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in HD patients&#44; response to the HB vaccine is quite variable and lower than in the general population&#44;<span class="elsevierStyleSup">4&#44;5</span> with a response even below 50&#37; with the administering of three doses of vaccine<span class="elsevierStyleSup">6&#44;7</span> and slightly higher when a four-dose course is administered&#46;<span class="elsevierStyleSup">8</span> In addition to this&#44; persistence in the immunological response is also lower&#44; with a fast decrease in the protective antibody titres in many of these patients&#46;<span class="elsevierStyleSup">4&#44;5&#44;9</span></p><p class="elsevierStylePara">The mechanisms responsible for this decrease in the immunological response are unknown&#46; It has recently been proven that the low serological response to the HB virus in this population is closely linked to the deficit in specific-antigent dependent production of IL-2 by CD4&#43; Tcells&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">With the aim of improving response to the HB vaccine in the HD population&#44; several alternatives have been proposed&#44; such as increasing the administered vaccine dose&#44;<span class="elsevierStyleSup">11</span> intradermal application&#44;<span class="elsevierStyleSup">12</span> co-administration of zinc or several immunomodulators&#44;<span class="elsevierStyleSup">4&#44;5</span> or the more recent use of a new adjuvant&#44; AS04&#44; a derivative of bacterial lipopolysaccharides&#46;<span class="elsevierStyleSup">13</span> These interventions have obtained variable results&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">Many of the studies published on the HB virus in haemodialysis patients are centred on the results of this population&#191;s seroconversion&#44;<span class="elsevierStyleSup">8</span> but the information on immunity evolution of responding patients or those that have been revaccinated is much more limited&#46;</p><p class="elsevierStylePara">The aims of this study were&#58; a&#41; to assess the initial response to the HB vaccine in haemodialysis patients&#44; 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Rixensart&#44; Belgium&#41;&#44; injected intramuscularly in the deltoids&#44; at months 0&#44; 1 and 6&#46; Annual antibody tests were performed and an annual booster double dose of vaccine was administered to non-responding patients or in the case of responding patients that lost their antibody levels &#40;&#60; 10UI&#47;ml&#41;&#46; Patients were followed until 2007 or until their decease&#44; change of treatment service or kidney transplant&#46; </p><p class="elsevierStylePara">Response to the vaccine was analysed in all patients&#44; together with the factors influencing immunization and the efficiency of revaccination in patients who did not respond to the initial vaccination&#46; Maintenance of the level of antibodies after the first positive revaccination was also assessed&#46;</p><p class="elsevierStylePara">A subgroup of 63 patients with a three year follow-up after the first year of vaccination was analysed for the probability of maintaining the immunological response according to the antibody titres reached during the first annual control&#46; Patients were classified into three groups&#58; group I&#44; patients with antibodies &#62; 1&#44;000UI&#47;ml&#59; group II&#44; patients with antibodies between 100 and 999UI&#47;ml&#59; and group III&#44; patients with antibodies from 11 to 99UI&#47;ml&#46;</p><p class="elsevierStylePara">Finally&#44; a subgroup of 31 patients was analysed to check if the biannual antibody level tests contributed any additional information to their annual tests&#46; </p><p class="elsevierStylePara">The anti-Hbs antibodies were determined via microparticle enzyme immunoassay &#40;MEIA&#41;&#46; The lower limit of antibody detection was 2mUI&#47;ml and the intra- and inter-assay variation coefficient was 4&#46;4 and 4&#46;8&#37;&#44; respectively&#46; Patients with titres equal to or over 1&#44;000UI&#47;ml were considered as &#62; 1&#44;000UI&#47;ml&#46;</p><p class="elsevierStylePara">The anti-Hbs antibody titres &#62; 10UI&#47;ml were considered protective&#44; while the lower titres were defined as loss of immunity&#46;</p><p class="elsevierStylePara">The statistical analysis was performed using the SPSS 11&#46;0 program&#46; Results are expressed as mean &#43; SD&#46; The comparison between quantitative variables was carried out with Student&#191;s T-test and for the categorical variables the chi-square was used&#46;</p><p