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Defective immune response to tetanus toxoid in hemodialysis patients and its association with diphtheria vaccination
Vaccine 17 (1999) 1145±1150
Defective immune response to tetanus toxoid in hemodialysis patients and its association with diphtheria vaccination Sabine KruÈger a, *, Michael Seyfarth b, Klaus Sack a, Burkhard Kreft a a Department of Internal Medicine I, University of LuÈbeck Medical School, Ratzeburger Allee 160, 23538 LuÈbeck, Germany Institute of Immunology and Transfusion Medicine, University of LuÈbeck Medical School, Ratzeburger Allee 160, 23538 LuÈbeck, Germany
b
Received 11 May 1998; received in revised form 24 July 1998; accepted 19 August 1998
Abstract The incidence of infectious diseases is increased in patients with chronic renal failure. This is thought to be due to an impaired T cell stimulation by antigen presenting cells. Immunization programs are of great signi®cance in the prevention of infections in immunocompromised individuals. However, the immune response to various vaccinations is impaired in patients with chronic renal failure. So far only few studies have focused on seroresponse to tetanus toxoid. Therefore we measured the levels of antitetanus toxoid antibodies in 71 hemodialysis patients with unknown vaccination history. The antibody levels were detected prior to and twelve months after a single ``Td'' or ``Td±d±d'' vaccination. Initially only 31 (44%) of the patients had a sucient protection against tetanus. Of the unprotected patients 15 (38%) seroconverted after immunization, while 25 (63%) did not respond. We found a high association ( p < 0.04, Fisher's exact test) between the ecacy of vaccination against diphtheria and tetanus. Out of 38 initially unprotected patients 27 (71%) showed a similar response to both vaccines: 9 (24%) individuals seroconverted, while 18 (47%) did not. Our data clearly demonstrate the need for frequent monitoring of antibody levels after immunization against tetanus and diphtheria in hemodialysis patients. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: Tetanus and diphteria vaccination; Chronic renal failure; Hemodialysis
1. Introduction The vaccination against tetanus has led to a signi®cant decrease of the disease after infection with Clostridium tetani. However, recent epidemiologic studies indicate that the number of insuciently protected individuals has increased especially in the elderly [1, 2]. Patients with chronic renal failure have a higher incidence of infectious diseases [3], this is thought to be related to an impaired T cell activation by antigen presenting cells [4]. Therefore the response of hemodialysis patients to T cell dependent and independent vaccination is of interest. T cell independent pneumococcal vaccine initially causes a sucient immune response in children and young adults with chronic renal * Corresponding author. Tel.: +49-451-500-3388; fax: +49-451500-3380. 0264-410X/99/$19.00 # 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 2 6 4 - 4 1 0 X ( 9 8 ) 0 0 3 3 4 - X
disease followed by a rapid decline of antibody levels after six and twelve months [5]. In contrast hemodialysis patients have shown a normal response to vaccination against varicella virus [6] while trivalent in¯uenza vaccination [7] produced signi®cantly lower antibody levels compared to healthy controls. Few studies focused on seroconversion after immunization with tetanus toxoid in patients with chronic renal failure [9, 19]. Girndt et al. found a high association of impaired immune response to triple tetanus vaccination and a previously administered vaccination against hepatitis B [9]. We have previously demonstrated an impaired immune response to single and triple diphtheria vaccination in hemodialysis patients [8]. These patients received a simultaneous vaccination against tetanus and diphtheria. We hypothesize that the immune response to tetanus toxoid is correlated to the ecacy of diphtheria or hepatitis B immunization or certain clinical parameters.
