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Vaccinations for kidney transplantation

What role does immunosuppression play

Vaccinations are an essential part of our healthcare. This also and even more so applies to patients under immunosuppression, i.e. patients who have undergone an organ transplant. Vaccinations are generally among the most effective health maintenance measures

Vaccines are divided into the two categories of "inactivated vaccines" and "live vaccines". In the case of inactivated vaccines, only killed pathogens or parts of the pathogen are used for vaccination, which means that the pathogen itself can no longer multiply and cannot cause disease. This is to be distinguished from "live vaccinations", in which the vaccination is carried out with a so-called "attenuated" pathogen, i.e. one that is weakened but still has a limited ability to reproduce.
The body is therefore presented with dead or weakened pathogens of certain infectious diseases, which leads to antibody production.
These antibodies then protect against the outbreak of this infectious disease in the future. Vaccinations are therefore often useful for transplanted patients - who are susceptible to infection due to immunosuppression - but the following three points should be noted:

1: which vaccine

In general, only so-called inactivated vaccines, i.e. vaccines in which proteins of the virus are administered together with adjuvants, should be used in organ transplant recipients. In a healthy person, the immune system is generally able to cope with a live vaccine so that no disease develops and protective antibodies are still formed at the same time. In a weakened immune system, however, there is a risk that pathogens can multiply uncontrollably and cause the original disease in part or even in its full clinical picture.

Vaccines based on messenger RNA (mRNA) are also to be regarded as dead vaccines and should not pose a risk in connection with transplantation and under immunosuppressive / immunomodulating therapy. However, no studies have yet been carried out on this.

2: when to vaccinate

Following an organ transplant, vaccinations may generally only be administered after a waiting period of several months, as the immune response is unlikely to be sufficient beforehand due to drug immunosuppression.

As the intensity of immunosuppression after transplantation changes over time, the best vaccination response is expected from six months to one year after organ transplantation.

The timing of the vaccination should be agreed with the transplant center. In principle, the response to vaccination in patients after kidney transplantation is determined by the extent of immunosuppressive therapy, i.e. which and how many drugs are taken and at what dose.

3: how to vaccinate

For patients with kidney transplants, it is particularly important to differentiate between the time before and after the transplant, as the recommended vaccinations differ. In addition, the patient's vaccination status should be checked before a planned kidney transplant and any outstanding vaccinations, especially missing live vaccinations, should be carried out.
It is important to ensure that a time interval of at least three months is observed between the live vaccination and the transplant. Furthermore, the vaccination status of the patient's family members should also be checked and refreshed.
This leads to so-called herd immunity, which protects the immunocompromised patient after transplantation by ensuring that those around them are vaccinated and therefore do not serve as disease carriers for the respective germ.

List of useful vaccinations after transplantation

Vaccinations recommended for all transplanted patients

  • Influenza including new flu or so-called "swine flu") - annually
  • Tetanus and diphtheria - every 5 years
  • Polio ("polio") - in the absence of basic immunization, no regular boosters for adults

Vaccinations for transplant patients who are particularly at risk

  • Pneumococcus - for all patients > 60 years of age or with frequent respiratory infections, booster every 6 years
  • TBE (meningitis transmitted by ticks)- in corresponding risk areas
  • Meningococcal disease (meningitis) - in the event of an acute outbreak with several cases of the disease in the surrounding area
  • Rabies - only if bitten by an animal considered to be infected
  • Hepatitis A - when travelling to risk areas and lack of basic immunization
  • Hepatitis B - should generally be carried out in the pre-dialysis stage

(Live) vaccinations not recommended

  • Measles, mumps, rubella
  • Chickenpox or shingles
  • Tuberculosis
  • Yellow fever - necessary for travel to regions in Africa and South America
  • Oral typhoid vaccine

List of vaccinations and boosters that are useful before a planned transplantation

Please only vaccinate after close consultation with the transplant center, as immunosuppression should be avoided within three months of a live vaccination*.