class="elsevierStylePara">Duration of immunity according to the anti-Hbs antibodies was analysed using the Kaplan-Meier estimator&#46;</p><p class="elsevierStylePara">Values p &#60; 0&#46;05 were considered significative&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Responding patients</span></p><p class="elsevierStylePara">Seventy four patients &#40;54&#46;4&#37;&#41; developed immunity against the HB vaccine&#46; Of these&#44; 39 patients &#40;52&#46;7&#37;&#41; presented an antibody titre &#62; 100UI&#47;ml&#44; a level which has been considered as the necessary threshold to maintain adequate seroprotection in HD patients&#46; Response to the HB vaccine was related to age&#44; the average non-responding age was higher than that of the responding patients&#46; Conversely&#44; the sex and aetiology of the chronic renal disease did not influence the response &#40;table 1&#41;&#46;</p><p class="elsevierStylePara">In successive annual tests a progressive decrease in the levels of antibodies was detected&#46; In the first annual post-vaccination testing&#44; 67&#46;8&#37; of the patients maintained protective levels&#44; and six years later&#44; only 17&#46;8&#37; of the patients maintained the immunological memory&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Non-responding patients</span></p><p class="elsevierStylePara">The 62 patients that did not respond to the three initial doses of vaccines were subject to an additional booster dose&#59; although only 46 patients were evaluated at the end of the first years&#44; since the remaining patients passed away&#44; had transplants or were transferred to another service&#46; The global efficiency for these doses was 21&#46;6&#37;&#58; with the first dose&#44; 23&#46;9&#37; of the patients seroconverted&#59; with the second dose&#44; 12&#37;&#59; and with the third&#44; 37&#46;7&#37; &#40;table 2&#41;&#46; 42&#46;8&#37; of the seroconverted patients presented a level of anti-Hbs antibodies &#62; 100UI&#47;ml&#46; The percentage of patients that maintained protecting levels of antibodies after the first booster dose was 69&#46;2&#37; in the first annual control&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Immunological response and antibody titre</span></p><p class="elsevierStylePara">In the 63-patient subgroup with a three year follow-up&#44; 7 patients were included in group I&#44; 28 in group II and 28 in group III&#46; The average age of these groups was 55&#46;5 &#40;33-78&#41;&#44; 62&#46;8 &#40;29-78&#41; and 57&#46;2 &#40;26-75&#41;&#44; respectively&#46; The antibody titre in groups II and III was 55 &#40;12-98&#41; and 290 &#40;100-978&#41; UI&#47;ml&#44; respectively&#46;</p><p class="elsevierStylePara">Figure 1 details the probability of patients remaining protected after vaccination&#46; After follow-up&#44; 75&#37; of the patients in group I maintained seroprotection versus 47&#37; in group II &#40;p &#61; 0&#46;08&#41; and 34&#37; in group III &#40;p &#61; 0&#46;02&#41;&#46; Conversely&#44; no significant differences were found between groups II and III&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Importance of the biannual antibody tests</span></p><p class="elsevierStylePara">Of the 31 patients that had biannual and annual antibody tests&#44; the biannual tests supplied additional information&#46; In four of the 25 responding patients&#44; the levels of antibodies had become negative six months later&#46; Therefore&#44; these patients could have benefited from an earlier booster shot&#46; Finally&#44; seven non-responding patients to the annual testing presented protecting antibody levels in the biannual tests&#46; This group of patients would have been considered non-responding to the vaccine if they had undergone only one annual test&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">In this study&#44; an HB vaccination protocol which ended in 2002 is presented&#44; using the conventional guideline of three double doses of vaccine&#46; Since 2003&#44; this protocol was amended&#44; upon completion of the study&#44; increasing it to four double doses of vaccine&#44;<span class="elsevierStyleSup">15&#44;16</span> guideline which is currently being followed in our Service&#46;</p><p class="elsevierStylePara">Despite the current controversy as to the effectiveness of the HB vaccine in HD patients&#44; due to the reduced efficiency of the vaccine and the low incidence of infection by the HB virus&#44; its use has become generalised in this population of patients&#46;<span class="elsevierStyleSup">17</span> In our experience&#44; 54&#46;4&#37; of