P296
PRE-TRANSPLANT VACCINATION AGAINST CHICKEN POX
Jayanti, A, Morton, M, Klapper, P, Picton, M
Manchester Royal Infirmary
INTRODUCTION: Varicella Zoster virus (VZV) re-activations are a well recognised problem in
solid organ transplant recipients. However, primary Varicella infections occurring in adult
seronegative kidney transplant recipients are rare (1%) and potentially fatal with published mortality
rates in the immunocompromised of 22-53%. Current UK Renal association guidance (2008) suggests
that all potential transplant recipients are screened for prior exposure to viral infections including
VZV. Immunization should be offered to all Hepatitis B and VZV antibody negative patients before
transplantation. Reported seroconversion rates post-vaccination in paediatric ESRF populations are
98% and in adults 64%. Efficacy may be improved by administering 2 doses. Pre-transplant
vaccination strategies appear safe in renal patients.
METHOD:
(1) We identified cases of primary Varicella Zoster infection occurring in our adult
renal transplant population between 2003 and 2009. Medical notes were reviewed with clinical
presentations and outcomes recorded and analysis made of morbidity and mortality.
(2) Identification of VZV naïve patients entering transplant workup during 2008 in our unit was made.
Screening and vaccination strategies for VZV were then reviewed in our unit and other transplant
centres in the UK.
FINDINGS: (1) 5 cases of primary VZV were identified over 7 years in a transplant follow up
population of 900. Patient survival at one month was only 40%. Total in-patient stay following
diagnosis was 51 days (median 7 per patient).
Sex M/F Primary
Time from Symptoms
Organ involvement
1 month Pt
(Age)
disease
Transplant
survival
M (49)
HT
7 yrs
Abdo pain, rash ARF, DIC, Hepatitis
No
F (27)
DM
1month
Rash, GI bleed
GI tract, skin
No
F (29)
DM
1 yr
Rash,
ARF, DIC, Hepatitis,
No
pneumonia
Pneumonia
M (44)
Unknown 17 yrs
Breathless
ARF, Hepatitis,
Yes
Pneumonia, Encephalitis
M (31)
DM
1 yr
Fever, Rash
Skin
Yes
(2) 6 (4%) of 136 transplant work up patients in 2008 were VZV seronegative compared to a
seronegative rate for CMV of 43% and EBV 8%. VZV vaccination for seronegative potential
transplant recipients is not currently practised in our unit. A survey of UK transplant units showed
variable practice with many centres offering testing but not vaccination.
CONCLUSION: The fatal consequences of this infection in the immunosuppressed should be
reinforced. 6-8 new seronegative transplant work up patients per year (in our unit), are likely to be
identified and could benefit from pre-transplant vaccination.
RELEVANCE: All care providers, looking after patients with chronic kidney disease and
nephrologists with interest in transplantation medicine.
FUTURE RESEARCH is needed into the optimal timing and dosing schedule for vaccination, the
degree and duration of the immunity conferred, pre transplant vaccination of the seropositive to boost
immune responses and use of the heat inactivated vaccine.