Vaccination gaps and infection risk at dialysis initiation

Abstract

In this editorial, we comment on the study by Puri et al published in the World Journal of Nephrology, which highlights a neglected gap in preventive care at dialysis initiation: Inadequate protection against vaccine-preventable and endemic infections in advanced chronic kidney disease. In an incident hemodialysis cohort from a tertiary centre in North India, the authors report major deficiencies in adult vaccination against hepatitis B virus, pneumococcus, and influenza at dialysis entry, with more than half of patients having received none of the recommended immunizations. Concurrently, a substantial burden of tuberculosis - predominantly extrapulmonary - was observed, underscoring a dual infectious vulnerability at the outset of renal replacement therapy in endemic, resource-constrained settings. Importantly, vaccination uptake aligned with markers of health-system engagement rather than patient characteristics or presumed biological limitations: Prior nephrology follow-up and structured pre-transplant evaluation were associated with higher vaccination rates and indicators of anticipatory care, including permanent vascular access. These findings suggest that impaired immunogenicity may not be the sole barrier to vaccination in advanced kidney disease and are consistent with an association between delayed referral, fragmented care pathways, and avoidable infectious risk. Although limited by its single-centre, cross-sectional design, this study supports viewing dialysis initiation as a sentinel checkpoint for infection prevention. We argue for integrating vaccination assessment, delivery, serologic monitoring, and tuberculosis screening into pre-dialysis and dialysis-start workflows to operationalize preventive nephrology in routine practice.

Key Words: Chronic kidney disease; Hemodialysis initiation; Vaccination coverage; Infection prevention; Tuberculosis

Core Tip: Dialysis initiation is a high-risk checkpoint where preventable infections cluster early, yet vaccination and screening are commonly missed. In an incident hemodialysis cohort from North India, major gaps in adult immunization against hepatitis B, pneumococcus, and influenza were evident at dialysis entry, alongside a substantial burden of tuberculosis, often extrapulmonary. Importantly, vaccine uptake tracked with health-system engagement - prior nephrology follow-up, transplant evaluation, and planned vascular access - rather than patient factors alone, reframing “poor vaccine response” as a systems-delivery problem. Embedding vaccination assessment, serologic monitoring, and tuberculosis screening into pre-dialysis and dialysis-start workflows can operationalize preventive nephrology and reduce avoidable morbidity.

This editorial refers to “Vaccination gaps in incident hemodialysis patients: An opportunity for preventive nephrology, a prospective, cross-sectional study” by Puri et al, 2026; https://doi.org/10.5527/wjn.v15.i1.114748.

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INTRODUCTION

The transition from advanced chronic kidney disease (CKD) to maintenance hemodialysis is among the most vulnerable inflection points in the natural history of kidney failure[1-4]. It is characterized by profound physiological stress, sudden intensification of healthcare contact, and a steep rise in short-term morbidity and mortality[3,4]. Yet, despite decades of advances in dialysis technology, vascular access planning, and infection control protocols, dialysis initiation continues to be treated primarily as a technical or procedural milestone rather than a culmination of preventive care[4,5].

Infectious complications remain the second leading cause of death in patients receiving hemodialysis, surpassed only by cardiovascular disease[2]. This burden is not restricted to late dialysis vintage; rather, it is front-loaded, with the highest rates of infection-related hospitalization and mortality occurring in the first year after dialysis initiation[3]. Preventive interventions during the pre-dialysis phase therefore have disproportionate potential to alter early outcomes[2-4].

Vaccination against hepatitis B virus (HBV), pneumococcus, and influenza has long been recognized as a cornerstone of infection prevention in CKD. International guidelines consistently recommend early immunization, ideally before dialysis dependence, when immune responsiveness is relatively preserved. Nevertheless, adult vaccination coverage in CKD remains poor worldwide, and particularly so in resource-constrained settings where late referral and fragmented care are common[6-8].

