Immune response to influenza vaccination in ESRD patients undergoing hemodialysis vs. hemodiafiltration

Arkom Nongnuch,Prasert Auewarakul,Chompunuch Boonarkart,Sutheera Thongpraphai,Malinee Chittaganpitch,Nutaporn Sanmeema,Artit Wongsa,Boonrat Tassaneetrithep,Andrew Davenport,Wattanachai Ngampongpan,Angsana Phuphuakrat,Sirawat Srichatrapimuk,Florian Krammer

doi:10.1371/journal.pone.0227719

Abstract

BackgroundOn-line hemodiafiltration (HDF) clears more azotemic toxins compared to high-flux hemodialysis (HD). The response to vaccination is impaired in dialysis patients. We wished to determine whether the immune responses to influenza vaccine in dialysis patients treated by HDF were stronger than those treated by HD.Materials and methodsWe conducted a prospective cohort study in chronic dialysis patients during the 2016 and 2017 influenza seasons. All participants received a single standard dose of trivalent influenza vaccine, and we studied the elicited humoral immune response by hemagglutination inhibition test, and cell-mediated immune response by enumeration of lymphocyte cellular markers and proliferation assays.ResultsWe immunized 60 end-stage renal disease (ESRD) patients: 42 (70%) treated with HD and 18 patients (30%) with HDF. The median (interquartile range) age was 65.0 (55.0–74.5) years. All patients developed seroprotection to at least one influenza vaccine strain at one month post-vaccination, and did not differ between groups. By logistic regression, age was the only factor independently associated with seroconversion to all vaccine strains (odds ratio 0.89, 95% confidence interval 0.80–0.98; p = 0.022). Seroprotection to all vaccine strains was sustained for longer in patients treated with HDF, and the results remained the same after age adjustment. For cellular immune response, patients who seroconverted to all vaccine strains had higher CD38+ T cell subpopulations pre-vaccination. Patients treated by HDF had higher lymphocyte proliferation to circulating influenza A strains.ConclusionsSeroconversion to all influenza vaccine strains was associated with age. Patients treated with HDF demonstrated seroprotection was sustained for longer compared to those treated by HD and greater lymphocyte proliferation to circulating influenza A strains. These encouraging results for HDF require confirmation in a larger dialysis population.Trial registrationClinicalTrial.gov, NCT04122222.

Highlights

The retention of waste products of metabolism in patients with chronic kidney disease (CKD) leads to impaired function of the immune system; both innate and adaptive immunity [1,2,3]
Age was the only factor independently associated with seroconversion to all vaccine strains
Patients treated with HDF demonstrated seroprotection was sustained for longer compared to those treated by HD and greater lymphocyte proliferation to circulating influenza A strains

Summary

Introduction

The retention of waste products of metabolism in patients with chronic kidney disease (CKD) leads to impaired function of the immune system; both innate and adaptive immunity [1,2,3]. There have been reports directly linking the accumulation of azotemic toxins, non-protein nitrogenous compounds in blood such as blood urea nitrogen, creatinine, phenols, advanced glycosylation end products, and an impaired or dysregulated immune response [4,5,6], including reduced neutrophil phagocytosis [7], as well as reduced numbers of circulating monocytes [8], T-lymphocytes [9], and B-lymphocytes [10] This immune dysregulation increases the risk of infection, and as deaths from cardiovascular disease continue to fall, infection is an increasing cause of death in CKD patients.

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