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2. Methods 2.1. Patients and serum sampling A total of 71 patients (43 male and 28 female) on chronic hemodialysis were included into our study. The tetanus vaccination history of these patients was unknown, which provided an indication for immunization. The average age was 59.7 2 7.7 yr. Informed consent was taken of each patient prior to the ®rst blood test. The study design was approved by the local ethics committee. Blood samples for anti-tetanus toxoid antibody measurement were taken before and twelve months after a ``Td'' or ``Td±d±d'' vaccination with 40 IU/ml tetanus toxoid and 4 IU/ml diphtheria toxoid each (Td: charge 21021A, d: charge 26071 and 27011, Chiron-Behring, Marburg, Germany) [8]. The vaccine was injected into the M. deltoideus of the contralateral arm of vascular dialysis access. The two following diphtheria vaccines (d±d) were given one and six months after the Td vaccine. Patients treated with immunosuppressive drugs or with severe acute or chronic diseases were not included into the study. Beside the anti-tetanus toxoid antibody levels, serum levels of phosphate, calcium, parathyroid hormone and anti-HBs antibody were measured before the ®rst vaccination. Furthermore, the response to diphtheria and hepatitis B vaccination was recorded as well as underlying renal diseases, duration and intensity of hemodialysis and therapy with dihydroxyvitamin D3 (1,25-D3) and erythropoietin. 2.2. Detection of anti-tetanus toxoid antibodies The level of antibodies against tetanus toxoid was measured by enzyme-linked immunosorbent assay (ELISA, Immuno, Heidelberg) as previously described [11, 14, 15]. Blood samples were centrifuged (10 min, 206 g, 48C) immediately after they had been drawn, and testsera were stored at ÿ208C until antibody detection. The ELISA procedures were performed in anti-tetanus toxoid antibody coated microtiter plates according to the manufacturer's protocol. The enzymatic turnover of tetramethylbenzidine by peroxidase was measured at 450 nm. The speci®c antibody concentration was determined by comparison with standard control sera. 2.3. Statistical analysis All sera were measured twice and the mean value was taken for statistical analysis. The Mann±Whitney U-test was used to evaluate the in¯uence of age, months on hemodialysis, dialysis time per week, hemoglobin, white blood cell count, platelets, serum phosphate, calcium, parathyroid hormone, anti-HBs
antibody level and the dose of 1,25-D3 and erythropoietin treatment on seroconversion after tetanus vaccination. Antibody concentration and possible factors of in¯uence were tested with the Spearman rank correlation. Categories were compared using Fisher's exact test. A p-value of <0.05 was considered to be signi®cant. 3. Results 3.1. Immunity against tetanus in hemodialysis patients Protection against tetanus was de®ned as an initial antibody level of >0.1 IU/ml as previously described [1]. Out of 71 patients on chronic hemodialysis only 31 (44%) had a sucient protection against tetanus. In the healthy control group, however, 8 of 9 individuals (89%) were protected. When regarding dierent sexes in our hemodialysis collective, the proportion of protected patients was larger in males compared to females, but the dierence was statistically not signi®cant (Fig. 1a). Additionally, in women we found a signi®cantly lower antibody concentration than in men (0.54 21.2 vs. 1.15 2 1.84; p < 0.03). There was no correlation between dierent modalities of renal replacement therapy (hemo®ltration, hemodialysis, hemodia®ltration) and antibody concentrations. 3.2. Seroconversion rates after tetanus vaccination A seroconversion from <0.1 to r0.1 IU/ml twelve months after vaccination was considered to be a response, while no increase r0.1 IU/ml or a decrease to <0.1 IU/ml was considered a non-response. 15 (38%) of 40 hemodialysis patients unprotected before vaccination responded to the tetanus vaccine whereas the majority of 25 (62%) patients did not respond. In our hemodialysis collective, there were more men than women (43 vs. 28). Yet, in the responder and nonresponder groups only half of the patients were male (Fig. 1b). Concerning the antibody concentrations twelve months after vaccination, no signi®cant dierence between male and female could be found ( p < 0.09) (Fig. 2). For 1,25-D3 and erythropoietin dierent immunomodulating properties have been shown in hemodialysis patients [12, 13]. Therefore, we tested whether therapy with 1,25-D3 or erythropoietin had an in¯uence on immune response to tetanus vaccination. However, no correlation was found between 1,25-D3 and erythropoietin therapy and seroconversion after tetanus vaccination. Because it is known that the antibody production is impaired in elderly people [14, 15], we studied the seroconversion in initially unprotected
S. KruÈger et al. / Vaccine 17 (1999) 1145±1150
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Fig. 1. Relation between male and female in our hemodialysis collective concerning rates of protection (antibody level of r0.1 IU/ml) (a) and seroconversion of unprotected patients (responder: from <0.1 IU/ml prior to to r0.1 IU/ml after vaccination; non-responder: <0.1 IU/ml) after vaccination with tetanus toxoid (b). Hatched q = female; shaded q = male. HD: hemodialysis.
