Diabetes, Immunology, and HBV Vaccine in Dialysis Patients
Diabetes, Immunology, and HBV Vaccine in Dialysis Patients
Background Patients on maintenance dialysis typically show a suboptimal immune response to hepatitis B virus vaccine compared with the non-uraemic population. A variety of inherited or acquired factors have been implicated in this diminished response. It is well known that patients with diabetes mellitus have a compromised immune system, and diabetic nephropathy is an important cause of chronic kidney disease. However, the impact of diabetes mellitus on the immune response to HBV vaccine in patients receiving long-term dialysis remains unclear.
Aim To evaluate the influence of diabetes mellitus on the immune response to HBV vaccine in dialysis population by performing a systematic review of the literature with a meta-analysis of clinical studies.
Methods We used the random effects model of DerSimonian and Laird with heterogeneity and sensitivity analyses. The end-point of interest was the rate of patients showing seroprotective antibody against hepatitis B surface antigen at completion of vaccine schedule in the diabetic vs. the nondiabetic dialysis individuals.
Results We identified 12 studies involving 1002 unique patients on long-term dialysis. Aggregation of study results showed a significant decrease in response rates among the diabetic vs. the nondiabetic patients [pooled odds ratio = 0.52 (95% CI 0.38–0.71)]. The P-value was 0.29 for our test of study heterogeneity. Stratified analysis in various subgroups of interest did not meaningfully change our results.
Conclusions Our meta-analysis showed a clear association between diabetes mellitus and impaired response to hepatitis B virus vaccine in individuals on long-term dialysis. Such a relationship is biologically plausible. Vaccination schedules with adapted vaccine doses and frequent serum testing for loss of immunity against hepatitis B virus should be considered in patients on maintenance dialysis with diabetes mellitus.
The frequency of hepatitis B virus (HBV) infection, as detected by persistent positivity for hepatitis B surface antigen in serum, is low but not negligible among patients with chronic kidney disease (CKD) on maintenance dialysis in the industrialised world. In 2002, the Centers for Disease Control and Prevention (CDC, Atlanta, GA, USA) has reported that the prevalence of HBsAg seropositivity among dialysis patients was 1% in the US. Also, outbreaks of HBV infection in haemodialysis (HD) units continue to occur. Prevalence and incidence rates of HBV infection remain much higher within dialysis units in less-developed countries. It is well known that patients undergoing long-term dialysis have a lower response to HBV vaccine compared with the non-uraemic population: the number of patients who develop protective antibody (anti-HBs) against HBV surface antigen (HBsAg) is lower, the antibody titres of those who mount an antibody response are reduced and decline faster over time.
Diabetic patients have a compromised immune system and their immunological response to HBV vaccine is less optimal than nondiabetic individuals; nevertheless, the influence of this metabolic disease on seroprotection rate after HBV vaccination is not well investigated in chronic dialysis patients. A few studies on HBV vaccination of patients with CKD and diabetes mellitus have been published and preliminary results have been given.
The goal of this study was to investigate the available evidence on the relationship between diabetes mellitus and immune response to HBV vaccination in long-term dialysis population by performing a systematic review of the literature with a meta-analysis of clinical studies.
Abstract and Introduction
Abstract
Background Patients on maintenance dialysis typically show a suboptimal immune response to hepatitis B virus vaccine compared with the non-uraemic population. A variety of inherited or acquired factors have been implicated in this diminished response. It is well known that patients with diabetes mellitus have a compromised immune system, and diabetic nephropathy is an important cause of chronic kidney disease. However, the impact of diabetes mellitus on the immune response to HBV vaccine in patients receiving long-term dialysis remains unclear.
Aim To evaluate the influence of diabetes mellitus on the immune response to HBV vaccine in dialysis population by performing a systematic review of the literature with a meta-analysis of clinical studies.
Methods We used the random effects model of DerSimonian and Laird with heterogeneity and sensitivity analyses. The end-point of interest was the rate of patients showing seroprotective antibody against hepatitis B surface antigen at completion of vaccine schedule in the diabetic vs. the nondiabetic dialysis individuals.
Results We identified 12 studies involving 1002 unique patients on long-term dialysis. Aggregation of study results showed a significant decrease in response rates among the diabetic vs. the nondiabetic patients [pooled odds ratio = 0.52 (95% CI 0.38–0.71)]. The P-value was 0.29 for our test of study heterogeneity. Stratified analysis in various subgroups of interest did not meaningfully change our results.
Conclusions Our meta-analysis showed a clear association between diabetes mellitus and impaired response to hepatitis B virus vaccine in individuals on long-term dialysis. Such a relationship is biologically plausible. Vaccination schedules with adapted vaccine doses and frequent serum testing for loss of immunity against hepatitis B virus should be considered in patients on maintenance dialysis with diabetes mellitus.
Introduction
The frequency of hepatitis B virus (HBV) infection, as detected by persistent positivity for hepatitis B surface antigen in serum, is low but not negligible among patients with chronic kidney disease (CKD) on maintenance dialysis in the industrialised world. In 2002, the Centers for Disease Control and Prevention (CDC, Atlanta, GA, USA) has reported that the prevalence of HBsAg seropositivity among dialysis patients was 1% in the US. Also, outbreaks of HBV infection in haemodialysis (HD) units continue to occur. Prevalence and incidence rates of HBV infection remain much higher within dialysis units in less-developed countries. It is well known that patients undergoing long-term dialysis have a lower response to HBV vaccine compared with the non-uraemic population: the number of patients who develop protective antibody (anti-HBs) against HBV surface antigen (HBsAg) is lower, the antibody titres of those who mount an antibody response are reduced and decline faster over time.
Diabetic patients have a compromised immune system and their immunological response to HBV vaccine is less optimal than nondiabetic individuals; nevertheless, the influence of this metabolic disease on seroprotection rate after HBV vaccination is not well investigated in chronic dialysis patients. A few studies on HBV vaccination of patients with CKD and diabetes mellitus have been published and preliminary results have been given.
The goal of this study was to investigate the available evidence on the relationship between diabetes mellitus and immune response to HBV vaccination in long-term dialysis population by performing a systematic review of the literature with a meta-analysis of clinical studies.