the vaccinated patients developed immunity&#44; a figure similar to that shown in other studies&#46;<span class="elsevierStyleSup">8&#44;18</span> Even in the protocols that include four double doses of vaccine in months 0&#44; 1&#44; 2 and 6&#44; the seroconversion results obtained are not optimal either and oscillate between 58 and 80&#37;&#46;<span class="elsevierStyleSup">8&#44;19</span> This insufficient response to the HB vaccine is related to deficiency in immunocompetence&#44; characteristic of advanced chronic renal disease&#46;<span class="elsevierStyleSup">4&#44;5</span> Other modulating factors that negatively affect this response have been identified&#44; such as age&#44; diabetes&#44; malnutrition&#44; erythropoietin deficiency and suitability and duration of dialysis&#44; among others&#46;<span class="elsevierStyleSup">19&#44;20</span> The lack of response of our patients was related to age&#44; the percentage of responding patients decreasing the higher the patient age&#46; In contrast&#44; other factors&#44; such as the presence of diabetes&#44; did not influence the response in this population&#46;</p><p class="elsevierStylePara">In patients who did not respond to the initial vaccination&#44; revaccination was recommended with three additional vaccine doses&#44; obtaining a response in 40-50&#37; of the patients&#44;<span class="elsevierStyleSup">8</span> although in some studies these were much lower&#46;<span class="elsevierStyleSup">7</span> Intradermal injection has proven to be useful as a revaccination method in non-responding patients&#44; although it poses technical problems in its administration&#46;<span class="elsevierStyleSup">12</span> There is speculation that the non-responding patients to the initial vaccine could have developed cellular immunity without humoral immune response and that revaccination could be able to induce humoral immunity in this population&#46;<span class="elsevierStyleSup">21</span></p><p class="elsevierStylePara">The guide to viral infections in haemodialysis by the Spanish Society of Nephrology &#40;SEN&#41;<span class="elsevierStyleSup">2</span> recommends the administration of a second vaccine guideline in patients who have not responded to vaccination &#40;AcHbs &#60; 10UI&#47;L&#41;&#46; If there is still no response&#44; the patients are then definitively considered non-responding patients&#44; and there is no evidence that non-responding patients with both guidelines applied have a higher rate of subsequent response&#46; Our results show that the establishment of a booster dose administration protocol in patients without initial response allows for immunisation in a large number of patients&#46; Thus&#44; with this protocol&#44; with the first dose&#44; a quarter of the non-responding patients were immunised and the administration of new booster doses obtained new immunisations&#44; even after five booster doses&#46;</p><p class="elsevierStylePara">One third of our responding patients loss immunological memory in the first year&#44; a similar result to other studies&#46;<span class="elsevierStyleSup">8&#44;19</span> he antibody titre immediately after completing vaccination is the major predictive factor of immunity maintenance in these patients&#46;<span class="elsevierStyleSup">19&#44;22</span> Thus&#44; 75&#37; of the patients with antibodies &#62; 1&#44;000UI&#47;ml maintained seroprotection four years after vaccination&#44; while this percentage was less in patients with lower antibody titres&#46; A striking fact in our study was not finding significant differences in the maintenance of immunological memory among patients with initial titres between 11-99 and 100-999UI&#47;ml&#46; An antibody titre of 100UI&#47;ml is considered as the necessary threshold to maintain adequate immunological protection in immunocompromised patients&#46;<span class="elsevierStyleSup">13</span> In our study&#44; in the long-term&#44; this titre did not offer greater seroprotection than inferior titres&#44; which suggests that other factors&#44; independent of the initial vaccination response&#44; could influence in the maintenance or loss of immunological memory&#46;</p><p class="elsevierStylePara">Current recommendations in the follow-up of vaccinated patients against HB suggest carrying out annual anti-HB antibody tests&#44;<span class="elsevierStyleSup">16</span> although there is no unanimity in relation to the frequency of these tests&#46; Indeed&#44; there is great variability in the frequency of these tests in different dialysis services&#46;<span class="elsevierStyleSup">23</span> Furthermore&#44; due