patients with the age of R60 yr. In this group (n = 13) six people (46%) responded, while 7 (54%) did not respond to the vaccine. Though the number of patients R60 yr of age was relatively small, there was a tendency that patients treated with a higher dose of 1,25D3 showed a better response toward vaccination
( p < 0.09). The responders received an average dose of 2.63 21.84 mg/week while the non-responders were treated with less than the half dose (0.962 0.80 mg/ week). Birmingham et al. found an improved response to tetanus immunization after the application of human recombinant erythropoietin [10]. Neither in all
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Fig. 2. Antibody levels of hemodialysis patients (HD) before and twelve months after immunization with tetanus toxoid are given according to sexes. Hatched q = female; shaded q = male. MW2S.D. Signi®cant correlations were determined by Mann±Wilcoxon U-test and are indicated as *=p < 0.05.
patients nor in this group R60 yr of age had erythropoietin therapy an in¯uence on immune response (data not shown). We further investigated whether dierent serum parameters such as calcium, phosphate and parathyroid hormone or white blood cell count, platelets, hemoglobin, anti-HBs antibody level and weekly hours of hemodialysis correlated with the response rate and found that seroconversion occurred independently of those parameters (data not shown). 3.3. Immune response to tetanus toxoid in comparison to diphtheria and hepatitis B vaccination The response to diphtheria vaccination in 69 out of 71 patients immunized against tetanus was known because these patients were included in another study [8]. Eective seroconversion concerning diphtheria was de®ned as an increase of antibody concentration from <0,1 IU/ml prior to to r0.1 IU/ml
three or six months after vaccination. 41 patients (59%) did not respond while 28 patients (41%) responded to the diphtheria vaccine. For a comparison only those patients that were unprotected prior to tetanus vaccination were included (n = 38). 18 of the nonresponders (47%) against diphtheria vaccine also failed to develop sucient anti-tetanus toxoid antibody levels, while 9 patients (23%) responded to both vaccines. The response to tetanus toxoid was highly associated with the response to diphtheria vaccination ( p < 0.04; Fisher's exact test) (Table 1, left). We also tested whether there is an association with the outcome after hepatitis B vaccination as reported in another study [9]. The data of seroconversion after hepatitis B vaccination were compiled retrospectively in only 30 patients. 21 hemodialysis patients (70%) responded to hepatitis B vaccination, while 9 (30%) did not respond. No signi®cant association was found with seroconver-
Table 1 Association between the response to tetanus toxoid and the response to diphteria toxoid after simultaneous immunization (left) and the response to previously administered hepatitis B vaccine (right) Tetanus Diphtheria Responder Non-Responder
Tetanus
responder
non-responder
9 (24%) 5 (13%) 14
6 (16%) 18 (47%) 24
15 23 n = 38
Hepatitis B
responder
non-responder
Responder Non-Responder
10 (33%) 1 (3%) 11
11 (37%) 8 (27%) 19
21 9 n = 30
S. KruÈger et al. / Vaccine 17 (1999) 1145±1150
sion rates after immunization against hepatitis B and tetanus (Table 1, right). 4. Discussion The manifest disease after infection with Clostridium tetani can easily be prevented by vaccination. Therefore, in industrialized countries, the incidence of tetanus is a result of incomplete immunization. Dierent groups in the United States and Europe have shown that mainly elderly people and women more than 40 yr of age lack a sucient antibody protection [1, 2, 16, 17]. Also, the incidence of tetanus and the case-fatality ratio is higher in older people [2, 18]. The immunode®ciency in patients with chronic renal failure makes them prone to more fatal outcomes of infectious diseases. Few studies exist on immunization against tetanus in patients with chronic renal failure [9, 10, 19]. In our group of hemodialysis patients, all lacking a documented vaccination history, only 44% had a protective anti-tetanus toxoid antibody level. Another group found a protection rate of 39.4% [19] in their hemodialysis collective, while Girndt et al. had 23% unprotected in their study group [9], which might be underestimated since they did not screen antibody levels in immunized patients that were included in their study. Seronegative patients on chronic hemodialysis showed an impaired immune response after immunization with tetanus toxoid. The majority (63%) did not respond after a single vaccination. These data con®rm former studies reporting non-responder rates of 69% [9] and 62% [19] after triple vaccination. Guerin et al. found a seroconversion rate one month after the third vaccination of 97% which declined six months later to 62%. These ®ndings provide evidence that the outcome after single or triple vaccination is quite similar. The immune defect of patients with chronic renal failure is characterized by the lacking ability of antigen presenting cells to provide a costimulatory signal in association with presented antigen [4, 20]. This leads to impaired T helper cell stimulation with the consequence of less dierentiation of B cells to speci®c antibody producing plasma cells. Tetanus toxoid is a T cell dependent vaccine such as diphtheria toxoid and hepatitis B vaccine. Therefore, we tested the hypothesis that hemodialysis patients have a similar seroconversion rate after immunization against diphtheria, hepatitis B and tetanus. We found a correlation of the response rate to tetanus toxoid with that to diphtheria toxoid ( p < 0.04; Fisher's exact test). 71% of the patients showed the same reaction towards tetanus and diphtheria vaccination. In contrast to other investigators [9], we found no signi®cant association between vaccination against tetanus and hepatitis B.
