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Brazilian Journal of Nephrology

Print version ISSN 0101-2800

J. Bras. Nefrol. vol.33 no.3 São Paulo July/Sept. 2011 



Hepatitis B vaccination in hemodialysis patients: different points of view for conclusion


A vacinação contra hepatite B em pacientes em hemodiálise: diferentes pontos de vista para a conclusão



Seyed Moayed Alavian

Baqiyatallah Research Center for Gastroenterology and Liver Disease

Correspondence to




The present letter to the editor shows the other aspect of Hepatitis B vaccination in hemodialysis patients.

Keywords: Renal dialysis. Vaccination. Hepatite B. Hepatitis B.


A presente carta para o editor mostra ou- tro aspecto da vacinação contra Hepatite B em pacientes de hemodiálise.

Palavras-chave: Diálise renal. Vacinação.




I read with interest the recently published article entitled "Low response to intradermal hepatitis B vaccination in incident hemodialysis patients", by Medeiros et al.1 in your journal. Despite preventive control measures for hepatitis B virus (HBV) infection and decline in incidence of HBV infection, hemodialysis (HD) patients seem to be at considerable risk of acquiring this infection.2 Due to lower response to HBV vaccine in hemodialysis patients, there are some recommendations such as using different inoculations routes, adding some adjuvants,3 and increasing the number of HBV vaccine injection to increase anti-HBV response in HD patients. The rate of sero-protection after HBV vaccination in hemodialysis patients is highly variable and generally lower than that of the general population.

In this study, intradermal (ID) and intramuscular (IM) groups received inoculations at equal time intervals, while in most studies that have shown the priority of ID route over IM route, HD patients had received more number of vaccine injections. Failure to maintain sero-response after vaccination in HD patients has been also attributed to inherited and acquired factors such as sex, age, uremic state, nutritional status, route of administration, and relative immunodeficiency diseases which characterized impaired response to several other vaccines.4 Another important factor is age. Fabrizi et al. - in a meta-analysis on 8 trials that had assessed the HB vaccine response rate according to the age, with cutoff point of 40 years old - found that dialysis subjects who were over 40 years old have 0.7 of probability of subjects younger than 40 years to develop sero-protection after hepatitis B vaccination.5 There are several reports of trials that compared effect of using different routes of vaccination on hepatitis B vaccine sero-protection in dialysis subjects with renal failure. The cost and side effects of vaccination should be considered in our conclusion.4 The authors finished the study after interim evaluation that the antibody titers were not protective in ID group. I think they had another choice and it was crossing the two groups. It also should be mentioned that the correct unit of vaccine dose is microgram, not milligram; it seems it was a typing mistake. Finally, I would like to mention that it is very soon to conclude that vaccine administration is less effective by IM route than ID route. Nevertheless, lower doses of ID vaccine have been effectively used in healthy subjects. Additionally, it should not be overlooked that adequate immune responses were induced by higher doses of ID vaccine, or with more frequent vaccine injections.4



1. Medeiros RH, Figueiredo AE, Poli-de-Figueiredo CE, d'Avila DO, de Los Santos CA. Low response to intradermal hepatitis B vaccination in incident hemodialysis patients. J Bras Nefrol 2011;33:45-9.         [ Links ]

2. Mahdavimazdeh M, Hosseini-Moghaddam SM, Alavian SM, Yahyazadeh H. Hepatitis B infection in hemodialysis patients in Tehran Province, Iran. Hepat Mon 2009;9:206-10.         [ Links ]

3. Alavian SM, Tabatabaei SV. Effects of oral levamisole as an adjuvant to hepatitis B vaccine in adults with end-stage renal disease: a meta-analysis of controlled clinical trials. Clin Ther 2010;32: 1-10.         [ Links ]

4. Fabrizi F, Dixit V, Messa P, Martin P. Intradermal vs intramuscular vaccine against hepatitis B infection in dialysis patients: a meta-analysis of randomized trials. J Viral Hepat 2010 [Epub ahead of print]         [ Links ].

5. Fabrizi F, Martin P, Dixit V, Bunnapradist S, Dulai G. Meta-analysis: the effect of age on immunological response to hepatitis B vaccine in end-stage renal disease. Aliment Pharmacol Ther 2004;20:1053-62.         [ Links ]



Correspondence to:
Seyed Moayed Alavian
Postal Address: P.O.Box
14155/3651, Tehran, I.R.Iran

Data de submissão: 07/06/2011
Data de aprovação: 07/06/2011

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