dialysis patients over 50 years of age (see Table 62.1 ).
Infection Prevention
Probably because of their impaired immune response, including reduced B- and T-cell responses and phagocytosis, dialysis patients have a higher incidence of and are at higher risk of poor outcomes and complications with bacterial infections. Efforts to reduce dialysis access–associated infections may include the local application of antibiotic creams to access exit sites and intranasal application of antistaphylococcal creams in nasal carriers. Antimicrobial prophylaxis should also be considered a preventive strategy.
Diabetic Foot Care
A routine diabetic foot care program, including nursing assessment and patient education, may be associated with better footwear adequacy and a reduction in neuropathy, ultimately leading to fewer foot ulcers and wounds.
Dental Care
Periodontal disease, premature tooth loss, and xerostomia are more common among dialysis patients and can lead to systemic inflammation and morbidity. Some have implicated periodontal disease as an inflammatory factor contributing to cardiovascular disease in dialysis patients. Gingivitis and periodontitis are manifestations of poor dental health and are more common in dialysis patients. The cause of periodontal disease in dialysis patients is unclear, but impaired humoral responses and possibly bacterial colonization in response to repeated gingival bleeding from heparinization during dialysis have been postulated. Routine dental care (brushing, flossing, use of mouthwashes, and preventive care by dentists and hygienists) is also less common among dialysis patients. In addition, renal osteodystrophy can involve the mandible and maxilla, resulting in tooth mobility, malocclusion, enamel hypoplasia, metastatic soft tissue calcifications, and demineralization. Educating patients about the importance of routine preventive dental care may help to avoid subsequent issues and infections.
Endocarditis Prophylaxis
There are no data on the usefulness of antibiotic prophylaxis to prevent endocarditis in dialysis patients. However, for patients with known valvular abnormalities, prosthetic heart valves, congenital heart abnormalities, a history of endocarditis, or a heart transplant, antibiotic prophylaxis before dental or periodontal procedures is recommended. A single oral dose of amoxicillin (2 g) or clindamycin (600 mg) in those allergic to penicillin 1 hour before the procedure is recommended. Because of the high risk of endocarditis in the setting of a central venous catheter, dialysis patients with tunneled catheters should probably be considered for antibiotic prophylaxis despite the lack of such recommendations by the American Heart Association (AHA). The generalized immune-suppressed state of kidney failure prompts some to argue for antibiotic prophylaxis for all dialysis patients undergoing invasive procedures and dental treatments. There are reports of peritonitis occurring after colonoscopy with biopsy in peritoneal dialysis (PD) patients. For this reason, many nephrologists suggest antibiotic prophylaxis according to the AHA endocarditis prevention guidelines in PD patients undergoing colonoscopies. All PD patients should undergo such procedures with a dry peritoneum to reduce the risk of bacterial seeding of the peritoneal cavity filled with dextrose-rich dialysate.
Tuberculosis Screening
Tuberculosis (TB) is more common in patients with kidney failure, ranging from 6 to 25 times higher than in the general population. Dialysis patients also have a higher risk of developing clinical TB after exposure. Thus, it is important to detect latent TB infection and offer treatment. The tuberculin skin test is based on a delayed hypersensitivity response to a purified protein derivative (PPD) of Mycobacterium tuberculosis but has limited sensitivity in dialysis patients. T-cell interferon-γ release assays are now available as screening tests for M. tuberculosis infection and seem to be more sensitive screening tests for latent TB infection in patients with kidney failure. Because of the possible spread of TB in a dialysis unit, consideration should be given to screening patients with one of the interferon-γ release assays (QuantiFERON-TB Gold In-Tube or T-SPOT.TB).
Screening
Several screening protocols are recommended in the general population, many of which can be reviewed online at the American Preventive Task Force's website ( http://www.uspreventiveservicestaskforce.org ). Some of the recommendations for screening for disease in the general population may be applicable to dialysis patients, but many will not be, in large part because dialysis patients have a lower expected survival, making development of the disease for which screening is suggested unlikely. When considering screening in general, therefore, it is important to consider not only the risk of that disease in the population being screened but also the likelihood that the patient to be screened will live long enough to benefit from screening. For populations such as those on dialysis, a poor prognosis will limit the cost-effectiveness of screening. In addition, one must understand the positive and negative predictive values of the tests chosen to use for screening. Some diseases to be considered for screening in dialysis patients include cancer, falls and frailty, abdominal aortic aneurysms (AAAs), alcohol abuse, cognitive impairment, depression, and hearing and vision loss.
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