  • Hepatitis B
  • Hepatitis A
  • Tetanus/ diphtheria
  • Pneumococcus - pathogen of bacterial pneumonia
  • Haemophilus influenzae - bacteria that live on mucous membranes and can cause serious illnesses
  • Annual flu vaccination
  • Mumps, measles, rubella(*live vaccine) - if there is no proof of having had the disease or having been vaccinated (the detection of antibody titres is important)
  • Varicella zoster virus (*live vaccine) - virus that causes chickenpox and shingles, vaccination if VZV titre is negative
  • HPV vaccination in individual cases after consultation (human papilloma viruses are associated with various wart formations and cervical cancer)

Vaccination to protect against "Sars-CoV-2"

There are three main lines of development in the development of a vaccine for the novel coronavirus "Sars-Cov-2": Vaccines with vector viruses, inactivated vaccines with virus proteins or mRNA/DNA vaccines. You can find an overview of the candidates here.

What do we know about mRNA vaccines?

mRNA vaccines contain gene segments of the SARS-CoV-2 virus in the form of messenger RNA (mRNA for short), which is also known as messenger RNA. Based on the mRNA, proteins are produced in body cells after vaccination, which then stimulate the immune system to produce targeted antibodies against SARS-CoV-2 and a cellular defense against SARS-CoV-2-infected cells, thus generating an immune response. Proteins that stimulate an immune response are known as antigens. To enable uptake by a small number of body cells, the mRNA is coated with lipid substances to form so-called mRNA lipid nanoparticles. These are stable even after intramuscular injection and enable the mRNA to be taken up by a small number of muscle and immune cells. Studies have shown that the lipid nanoparticles are not cytotoxic (harmful to cells) and pose no danger to the human body. In the cells, the genetic information encoded on the mRNA is read out and translated into protein. This is a process that also takes place in body cells with the cell's own mRNA: Some COVID-19 mRNA vaccines are nucleoside-modified mRNA (modRNA), which encodes the SARS-CoV-2 surface protein (spike protein). The compatibility of modRNA is generally improved compared to unmodified mRNA. As an antigen, the viral protein formed from the mRNA stimulates the body's immune system to produce antibodies against SARS-CoV-2 (humoral immune response). Virus proteins can also trigger a T-cell response (CD4, CD8) (cellular immune response). The mRNA of the RNA vaccines is degraded by the cells after a short time. It is not converted into DNA and has no effect on human DNA, neither in somatic cells nor in germline cells. Once the mRNA has been broken down, no further production of the antigen takes place. mRNA-based vaccines have the advantage that a large number of vaccine doses can be produced within a few weeks. The mRNA-based COVID-19 vaccine candidates currently have to be transported and stored at low temperatures (-20 to -80 degrees C). For vaccines approved in Europe, their quality and production, safety and efficacy have been tested as part of controlled clinical trials in humans.

Source: STIKO / RKI 30.12.2020

What do we know about vector-based vaccines?

Vector-based vaccines consist of viruses that are harmless to humans and have been genetically modified so that they contain the genetic sequence with the blueprint for one or more components of the pathogen (antigen) in their genome. The COVID-19 vector vaccine candidates contain harmless, well-studied carrier viruses whose genome contains a gene that contains the blueprint for the SARS-CoV-2 surface protein, the spike protein. In the cells, the genetic information on the gene is read out and translated into protein. There are vector vaccines that are capable of replication and those that are not, neither of which cause disease in humans. The vector viruses therefore serve as a "gene shuttle" for the spike protein gene. As an antigen, the spike protein formed from the transferred gene stimulates the body's immune system to produce antibodies against SARS-CoV-2 (humoral immune response). In addition, a T-cell response (CD4, CD8) can be triggered (cellular immune response).

Vector viruses capable of replication only multiply for a limited time in the body of the vaccinated person. Vector viruses that are incapable of replication and capable of replication are controlled and eliminated by the immune system. Their genetic information is not incorporated into human DNA, neither in body cells nor in germline cells. After the degradation of the genetic information transferred by the vector viruses, no further production of the antigen takes place.

Vector vaccines have already been approved (e.g. Ebola vaccines) and can be produced relatively quickly. They can be transported and stored at temperatures of 2 to 8 degrees C.

The quality, production, safety and efficacy of vaccines licensed in Europe have been tested in controlled clinical trials in humans.



Source: STIKO / RKI 30.12.2020

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