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Although the immune response to both vaccines is T cell dependent, the response to bacterial and viral antigen might dier in detail. The in¯uence of treatment with 1,25-D3 on speci®c antibody production primarily has to be considered as not signi®cant. However, there was a tendency ( p < 0.09) among patients R60 yr of age to gain pro®t out of therapy with higher doses of 1,25-D3. Further studies with larger patient numbers are necessary to con®rm these ®ndings. These ®ndings could not be con®rmed by our results. This study provides evidence that more than half of hemodialysis patients has no sucient protection against infection with Clostridium tetani. However, a single vaccination with tetanus toxoid leads to a relatively poor seroconversion rate compared with studies in healthy individuals (62% vs. 91±96% reviewed in [18]). Regular controls of anti-tetanus toxoid antibodies are therefore recommended and further studies are needed to ®nd an appropriate time course of revaccination.
Acknowledgements This study was supported by the Deutsche Forschungsgemeinschaft, Sonderforschungsbereich 367, B3 [BK]. The authors appreciate the cooperation of Drs. Schulz/Winterho, LuÈbeck, Drs. SchuÈmann/ Wilhelm, LuÈbeck, Drs. Kirsch/FaÈrber, Reinbek and Drs. Graf/Wedel/Brockmann, Bad Bevensen (all Germany) and the technical assistance of Friederike MuÈller.
References [1] Klouche M, GoÈrg S, Wilhelm D, Kirchner H. Geschlechts- und altersabhaÈngige LuÈcken im Tetanusimmunschutz. Deutsche medizinische Wochenschrift 1994;119:827±32. [2] Gergen PJ, McQuillan GM, Kiely M, Ezzati-Rice TM, Sutter RW, Virella G. A population-based serologic survey of immunity to tetanus in the united states. The New England Journal of Medicine 1995;332:761±6. [3] KoÈhler H, Girndt M, Dumann H, Klingel R. Immundefekt bei Niereninsuzienz. Deutsche medizinische Wochenschrift 1993;118:790±5. [4] Girndt M, KoÈhler H, Schiedhelm-Weick E, Meyer zum BuÈschenfelde K-H, Fleischer B. T cell activation defect in hemodialysis patients: evidence for a role of the B7/CD28 pathway. Kidney International 1993;44:359±65. [5] Fuchshuber A, KuÈhnemund O, Keuth B, LuÈtticken R, Michalk D, Querfeld U. Pneumococcal vaccine in children and young adults with chronic renal disease. Nephrology Dialysis Transplantation 1996;11:468±73. [6] Broyer M, Boudailliez B. Varicella vaccine in children with chronic renal insuciency. Postgraduate Medical Journal 1985;61:103±6.
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[7] Beyer WEP, Versluis DJ, Kramer P, Diderich PPMN, Weimar W, Masurel N. Trivalent in¯uenza vaccine in patients on haemodialysis: impaired seroresponse with dierences for A-H3N2 and A-H1N1 vaccine components. Vaccine 1987;5:43±8. [8] Kreft B, Klouche M, Kreft R, Kirchner H, Sack K. Low eciency of active immunization against diphtheria in chronic hemodialysis patients. Kidney International 1997;52:212±6. [9] Girndt M, Pietsch M, KoÈhler H. Tetanus immunzation and its association to hepatitis B vaccination in patients with chronic renal failure. American Journal of Kidney Diseases 1995;26:454±60. [10] Birmingham DJ, Shen XP, Hartman JA, Dillon JJ, Hebert LA. Eect of human recombinant erythropoietin therapy on antibody response to immunization in chronic hemodialysis patients. Kidney International 1996;50:543±9. [11] Stier-Rosenberg G, Fey H. Messung von Tetanus-Antitoxin mit dem Enzyme-linked immunosorbent assay (ELISA). Schweiz. med. Wschr. 1977;107:1101±4. [12] HuÈbel E, Kiefer T, Weber J, Mettang T, Kuhlmann U. In vivo eect of 1,25-dihydroxyvitanin D3 on phagocyte function in hemodialysis patients. Kidney International 1991;40:927±33. [13] Zarrabeitia MT, Riancho JA, de Francisco ALM, GonzalezMacias J. Eect of physiological concentrations of calcitriol on lymphocyte proliferation in normal subjects and in patients with renal failure. Nephron 1990;55:110±3.
