Since haemodialysis patients are at a high risk of contracting hepatitis B virus (HBV), vaccination is used routinely as prophylaxis. Globally, the prevalence of HBV among dialysis patients is about 3-10%.¹ The prevalence of HBV infection among haemodialysis patients varies from 4.5% to 21.6%.² ⁶ In Bangladesh, about 12% of all maintenance haemodialysis patients were serologically positive for HBV infection.7 Blood-product transfusions, contamination from dialysis equipment, and infections from other environmental sources are the major sources of infection in haemodialysis patients.⁸ The response rate to HBV vaccine in haemodialysis patients is poor compared to healthy population.⁹ The risk factors that are associated with low immune response or non-response to the hepatitis B vaccine include chronic kidney disease, diabetes mellitus, low complement IV factor, inadequate cytokine response creatinine, use of low biocompatibility dialysis materials, hyperparathyroidism, weight, anaemia, overload of iron, malnutrition (low albumin), weight, concomitant infection with hepatitis C virus, advanced age, and gender.¹⁰ ¹²

On the other hand, young age (<40 years), good nutritional status, and adequacy of dialysis are associated with good response to the hepatitis B vaccine.¹³ Therefore, hepatitis B vaccination is recommended for all chronic kidney disease patients before they become dependent on dialysis and also for patients who are currently on dialysis.¹⁴

To improve the seroconversion rates of hepatitis B vaccine, an extra dose of vaccine for a four-vaccine series and doubling the dose of vaccine to 40 μg per dose is recommended.¹⁵ Some studies have reported an 80% seroconversion rate with this regime.¹⁶ So far, only one study was published from IPGMR,

Bangladesh regarding vaccine response on haemodialysis patients. So, the present study was performed to observe the immune response with a double dose of hepatitis B vaccine and the factors influencing the response rate was tested by the chemiluminescent enzyme immunoassay method (Immulite 2000, USA) one month after the last dose of the vaccine. Based on the level of anti-HBs antibody response, the subjects were divided into three groups: good responders (>100 mIU /mL, poor responders (10-100 mIU/mL), and non-responders (<10 mIU/mL). Screening for hepatitis B surface antigen (HBsAg) and total antibody to core antigen (anti-HBc) was performed by the enzyme-linked immunosorbent assay method (4th generation) and immuno chromato graphic immunoassay respectively. Factors, such as duration of dialysis, weight, haemoglobin, serum creatinine, and presence of diabetes mellitus, were also determined.

Study site and sample:

The study was conducted during January-December 2008 at the Department of Virology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Fifty haemodialysis patients (20 males and 30 females) aged 20-70 (mean age 46.52±12.36) years were selected from BSMMU, Renaessance Hospital and Research Institute Limited and the Kidney Hospital and Dialysis Centre, Dhaka, Bangladesh. Their mean serum creatinine level was 8.53±2.[14] (mg %). Of the 50 subjects, 18 (36%) were diabetic, and 32 (64%) were non-diabetic. The hepatitis B vaccine was administered to the study subjects who were negative for HBsAg, antibody against hepatitis B core antigen (anti-HBc), and anti-HCV antibody and had not received any dose of HBV vaccine previously. With four doses (40 μg per dose) of the vaccine Engerix B (GlaxoSmithKline Biologicals, Belgium)—intramuscularly at deltoid muscle at 0, 1, 2, and 6 months. Anti-HBs antibody was tested by the chemiluminescent enzyme immunoassay method (Immulite 2000, USA) one month after the last dose of the vaccine. Based on the level of anti-HBs antibody response, the subjects were divided into three groups: good responders (>100 mIU /mL, poor responders (10-100 mIU/mL), and non-responders (<10 mIU/mL). Screening for hepatitis B surface antigen (HBsAg) and total antibody to core antigen (anti-HBc) was performed by the enzyme-linked immunosorbent assay method (4th generation) and immuno chromato graphic immunoassay respectively. Factors, such as duration of dialysis, weight, haemoglobin, serum creatinine, and presence of diabetes mellitus, were also determined.

Data were analyzed using the SPSS software for windows (version 11.5). Test of significance was estimated using the statistical method. Values were expressed as mean±standard deviation (SD). Antibody responses among the variables were compared by chi-square test. The p value of <0.05 was considered significant.

Ethical clearance was obtained from the Ethical Committee of BSMMU

After the completion of the vaccination schedule, the overall seroconversion rate was 80%. Only 10 (20%) patients did not respond (Table 1). Of the 40 responders, the mean (±SD) time (months) on dialysis, weight (kg), haemoglobin (%), and serum creatinine (mg/dL) were 6.20±3.74, 53.80±9.83, 8.99±1.36, and 9.64±1.78 respectively. Of these 40 responders, 15 (37.5%) patients were diabetic. Among the 10 non-responders, the mean time (months) on dialysis was 5.09±3.05, the mean weight (kg) was 57.63±9.38, the mean haemoglobin (%) was 9.76±1.27, and the mean serum creatinine (mg/dL) was 8.25±2.15. Diabetes mellitus was present in three (30.3%) of the 10 non-responding subjects [Table 2]. The difference in these variables among the responders and non-responders was not significant (p=0.94). Of the male subjects, 14 (70%) were responders, and six (30%) were non-responders. In the case of the 30 females, 26 (86.7%) were responders, and four (13.3%) were non-responders. The seroconversion rate was higher (86.7%) in female subjects than the male subjects (p=0.15). Of the younger subjects aged less than 40 years, 14 (93.3%) were responders while only one (6.7%) was non-responder. However, 26 (74.3%) of the subjects aged above 40 years were responders, and nine (25.7%) were non-responders. The antibody response rate of the younger subjects was higher compared to the older subjects (p=0.25). Of the diabetic subjects, 15 (83.3%) were responders, and three (16.7%) were non-responders. In the non-diabetic subjects, 25 (78.1%) were responders, and seven (21.9%) were non-responders. Thus, the seroconversion rate was comparatively higher among the diabetic patients than the non-diabetic patients (p=0.94) [Table 3].