to the elevated percentage of patients who lose their immunological memory and that the loss of antibodies can be premature&#44; it has been suggested that it may be useful in these patients to perform more frequent tests&#44; 6-12 months after vaccination&#46;<span class="elsevierStyleSup">24</span> In our study&#44; annual antibody testing makes the elapsed time between the last vaccine dose and the determination of the antibody rate very variable and those patients classified as non-responding&#44; in reality&#44; could be responding patients with a low rate of antibodies and fast disappearance of this rate&#46; Indeed&#44; our results show that biannual testing could facilitate detection of a large number of patients who could benefit from a biannual booster dose instead of an annual one and&#44; moreover&#44; would expedite correct identification of the vaccination response in these non-responding patients&#46;</p><p class="elsevierStylePara">To sum up&#44; in our experience&#44; the administration of three double doses of recombinant vaccine against HB immunises half of the HD patients&#46; Age is a determining factor in the initial response to vaccination&#46; One third of the patients lose their immunological memory in the first year of follow-up&#46; The antibody titre after completing the vaccination protocol is a predictor of the maintenance of this memory&#46; The administration of booster doses immunises one fourth of the non-responding patients and biannual testing can be of use to better control and manage vaccinations in this population&#46;<br></br></p><p class="elsevierStylePara"><a href="grande&#47;41118078&#95;t1&#95;pag417&#46;jpg" class="elsevierStyleCrossRefs"><img src="41118078_t1_pag417.jpg" alt="Initial response to the hepatitis B vaccine"></img></a></p><p class="elsevierStylePara">Table 1&#46; Initial response to the hepatitis B vaccine</p><p class="elsevierStylePara"><a href="grande&#47;41118078&#95;t2&#95;pag418&#46;jpg" class="elsevierStyleCrossRefs"><img src="41118078_t2_pag418.jpg" alt="Additional booster doses in non-responding patients"></img></a></p><p class="elsevierStylePara">Table 2&#46; Additional booster doses in non-responding patients</p><p class="elsevierStylePara"><a href="grande&#47;41118078&#95;f1&#95;pag418&#46;jpg" class="elsevierStyleCrossRefs"><img src="41118078_f1_pag418.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p>"
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        "resumen" => "<p class="elsevierStylePara">La respuesta inmunitaria a la vacuna de la hepatitis B &#40;HB&#41; est&#225; impedida en los pacientes en hemodi&#225;lisis &#40;HD&#41;&#44; y la persistencia de la inmunidad&#44; la eficacia de la revacunaci&#243;n y la periodicidad de la realizaci&#243;n de controles serol&#243;gicos no est&#225;n bien definidas&#46; Presentamos la experiencia de un protocolo de vacunaci&#243;n de la HB con tres dosis intramusculares de 40 &#956;g de vacuna recombinante &#40;Engerix&#174;-B&#41; en un grupo de 136 pacientes atendidos en una unidad de HD a lo largo de 18 a&#241;os&#46; Se realizaron controles anuales de anticuerpos anti-HB en todos los pacientes&#44; y semestrales en 31&#59; y se administraba anualmente una dosis doble de vacuna a los pacientes que no respond&#237;an o cuando los niveles de anticuerpos descend&#237;an por debajo de 10 UI&#47;ml&#46; Setenta y cuatro pacientes &#40;54&#44;4&#37;&#41; presentaron seroconversi&#243;n&#44; mientras que 62 pacientes no respondieron&#46; La edad de los pacientes era superior en el grupo de no respondedores&#44; pero no se observaron diferencias en el sexo ni en la etiolog&#237;a de la enfermedad renal&#46; Un 32&#37; de los pacientes respondedores perdi&#243; la memoria inmunol&#243;gica al primer a&#241;o de la vacunaci&#243;n&#44; y tan s&#243;lo un 18&#37; de los pacientes permaneci&#243; inmunizado a los seis a&#241;os&#46; El t&#237;tulo de anticuerpos inmediatamente despu&#233;s de completar la vacunaci&#243;n fue predictor del mantenimiento de la memoria inmunol&#243;gica&#58; un 75&#37; de los pacientes con t&#237;tulos de anticuerpos &#62;1&#46;000 UI&#47;ml mantuvo la seroprotecci&#243;n a los tres a&#241;os en comparaci&#243;n con un 47&#37; con t&#237;tulos entre 100-999 &#40;p &#61; 0&#44;08&#41;&#44; y un 34&#37; con t&#237;tulos entre 11-99 &#40;p &#61; 0&#44;02&#41;&#46; La administraci&#243;n de dosis de refuerzo fue efectiva en un 24&#37; de los pacientes no respondedores&#44; y un 69&#37; manten&#237;a la respuesta inmunol&#243;gica al final del primer a&#241;o&#46; Las dosis de refuerzo repetidas en pacientes no respondedores a una primera dosis consiguieron nuevas seroconversiones en un 19&#44;6&#37; de los pacientes&#46; La pr&#225;ctica de controles semestrales podr&#237;a haber permitido administrar dosis de recuerdo antes del per&#237;odo anual en un 16&#37; de los pacientes respondedores&#46; En conclusi&#243;n&#44; nuestros resultados demuestran que un protocolo de vacunaci&#243;n de la HB con un seguimiento serol&#243;gico regular y dosis de refuerzo sucesivas consigue una aceptable seroprotecci&#243;n en los pacientes en hemodi&#225;lisis&#46;</p>"