[14] Ruben FL, Nagel J, Fireman P. Antitoxin responses in the elderly to tetanus-diphtheria (TD) immunization. American Journal of Epidemiology 1978;108:145±9. [15] Kishimoto S, Tomino S, Mitsuya H, Fujiwara H, Tsuda H. Age-related decline in the in vitro and in vivo syntheses of antitetanus toxoid antibody in humans. Journal of Immunology 1980;125:2347±52. [16] Weiss B, Strassburg MA, Feeley JC. Tetanus and diphtheria immunity in an elderly population in Los Angeles County. American Journal of Public Health 1983;73:802±4. [17] Hammer K, Rothkopf-Ischebeck M, Meixner M. Aktuelle Impfstatuserhebung fuÈr Tetanus, Diphtherie und Poliomyelitis bei Erwachsenen. InfFo des Robert-Koch-Instituts 1997;1:35±7. [18] Wassilak SGF, Orenstein WA, Sutter RW. Tetanus toxoid. In: Plotkin SA, Mortimer EA Jr, editors. Vaccines. Philadelphia: Saunders, 1994:57±90. [19] Guerin A, Biusson Y, Nutini MT, Saliou P, London G, Marchais S. Response to vaccination against tetanus in chronic haemodialysed patients. Nephrology Dialysis Transplantation 1992;7:323±6. [20] Meuer SC, Hauer M, Kurz P, Meyer zum BuÈschenfelde KH, KoÈhler H. Selective blockade of the antigen-receptor-mediated pathway of T cell activation in patients with impaired immune responses. Journal of Clinical Investigation 1987;80:743±9.
Defective immune response to tetanus toxoid in hemodialysis patients and its association with diphtheria vaccination Sabine KruÈger a, *, Michael Seyfarth b, Klaus Sack a, Burkhard Kreft a a Department of Internal Medicine I, University of LuÈbeck Medical School, Ratzeburger Allee 160, 23538 LuÈbeck, Germany Institute of Immunology and Transfusion Medicine, University of LuÈbeck Medical School, Ratzeburger Allee 160, 23538 LuÈbeck, Germany
b
Received 11 May 1998; received in revised form 24 July 1998; accepted 19 August 1998
Abstract The incidence of infectious diseases is increased in patients with chronic renal failure. This is thought to be due to an impaired T cell stimulation by antigen presenting cells. Immunization programs are of great signi®cance in the prevention of infections in immunocompromised individuals. However, the immune response to various vaccinations is impaired in patients with chronic renal failure. So far only few studies have focused on seroresponse to tetanus toxoid. Therefore we measured the levels of antitetanus toxoid antibodies in 71 hemodialysis patients with unknown vaccination history. The antibody levels were detected prior to and twelve months after a single ``Td'' or ``Td±d±d'' vaccination. Initially only 31 (44%) of the patients had a sucient protection against tetanus. Of the unprotected patients 15 (38%) seroconverted after immunization, while 25 (63%) did not respond. We found a high association ( p < 0.04, Fisher's exact test) between the ecacy of vaccination against diphtheria and tetanus. Out of 38 initially unprotected patients 27 (71%) showed a similar response to both vaccines: 9 (24%) individuals seroconverted, while 18 (47%) did not. Our data clearly demonstrate the need for frequent monitoring of antibody levels after immunization against tetanus and diphtheria in hemodialysis patients. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: Tetanus and diphteria vaccination; Chronic renal failure; Hemodialysis
1. Introduction The vaccination against tetanus has led to a signi®cant decrease of the disease after infection with Clostridium tetani. However, recent epidemiologic studies indicate that the number of insuciently protected individuals has increased especially in the elderly [1, 2]. Patients with chronic renal failure have a higher incidence of infectious diseases [3], this is thought to be related to an impaired T cell activation by antigen presenting cells [4]. Therefore the response of hemodialysis patients to T cell dependent and independent vaccination is of interest. T cell independent pneumococcal vaccine initially causes a sucient immune response in children and young adults with chronic renal * Corresponding author. Tel.: +49-451-500-3388; fax: +49-451500-3380. 0264-410X/99/$19.00 # 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 2 6 4 - 4 1 0 X ( 9 8 ) 0 0 3 3 4 - X