Against this backdrop, the prospective study by Puri et al[9] published in the World Journal of Nephrology provides timely and clinically grounded insight. By systematically assessing vaccination status at the point of hemodialysis initiation in an Indian tertiary-care cohort, the authors illuminate not merely a deficit in immunization coverage, but important gaps in preventive nephrology delivery. Their data compel a reframing of vaccination gaps - from perceived patient non-adherence or biological futility to markers of health-system readiness and continuity of care[9].

BIOLOGICAL SUSCEPTIBILITY IN ADVANCED CKD: MORE THAN IMMUNODEFICIENCY

The excess infection risk observed in advanced CKD and end-stage renal disease is rooted in complex immune dysregulation. Uremia exerts broad effects across both innate and adaptive immunity, impairing neutrophil chemotaxis, macrophage phagocytosis, antigen presentation, and T-cell activation. B-cell dysfunction and impaired memory responses further compromise humoral immunity, resulting in reduced antibody production and accelerated waning of vaccine-induced protection[7,8].

This immune impairment coexists paradoxically with chronic systemic inflammation, oxidative stress, and immune exhaustion. The net effect is not simply immunosuppression, but immune dysregulation - a state that predisposes to severe infection while blunting protective responses[7,8].

These biological alterations directly influence vaccine performance. Seroconversion rates following HBV vaccination decline with advancing CKD stage, and antibody titers decay more rapidly in dialysis-dependent patients. Similar attenuated responses have been documented for influenza and pneumococcal vaccines[10-15]. Importantly, however, diminished immunogenicity does not imply lack of efficacy. Studies consistently demonstrate that vaccination earlier in the CKD trajectory - prior to dialysis initiation - achieves higher seroprotection rates and more durable immunity[10,13,14]. Thus, the central question is not whether vaccines work in CKD, but when and how they are delivered.

DIALYSIS INITIATION: AMPLIFICATION OF INFECTIOUS RISK

The act of initiating hemodialysis introduces additional layers of infectious vulnerability that extend beyond baseline immune dysfunction. Vascular access - particularly central venous catheters - creates a direct conduit for bloodstream infection[16,17]. Recurrent exposure to dialysis units, invasive procedures, and hospitalization increases the risk of healthcare-associated infections. For HBV specifically, dialysis units remain recognized environments of transmission risk where incomplete immunization can have unit-level consequences[4,16-22].

Respiratory infections assume particular importance. Influenza and pneumococcal disease account for a substantial proportion of infection-related hospitalizations in dialysis populations, with downstream effects on cardiovascular events, functional decline, and mortality. Preventive vaccination therefore carries both direct and indirect survival benefits[11,12,21,22].

Dialysis initiation is thus not merely a therapeutic transition; it is a point at which biological vulnerability and environmental exposure converge. Failure to address preventable infection risk at this juncture represents a lost opportunity with immediate clinical consequences[4,16-18].

WHAT THE IN-PRESS STUDY SUGGESTS: VACCINATION AS A SYSTEMS SIGNAL

The study by Puri et al[9] offers several observations that are particularly instructive when interpreted through a systems framework.

Profound under-coverage at dialysis entry

At the time of dialysis initiation, fewer than half of patients had completed HBV vaccination, fewer than one-third had received pneumococcal or influenza vaccines, and more than half had received none of the recommended adult immunizations. These findings echo prior global observations but are especially concerning given the high infectious burden and healthcare exposure inherent to dialysis initiation in India[9,16,17,19-21].

Vaccination tracks with planned care, not patient biology

In this cohort, vaccination status aligned strongly with markers of health-system engagement rather than patient characteristics. Prior nephrology consultation emerged as the dominant predictor of vaccination uptake across all vaccines. Similarly, vaccinated patients were more likely to have undergone arteriovenous fistula creation and pre-transplant evaluation[9,23-25].