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        "resumen" => "Hemodialysis &#40;HD&#41; patients have an impaired response to hepatitis B &#40;HB&#41; vaccines&#44; and the persistence of immunity&#44; the efficacy of revaccination and the periodicity of postvaccination testing are not well defined&#46; We present the experience during 18 years in an outpatient dialysis center of 136 HD patients who completed a HB vaccination program consisting in 3 doses of 40 &#956;g intramuscular recombinant B vaccine &#40;Engerix-B&#41;&#46; In all patients anti-HBs titers were determined annually and in 31 patients every 6 months&#46; Nonresponders patients and responders patients that lost their antibodies &#40; <10 ui ml received annually a booster double dose of vaccine seventy-four patients 54 4 developed immunity and the remaining 62 were considered nonresponders when compared both groups gender etiology chronic kidney disease did not differ between two nevertheless significantly older than responders after 1 year followup 32 had no detectable anti-hbs levels only 18 remained immunoreactive 6 years afer vaccination peak titer immediately completion schedule was found to be major predictor maintaining immunity: 75 with titers greater 1000 iu 3 47 100-999 p="0&#46;02&#41;&#46;" 34 11-99 administration additional doses effective in 24 69 them seropositive at end 1-year follow up repeated first afforded seroconversion 19 performing post-vaccination testing every six months it would have allowed give 16 responder before annual period conclusion: this current study demonstrates that hb regular serological affords an acceptable seroprotection hd</10>"
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                  "referenciaCompleta" => "Fabrizi F, Andrulli S, Bacchini G, Corti M, Locatelli F. Intradermal versus intramuscular hepatitis B-re-vaccination in non-responsive chronic dialysis patients: a prospective randomized study with cost-effectiveness evaluation. Nephrol Dial Tranplant 1997;12:1204-11."
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Long-term assessment of the immunological response to hepatitis B vaccines in 136 haemodialysis patients
Evaluación a largo plazo de la respuesta inmunológica a la vacuna de la hepatitis B en 136 pacientes en hemodiálisis
M.. Pina, M.T.. Comptea, P.. Angeleta, C.. Gállegoa, C.. Gutiérrezb, A.. Martínez Veac
a Unidad Nefrológica, Hospital de la Santa Creu, Tortosa, Tarragona, España,
b Unidad de Investigación, Hospital Universitari Joan XXIII, Tarragona, Tarragona, España,
c Servicio de Nefrología, Hospital Universitari Joan XXIII. Tarragona IISPV. Universitat Rovira i Virgili, Tarragona, Tarragona, España,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">In the 1960s and 70s&#44; HB was a serious problem in the HD services&#46; In the last decades&#44; the rate of infection from the HB virus in this group of patients has markedly decreased due to improved study methods&#44; stricter monitoring in blood banks&#44; reduced transfusion requirements subsequent to the availability of erythropoietin&#44; optimisation of haemodialysis in patients infected with the HB virus and to the widespread use of vaccination&#46;<span class="elsevierStyleSup">1&#44;2</span></p><p class="elsevierStylePara">The immunological response to the HB vaccine is related to the degree of kidney failure&#44; with greater response in patients with predialysis chronic kidney disease&#44;<span class="elsevierStyleSup">3</span> and therefore earlier vaccination in this stage of the kidney disease is advisable&#46; On the contrary&#44; in HD patients&#44; response to the HB vaccine is quite variable and lower than in the general population&#44;<span class="elsevierStyleSup">4&#44;5</span> with a response even below 50&#37; with the administering of three doses of vaccine<span class="elsevierStyleSup">6&#44;7</span> and slightly higher when a four-dose course is administered&#46;<span class="elsevierStyleSup">8</span> In