disease followed by a rapid decline of antibody levels after six and twelve months [5]. In contrast hemodialysis patients have shown a normal response to vaccination against varicella virus [6] while trivalent in¯uenza vaccination [7] produced signi®cantly lower antibody levels compared to healthy controls. Few studies focused on seroconversion after immunization with tetanus toxoid in patients with chronic renal failure [9, 19]. Girndt et al. found a high association of impaired immune response to triple tetanus vaccination and a previously administered vaccination against hepatitis B [9]. We have previously demonstrated an impaired immune response to single and triple diphtheria vaccination in hemodialysis patients [8]. These patients received a simultaneous vaccination against tetanus and diphtheria. We hypothesize that the immune response to tetanus toxoid is correlated to the ecacy of diphtheria or hepatitis B immunization or certain clinical parameters.
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S. KruÈger et al. / Vaccine 17 (1999) 1145±1150
2. Methods 2.1. Patients and serum sampling A total of 71 patients (43 male and 28 female) on chronic hemodialysis were included into our study. The tetanus vaccination history of these patients was unknown, which provided an indication for immunization. The average age was 59.7 2 7.7 yr. Informed consent was taken of each patient prior to the ®rst blood test. The study design was approved by the local ethics committee. Blood samples for anti-tetanus toxoid antibody measurement were taken before and twelve months after a ``Td'' or ``Td±d±d'' vaccination with 40 IU/ml tetanus toxoid and 4 IU/ml diphtheria toxoid each (Td: charge 21021A, d: charge 26071 and 27011, Chiron-Behring, Marburg, Germany) [8]. The vaccine was injected into the M. deltoideus of the contralateral arm of vascular dialysis access. The two following diphtheria vaccines (d±d) were given one and six months after the Td vaccine. Patients treated with immunosuppressive drugs or with severe acute or chronic diseases were not included into the study. Beside the anti-tetanus toxoid antibody levels, serum levels of phosphate, calcium, parathyroid hormone and anti-HBs antibody were measured before the ®rst vaccination. Furthermore, the response to diphtheria and hepatitis B vaccination was recorded as well as underlying renal diseases, duration and intensity of hemodialysis and therapy with dihydroxyvitamin D3 (1,25-D3) and erythropoietin. 2.2. Detection of anti-tetanus toxoid antibodies The level of antibodies against tetanus toxoid was measured by enzyme-linked immunosorbent assay (ELISA, Immuno, Heidelberg) as previously described [11, 14, 15]. Blood samples were centrifuged (10 min, 206 g, 48C) immediately after they had been drawn, and testsera were stored at ÿ208C until antibody detection. The ELISA procedures were performed in anti-tetanus toxoid antibody coated microtiter plates according to the manufacturer's protocol. The enzymatic turnover of tetramethylbenzidine by peroxidase was measured at 450 nm. The speci®c antibody concentration was determined by comparison with standard control sera. 2.3. Statistical analysis All sera were measured twice and the mean value was taken for statistical analysis. The Mann±Whitney U-test was used to evaluate the in¯uence of age, months on hemodialysis, dialysis time per week, hemoglobin, white blood cell count, platelets, serum phosphate, calcium, parathyroid hormone, anti-HBs
antibody level and the dose of 1,25-D3 and erythropoietin treatment on seroconversion after tetanus vaccination. Antibody concentration and possible factors of in¯uence were tested with the Spearman rank correlation. Categories were compared using Fisher's exact test. A p-value of <0.05 was considered to be signi®cant. 3. Results 3.1. Immunity against tetanus in hemodialysis patients Protection against tetanus was de®ned as an initial antibody level of >0.1 IU/ml as previously described [1]. Out of 71 patients on chronic hemodialysis only 31 (44%) had a sucient protection against tetanus. In the healthy control group, however, 8 of 9 individuals (89%) were protected. When regarding dierent sexes in our hemodialysis collective, the proportion of protected patients was larger in males compared to females, but the dierence was statistically not signi®cant (Fig. 1a). Additionally, in women we found a signi®cantly lower antibody concentration than in men (0.54 21.2 vs. 1.15 2 1.84; p < 0.03). There was no correlation between dierent modalities of renal replacement therapy (hemo®ltration, hemodialysis, hemodia®ltration) and antibody concentrations. 3.2. Seroconversion rates after tetanus vaccination A seroconversion from <0.1 to r0.1 IU/ml twelve months after vaccination was considered to be a response, while no increase r0.1 IU/ml or a decrease to <0.1 IU/ml was considered a non-response. 