In contrast, demographic variables, body mass index, and serum albumin showed no meaningful association with vaccination status or antibody response. This suggests that poor nutrition or immune dysfunction may not be the sole or principal barrier to vaccination success in CKD[7,9,10,13,14]. Beyond the specific findings of this cohort, we interpret these observations as supporting vaccination status as a marker of system preparedness, rather than patient compliance or immune capacity.

Demonstrable vaccine responsiveness

Among HBV-vaccinated patients, two-thirds achieved protective anti-hepatitis B surface titers, confirming that meaningful immunogenicity is achievable even in advanced CKD when vaccination is delivered before prolonged dialysis exposure. The absence of correlation between antibody titers and nutritional indices further underscores that vaccination failure is not biologically predetermined[9,10,13,14]. Collectively, these observations support viewing vaccination as a marker of system preparedness rather than patient compliance or immune capacity.

EMERGENCY DIALYSIS STARTS: WHERE PREVENTION FAILS FIRST

More than four-fifths of patients in the cohort-initiated dialysis emergently, predominantly using temporary central venous catheters. Emergency dialysis initiation represents the antithesis of preventive nephrology[5,9,23,25-28]. It is the downstream manifestation of delayed referral, inadequate CKD surveillance, and fragmented care continuity[6,9,23,25,28].

In crisis-driven settings, preventive interventions such as vaccination are inevitably deprioritized. Vaccination requires anticipation, scheduling, follow-up, and documentation - features incompatible with emergency-only engagement. The strong association between vaccination status and the presence of a permanent arteriovenous fistula is therefore not coincidental; both reflect the same upstream system behaviors[9,24].

Evidence from Indian cohorts consistently demonstrates that late nephrology referral is associated with higher early mortality, catheter dependence, malnutrition, and infection-related hospitalization[2,3,23,25,27,28]. Vaccination gaps observed at dialysis initiation may be interpreted as part of this broader pattern of system delay rather than isolated omissions[9,16,23].

TRANSPLANT EVALUATION PATHWAYS: PREVENTION WORKS WHEN SYSTEMS FORCE IT

One of the most revealing observations in the in-press study is the markedly higher vaccination coverage among patients who had undergone pre-transplant evaluation. This finding is not incidental, nor is it unique to this cohort. Across nephrology practice globally, transplant pathways represent some of the most structured, protocol-driven environments within CKD care. Infection screening, vaccination verification, and serologic monitoring are treated as mandatory prerequisites rather than discretionary add-ons[9,29,30].

This rigor is driven by necessity. Post-transplant immunosuppression magnifies infectious risk to a degree that makes preventive lapses clinically unacceptable. Consequently, transplant programs operationalize vaccination through checklists, defined timelines, and shared accountability between nephrologists, transplant coordinators, and infectious disease specialists. In this context, vaccination uptake improves not because patients are more motivated or biologically advantaged, but because the system removes ambiguity[29,30].

Beyond the findings of this single cohort, we interpret the contrast with dialysis-only pathways as suggestive of a broader system-level pattern, wherein patients who are older, socioeconomically disadvantaged, or burdened with comorbidities are less likely to access structured preventive pathways despite higher infection risk. In this context, the findings by Puri et al[9] highlight a potential structural inequity, rather than definitively establishing its cause[29].

From an ethical standpoint, this distinction warrants careful consideration. From a public health standpoint, it is inefficient. Dialysis patients experience a higher incidence of infection-related hospitalization than transplant recipients in the early post-initiation period. Yet, preventive interventions are inconsistently delivered to them. The transplant pathway thus functions as a practical example for preventive nephrology - demonstrating that when systems enforce vaccination, uptake follows[29,30]. The challenge moving forward is not feasibility, but equity: Extending similar preventive discipline to all patients approaching kidney failure, irrespective of transplant candidacy[7,29].