addition to this&#44; persistence in the immunological response is also lower&#44; with a fast decrease in the protective antibody titres in many of these patients&#46;<span class="elsevierStyleSup">4&#44;5&#44;9</span></p><p class="elsevierStylePara">The mechanisms responsible for this decrease in the immunological response are unknown&#46; It has recently been proven that the low serological response to the HB virus in this population is closely linked to the deficit in specific-antigent dependent production of IL-2 by CD4&#43; Tcells&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">With the aim of improving response to the HB vaccine in the HD population&#44; several alternatives have been proposed&#44; such as increasing the administered vaccine dose&#44;<span class="elsevierStyleSup">11</span> intradermal application&#44;<span class="elsevierStyleSup">12</span> co-administration of zinc or several immunomodulators&#44;<span class="elsevierStyleSup">4&#44;5</span> or the more recent use of a new adjuvant&#44; AS04&#44; a derivative of bacterial lipopolysaccharides&#46;<span class="elsevierStyleSup">13</span> These interventions have obtained variable results&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">Many of the studies published on the HB virus in haemodialysis patients are centred on the results of this population&#191;s seroconversion&#44;<span class="elsevierStyleSup">8</span> but the information on immunity evolution of responding patients or those that have been revaccinated is much more limited&#46;</p><p class="elsevierStylePara">The aims of this study were&#58; a&#41; to assess the initial response to the HB vaccine in haemodialysis patients&#44; the factors that influence such response and its relationship with progressive antibody decay&#59; b&#41; to analyse the efficiency and usefulness of revaccination&#59; and c&#41; to assess if the biannual antibody level tests bring in additional information to that obtained in the annual tests&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND METHOD</span></p><p class="elsevierStylePara">Retrospective study that analyses a vaccination protocol against HB carried out in an HD service from 1989 to 2002&#46; One hundred and thirty six patients in the HD program with anti-Hbc &#40;-&#41; and anti-Hbs &#40;-&#41;&#44; with no evidence of previous infection or history of vaccinations&#44; were vaccinated against HB at the start of renal substitutive treatment&#46; The patients received three 40&#956;g doses of recombinant vaccine &#40;Engerix<span class="elsevierStyleSup">&#174;</span> -B&#44; Glaxo Smith Kline Biologicals&#44; Rixensart&#44; Belgium&#41;&#44; injected intramuscularly in the deltoids&#44; at months 0&#44; 1 and 6&#46; Annual antibody tests were performed and an annual booster double dose of vaccine was administered to non-responding patients or in the case of responding patients that lost their antibody levels &#40;&#60; 10UI&#47;ml&#41;&#46; Patients were followed until 2007 or until their decease&#44; change of treatment service or kidney transplant&#46; </p><p class="elsevierStylePara">Response to the vaccine was analysed in all patients&#44; together with the factors influencing immunization and the efficiency of revaccination in patients who did not respond to the initial vaccination&#46; Maintenance of the level of antibodies after the first positive revaccination was also assessed&#46;</p><p class="elsevierStylePara">A subgroup of 63 patients with a three year follow-up after the first year of vaccination was analysed for the probability of maintaining the immunological response according to the antibody titres reached during the first annual control&#46; Patients were classified into three groups&#58; group I&#44; patients with antibodies &#62; 1&#44;000UI&#47;ml&#59; group II&#44; patients with antibodies between 100 and 999UI&#47;ml&#59; and group III&#44; patients with antibodies from 11 to 99UI&#47;ml&#46;</p><p class="elsevierStylePara">Finally&#44; a subgroup of 31 patients was analysed to check if the biannual antibody level tests contributed any additional information to their annual tests&#46; </p><p class="elsevierStylePara">The anti-Hbs antibodies were determined via microparticle enzyme immunoassay &#40;MEIA&#41;&#46; The lower limit of antibody detection was 2mUI&#47;ml and the intra- and inter-assay variation coefficient was 4&#46;4 and 4&#46;8&#37;&#44; respectively&#46; Patients with titres equal to or over 1&#44;000UI&#47;ml were considered as &#62; 1&#44;000UI&#47;ml&#46;</p><p class="elsevierStylePara">The