15 (38%) of 40 hemodialysis patients unprotected before vaccination responded to the tetanus vaccine whereas the majority of 25 (62%) patients did not respond. In our hemodialysis collective, there were more men than women (43 vs. 28). Yet, in the responder and nonresponder groups only half of the patients were male (Fig. 1b). Concerning the antibody concentrations twelve months after vaccination, no signi®cant dierence between male and female could be found ( p < 0.09) (Fig. 2). For 1,25-D3 and erythropoietin dierent immunomodulating properties have been shown in hemodialysis patients [12, 13]. Therefore, we tested whether therapy with 1,25-D3 or erythropoietin had an in¯uence on immune response to tetanus vaccination. However, no correlation was found between 1,25-D3 and erythropoietin therapy and seroconversion after tetanus vaccination. Because it is known that the antibody production is impaired in elderly people [14, 15], we studied the seroconversion in initially unprotected
S. KruÈger et al. / Vaccine 17 (1999) 1145±1150
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Fig. 1. Relation between male and female in our hemodialysis collective concerning rates of protection (antibody level of r0.1 IU/ml) (a) and seroconversion of unprotected patients (responder: from <0.1 IU/ml prior to to r0.1 IU/ml after vaccination; non-responder: <0.1 IU/ml) after vaccination with tetanus toxoid (b). Hatched q = female; shaded q = male. HD: hemodialysis.
patients with the age of R60 yr. In this group (n = 13) six people (46%) responded, while 7 (54%) did not respond to the vaccine. Though the number of patients R60 yr of age was relatively small, there was a tendency that patients treated with a higher dose of 1,25D3 showed a better response toward vaccination
( p < 0.09). The responders received an average dose of 2.63 21.84 mg/week while the non-responders were treated with less than the half dose (0.962 0.80 mg/ week). Birmingham et al. found an improved response to tetanus immunization after the application of human recombinant erythropoietin [10]. Neither in all
1148
S. KruÈger et al. / Vaccine 17 (1999) 1145±1150
Fig. 2. Antibody levels of hemodialysis patients (HD) before and twelve months after immunization with tetanus toxoid are given according to sexes. Hatched q = female; shaded q = male. MW2S.D. Signi®cant correlations were determined by Mann±Wilcoxon U-test and are indicated as *=p < 0.05.
patients nor in this group R60 yr of age had erythropoietin therapy an in¯uence on immune response (data not shown). We further investigated whether dierent serum parameters such as calcium, phosphate and parathyroid hormone or white blood cell count, platelets, hemoglobin, anti-HBs antibody level and weekly hours of hemodialysis correlated with the response rate and found that seroconversion occurred independently of those parameters (data not shown). 3.3. Immune response to tetanus toxoid in comparison to diphtheria and hepatitis B vaccination The response to diphtheria vaccination in 69 out of 71 patients immunized against tetanus was known because these patients were included in another study [8]. Eective seroconversion concerning diphtheria was de®ned as an increase of antibody concentration from <0,1 IU/ml prior to to r0.1 IU/ml
three or six months after vaccination. 41 patients (59%) did not respond while 28 patients (41%) responded to the diphtheria vaccine. For a comparison only those patients that were unprotected prior to tetanus vaccination were included (n = 38). 18 of the nonresponders (47%) against diphtheria vaccine also failed to develop sucient anti-tetanus toxoid antibody levels, while 9 patients (23%) responded to both vaccines. The response to tetanus toxoid was highly associated with the response to diphtheria vaccination ( p < 0.04; Fisher's exact test) (Table 1, left). We also tested whether there is an association with the outcome after hepatitis B vaccination as reported in another study [9]. The data of seroconversion after hepatitis B vaccination were compiled retrospectively in only 30 patients. 21 hemodialysis patients (70%) responded to hepatitis B vaccination, while 9 (30%) did not respond. No signi®cant association was found with seroconver-
Table 1 Association between the response to tetanus toxoid and the response to diphteria toxoid after simultaneous immunization (left) and the response to previously administered hepatitis B vaccine (right) Tetanus Diphtheria Responder Non-Responder