TUBERCULOSIS AND DIALYSIS INITIATION: A PARALLEL PREVENTIVE FAILURE

Perhaps the most contextually significant finding in the study is the high prevalence of tuberculosis (TB) at dialysis initiation, with a predominance of extrapulmonary disease. This observation aligns closely with epidemiologic data from national and international cohorts demonstrating that end-stage renal disease confers a several-fold increase in TB risk compared with the general population[9,31-33].

The biological basis for this association is well established. CKD-related immune dysfunction disproportionately impairs cell-mediated immunity, the cornerstone of host defense against Mycobacterium TB. Defects in T-cell activation, macrophage function, and cytokine signaling facilitate reactivation of latent infection and promote atypical disease presentations. Extrapulmonary and disseminated TB are therefore common in dialysis populations, often leading to delayed diagnosis and increased mortality[6-8,31,34].

Importantly, TB risk in end-stage renal disease is not merely biological. It is amplified by social determinants of health, repeated healthcare exposure, and diagnostic delays. In TB-endemic countries such as India, these factors converge at dialysis initiation - a moment characterized by frequent hospitalization, invasive procedures, and immune stress[31-34].

The coexistence of TB and vaccine-preventable infections in the Puri et al[9] cohort highlights a dual infectious burden that is rarely addressed in an integrated manner. Vaccination programs are often conceptualized in isolation, while TB screening is treated as a separate public health mandate. In reality, both represent manifestations of the same systemic failure: The absence of structured infection prevention embedded within CKD care pathways[34].

National TB elimination strategies explicitly recognize CKD and dialysis as high-risk states. Yet, implementation within nephrology workflows remains inconsistent, fragmented, and largely reactive[31-34]. Dialysis initiation represents a unique operational checkpoint at which TB screening, vaccination review, and infection risk stratification could be aligned. Failure to do so perpetuates avoidable morbidity while undermining broader public health goals[34].

ADULT IMMUNIZATION IN INDIA: A POLICY AND INFRASTRUCTURE GAP

India’s success in childhood immunization stands in sharp contrast to the near absence of structured adult vaccination programs. High-risk adult populations - patients with CKD, diabetes, chronic lung disease, and immunocompromising conditions - remain largely outside the scope of routine immunization policy. Vaccination records are fragmented, financing mechanisms are poorly defined, and accountability is diffuse[35-39].

Within nephrology practice, this policy vacuum manifests as variability rather than intentional neglect. Vaccination depends on individual clinician awareness, time constraints, patient affordability, and opportunistic encounters. In busy dialysis units prioritizing volume and acuity, preventive interventions that are not system-mandated are predictably under-delivered[16,20,21,35-39].

The in-press study should therefore not be interpreted as an indictment of individual practice patterns, but as evidence of system-level gaps. Without institutional protocols, electronic prompts, and defined ownership, adult immunization remains optional rather than integral to CKD care[9,35-39].

Importantly, vaccination in CKD is not a resource-intensive intervention. Compared with the cost of dialysis, hospitalization, or treatment of severe infection, vaccination represents a low-cost, high-yield preventive strategy. Its underutilization therefore reflects failure of prioritization rather than feasibility[10,35,38,39].

RECONCEPTUALIZING VACCINATION AS A QUALITY INDICATOR

One of the most important conceptual contributions of the study by Puri et al[9] is its implicit challenge to how quality in CKD care is measured. Traditional quality metrics focus on biochemical targets, dialysis adequacy, and vascular access. Preventive care - particularly vaccination - has remained peripheral[9,24,29,40].

Vaccination status at dialysis initiation may be considered as a quality indicator of preventive nephrology. Like timely fistula creation or anemia management, it reflects upstream system performance rather than patient behavior. Its absence may reflect delayed referral, fragmented care, and missed opportunities[23-26,40]. Embedding vaccination into CKD pathways requires deliberate redesign rather than incremental reminders. Effective strategies include[6,10,18,19,23,24,29-35,40]: (1) Stage-based vaccination checkpoints beginning in CKD stages 3-4; (2) Mandatory vaccination documentation at dialysis initiation; (3) Early HBV vaccination with serologic monitoring and scheduled boosters; (4) Integration of vaccination review into transplant and access planning workflows; and (5) Parallel TB screening and surveillance in endemic regions.