Of the 21 haemodialysis patients treated with erythropoietin, 19 (90.45%) were responders, and two (9.55%) were non-responders. Of the 29 patients who did not receive erythropoietin, 21 (72.41%) were responders, and eight (27.59%) were non-responders. The response rate was comparatively much higher among the users of erythropoietin than the non-users (p=0.22).

Infection is the second leading cause of death of dialysis patients.The recombinant HBV vaccine has been recommended for all dialysis patients since the mid-1980s.⁹ Patients with renal failure have a lower response to vaccination due to suppression of the immune system.¹⁰ Previous studies have shown that unresponsiveness to the HBV vaccine was multifactorial and was related to the presence of several modulators.16 17 Although the majority of individuals vaccinated against HBV respond successfully to vaccination, 5-15% of these persons may not respond to the vaccine.¹⁸

Our study detected 20% non-responders and 80% responders after the completion of vaccination schedule. Of them, 32% were poor responders, and 48% were good responders. In other studies, 13-27% of patients were non-responders, 22-27% poor responders, and 51-59.2% good responders after the completion of the vaccination schedule.¹⁹- ²⁰ A study in Bangladesh reported a 75% vaccine response rate among dialysis patients.²¹ in India a 50% response rate after the third dose of vaccine.²² The response rate of the vaccination regime following the same vaccine schedule ranged from 73% to 87% in other studies.¹⁹ ² Various factors, such as uraemia, malnutrition, low body weight, diabetes mellitus, advanced age, HCV infection, impaired T cell receptor expression, and certain HLA types has been implicated for the poor antibody response in haemodialysis patients.¹²,²³- ²⁵ In our study, the mean time on dialysis, weight, serum haemoglobin, serum creatinine, and DM had no significant effect on the vaccine response. Other studies did not also observe any association with these factors and vaccine response.¹⁶, ²¹- ²⁰, ²⁶ Diabetic patients with chronic renal failure commonly have impaired insulin clearance and require less exogenous insulin due to diminished degradation by renal insulinase. Therefore, these patients can maintain their blood sugar at normal levels. A study in the USA observed that the mean body-weight was higher, and the mean serum creatinine level was lower in non-responders than responders, indicating a lower percentage of muscle mass among non-responders.⁹ These findings seem to correlate with the findings of our study. Although an association was reported between the increased antibody response rates and the increasing length of time on dialysis but not on the duration of dialysis²⁵ this could not be established in our study. Moreover, factors relating to HBV vaccine responses are variable in different ethnic groups. Thus, further studies with more patients are necessary to confirm these data.

A higher antibody response rate was observed in the female subjects (86.7%) than in the male subjects (70.0%) in our study, although this difference was not significant. Other investigators reported similar findings. ²⁶ ²⁷ Some studies observed that the gender of subjects did not influence the rate of response to the hepatitis B vaccine in haemodialysis patients. ²⁶ ²⁸ In this study, the antibody response , was higher in younger subjects (93.3%) than in older subjects (74.3%). Other studies also reported same findings.²⁹ ³⁰ A study in Egypt reported the response rate of 84.2% among patients aged less than 40 years, which decreased to 33.3% among patients aged 60 years or above.²⁷ In our study, the vaccine response rate was higher in the diabetic patients than the non-diabetic 

patients (83.3% vs 78.1%) (p=0.94). Some investigators reported a reduced efficacy of vaccination in adult diabetic patients with the longer duration of disease.32 Diabetic patients have lower degree of antigen presentation and T-cell function, low complement IV factor, decreased cytokine response after stimulation, and decreased function (chemotaxis, phagocytosis, killing) of neutrophil, monocytes/macrophage, which may all be responsible for the reduced vaccine response.¹¹ Some studies demonstrated the seroconversion rates of 90-92% to the hepatitis B vaccine in diabetic patients.³⁰, ³² Other studies reported a very little or no affect the vaccine.¹⁹, ³³ However, the number of diabetic patients was quite low in our study to reach a definite conclusion.

Although erythropoietin stimulates the proliferation of B lymphocytes and the production of immunoglobulin, it reduces the sensitization and responsiveness of T lymphocyte.26 In the present study the patients treated with erythropoietin had higher antibody than those not on erythropoietin treatment. Result of a study showed that erythropoietin therapy improved the response rate[34] while other studies did not observe any significant role of erythropoietin in the hepatitis B vaccine response. ¹⁶, ¹⁹, ²⁶Conversely, a study in China detected a 46% response rate among users of erythropoietin.³²

Our study concluded that the female were better responders to the hepatitis B vaccine than the male, and the vaccine response rate was higher in the younger than the older ones. Moreover, the users of erythropoietin had a better response rate than the non-users.

There were some potential limitations as regarding the low number of cases, including diabetic patients, while the distribution of age and gender was also not equal. Nevertheless, it should be considered that, in different ethnic groups, factors relating to HBV vaccine responses may vary, and perhaps unknown factors were responsible for this disagreement. Thus, further studies with a larger sample are necessary to confirm the findings of the present study. 

The authors acknowledge the help extended by the Renaessance Hospital and Research Institute Limited and the Kidney Hospital and Dialysis Centre, Dhaka The authors are also grateful to all the dialysis patients for their active participation in the study

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