Tetanus
responder
non-responder
9 (24%) 5 (13%) 14
6 (16%) 18 (47%) 24
15 23 n = 38
Hepatitis B
responder
non-responder
Responder Non-Responder
10 (33%) 1 (3%) 11
11 (37%) 8 (27%) 19
21 9 n = 30
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sion rates after immunization against hepatitis B and tetanus (Table 1, right). 4. Discussion The manifest disease after infection with Clostridium tetani can easily be prevented by vaccination. Therefore, in industrialized countries, the incidence of tetanus is a result of incomplete immunization. Dierent groups in the United States and Europe have shown that mainly elderly people and women more than 40 yr of age lack a sucient antibody protection [1, 2, 16, 17]. Also, the incidence of tetanus and the case-fatality ratio is higher in older people [2, 18]. The immunode®ciency in patients with chronic renal failure makes them prone to more fatal outcomes of infectious diseases. Few studies exist on immunization against tetanus in patients with chronic renal failure [9, 10, 19]. In our group of hemodialysis patients, all lacking a documented vaccination history, only 44% had a protective anti-tetanus toxoid antibody level. Another group found a protection rate of 39.4% [19] in their hemodialysis collective, while Girndt et al. had 23% unprotected in their study group [9], which might be underestimated since they did not screen antibody levels in immunized patients that were included in their study. Seronegative patients on chronic hemodialysis showed an impaired immune response after immunization with tetanus toxoid. The majority (63%) did not respond after a single vaccination. These data con®rm former studies reporting non-responder rates of 69% [9] and 62% [19] after triple vaccination. Guerin et al. found a seroconversion rate one month after the third vaccination of 97% which declined six months later to 62%. These ®ndings provide evidence that the outcome after single or triple vaccination is quite similar. The immune defect of patients with chronic renal failure is characterized by the lacking ability of antigen presenting cells to provide a costimulatory signal in association with presented antigen [4, 20]. This leads to impaired T helper cell stimulation with the consequence of less dierentiation of B cells to speci®c antibody producing plasma cells. Tetanus toxoid is a T cell dependent vaccine such as diphtheria toxoid and hepatitis B vaccine. Therefore, we tested the hypothesis that hemodialysis patients have a similar seroconversion rate after immunization against diphtheria, hepatitis B and tetanus. We found a correlation of the response rate to tetanus toxoid with that to diphtheria toxoid ( p < 0.04; Fisher's exact test). 71% of the patients showed the same reaction towards tetanus and diphtheria vaccination. In contrast to other investigators [9], we found no signi®cant association between vaccination against tetanus and hepatitis B.
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Although the immune response to both vaccines is T cell dependent, the response to bacterial and viral antigen might dier in detail. The in¯uence of treatment with 1,25-D3 on speci®c antibody production primarily has to be considered as not signi®cant. However, there was a tendency ( p < 0.09) among patients R60 yr of age to gain pro®t out of therapy with higher doses of 1,25-D3. Further studies with larger patient numbers are necessary to con®rm these ®ndings. These ®ndings could not be con®rmed by our results. This study provides evidence that more than half of hemodialysis patients has no sucient protection against infection with Clostridium tetani. However, a single vaccination with tetanus toxoid leads to a relatively poor seroconversion rate compared with studies in healthy individuals (62% vs. 91±96% reviewed in [18]). Regular controls of anti-tetanus toxoid antibodies are therefore recommended and further studies are needed to ®nd an appropriate time course of revaccination.
Acknowledgements This study was supported by the Deutsche Forschungsgemeinschaft, Sonderforschungsbereich 367, B3 [BK]. The authors appreciate the cooperation of Drs. Schulz/Winterho, LuÈbeck, Drs. SchuÈmann/ Wilhelm, LuÈbeck, Drs. Kirsch/FaÈrber, Reinbek and Drs. Graf/Wedel/Brockmann, Bad Bevensen (all Germany) and the technical assistance of Friederike MuÈller.
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