From a practical standpoint, the findings underscore that improving vaccination coverage in CKD does not require novel biologics or resource-intensive interventions, but earlier and more reliable integration into existing care pathways. Routine nephrology follow-up provides repeated, predictable touchpoints at which vaccination assessment and delivery can be operationalized, well before dialysis dependence. Embedding vaccination review into CKD clinics, access planning visits, and transplant evaluation workflows represents a feasible, low-cost strategy to shift infection prevention upstream and reduce avoidable infectious risk at dialysis initiation. Within this framework, TB screening should be integrated alongside vaccination assessment as part of the same preventive checklist at dialysis initiation, rather than approached as a parallel process[23,29,30,34,40]. These interventions are scalable, low-cost, and compatible with existing care models. Their implementation would represent a tangible shift from reactive to preventive nephrology[35-40] (Table 1).

Table 1 Vaccination coverage as a marker of health-system preparedness at dialysis initiation[9,23,24,29,30].

Preventive indicator	Association with vaccination	Systems interpretation
Prior nephrology consultation	Strong positive association	Longitudinal care enables prevention
Permanent vascular access	More frequent in vaccinated patients	Anticipatory planning
Pre-transplant evaluation	High vaccination uptake	Structured preventive workflow
Emergency dialysis initiation	Predominant among unvaccinated patients	Crisis-driven care
TB burden at initiation	High prevalence	Need for integrated infection prevention

TB: Tuberculosis.

FROM REACTIVE DIALYSIS TO PREVENTIVE NEPHROLOGY

The findings of the study underscore a broader truth about CKD care in low- and middle-income countries: Dialysis initiation often marks the first sustained interaction between patients and nephrology services. By this stage, opportunities for prevention have already narrowed[9,16,17,23,25-28]. Preventive nephrology must therefore begin earlier, extend beyond slowing progression, and explicitly incorporate infection risk mitigation as a core objective[40]. Vaccination, TB screening, access planning, and transplant evaluation should be viewed as interconnected components of preparedness for kidney failure - not optional adjuncts[18,23,24,29,30,34,35,40] (Table 2). This requires a shift in mindset. Dialysis initiation can be viewed as the final checkpoint of preventive care, not the starting line of intervention[39,40].

Table 2 Integrating infection prevention into chronic kidney disease care pathways[6,23,29,34,40].

CKD stage/transition	Preventive opportunity	Operational strategy
CKD stages 3-4	Vaccination initiation	HBV, pneumococcal, influenza vaccines
Advanced CKD (pre-dialysis)	Serologic monitoring	Anti-HBs titers, booster planning
Dialysis planning	Infection risk stratification	Access planning, TB screening
Dialysis initiation	Preventive audit	Vaccination checklist, documentation
Early dialysis vintage	Reinforcement	Missed vaccine catch-up

CKD: Chronic kidney disease; HBV: Hepatitis B virus; Anti-HBs: Antibody to hepatitis B surface antigen; TB: Tuberculosis.

CONCLUSION

Vaccination gaps at dialysis initiation are not incidental oversights but may reflect broader gaps in CKD care delivery. The in-press study by Puri et al[9] suggests that adult immunization in advanced kidney disease is feasible and can be effective when embedded within structured, anticipatory care pathways. In settings where infectious risk is amplified by endemic TB, high dialysis dependence, and constrained resources, inadequate prioritization of prevention may have important clinical consequences. Vaccination status at dialysis initiation may therefore be considered as a core quality metric of preventive nephrology. The transition to dialysis should be viewed not as the failure of prevention - but as its final checkpoint.