anti-Hbs antibody titres &#62; 10UI&#47;ml were considered protective&#44; while the lower titres were defined as loss of immunity&#46;</p><p class="elsevierStylePara">The statistical analysis was performed using the SPSS 11&#46;0 program&#46; Results are expressed as mean &#43; SD&#46; The comparison between quantitative variables was carried out with Student&#191;s T-test and for the categorical variables the chi-square was used&#46;</p><p class="elsevierStylePara">Duration of immunity according to the anti-Hbs antibodies was analysed using the Kaplan-Meier estimator&#46;</p><p class="elsevierStylePara">Values p &#60; 0&#46;05 were considered significative&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Responding patients</span></p><p class="elsevierStylePara">Seventy four patients &#40;54&#46;4&#37;&#41; developed immunity against the HB vaccine&#46; Of these&#44; 39 patients &#40;52&#46;7&#37;&#41; presented an antibody titre &#62; 100UI&#47;ml&#44; a level which has been considered as the necessary threshold to maintain adequate seroprotection in HD patients&#46; Response to the HB vaccine was related to age&#44; the average non-responding age was higher than that of the responding patients&#46; Conversely&#44; the sex and aetiology of the chronic renal disease did not influence the response &#40;table 1&#41;&#46;</p><p class="elsevierStylePara">In successive annual tests a progressive decrease in the levels of antibodies was detected&#46; In the first annual post-vaccination testing&#44; 67&#46;8&#37; of the patients maintained protective levels&#44; and six years later&#44; only 17&#46;8&#37; of the patients maintained the immunological memory&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Non-responding patients</span></p><p class="elsevierStylePara">The 62 patients that did not respond to the three initial doses of vaccines were subject to an additional booster dose&#59; although only 46 patients were evaluated at the end of the first years&#44; since the remaining patients passed away&#44; had transplants or were transferred to another service&#46; The global efficiency for these doses was 21&#46;6&#37;&#58; with the first dose&#44; 23&#46;9&#37; of the patients seroconverted&#59; with the second dose&#44; 12&#37;&#59; and with the third&#44; 37&#46;7&#37; &#40;table 2&#41;&#46; 42&#46;8&#37; of the seroconverted patients presented a level of anti-Hbs antibodies &#62; 100UI&#47;ml&#46; The percentage of patients that maintained protecting levels of antibodies after the first booster dose was 69&#46;2&#37; in the first annual control&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Immunological response and antibody titre</span></p><p class="elsevierStylePara">In the 63-patient subgroup with a three year follow-up&#44; 7 patients were included in group I&#44; 28 in group II and 28 in group III&#46; The average age of these groups was 55&#46;5 &#40;33-78&#41;&#44; 62&#46;8 &#40;29-78&#41; and 57&#46;2 &#40;26-75&#41;&#44; respectively&#46; The antibody titre in groups II and III was 55 &#40;12-98&#41; and 290 &#40;100-978&#41; UI&#47;ml&#44; respectively&#46;</p><p class="elsevierStylePara">Figure 1 details the probability of patients remaining protected after vaccination&#46; After follow-up&#44; 75&#37; of the patients in group I maintained seroprotection versus 47&#37; in group II &#40;p &#61; 0&#46;08&#41; and 34&#37; in group III &#40;p &#61; 0&#46;02&#41;&#46; Conversely&#44; no significant differences were found between groups II and III&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Importance of the biannual antibody tests</span></p><p class="elsevierStylePara">Of the 31 patients that had biannual and annual antibody tests&#44; the biannual tests supplied additional information&#46; In four of the 25 responding patients&#44; the levels of antibodies had become negative six months later&#46; Therefore&#44; these patients could have benefited from an earlier booster shot&#46; Finally&#44; seven non-responding patients to the annual testing presented protecting antibody levels in the biannual tests&#46; This group of patients would have been considered non-responding to the vaccine if they had undergone only one annual test&#46;<span class="elsevierStyleBold"></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">In this study&#44; an HB vaccination protocol which ended in 2002 is presented&#44; using the conventional guideline of three double doses of vaccine&#46; Since 2003&#44; this protocol was amended&#44; upon completion of the study&#44; increasing it to four double doses of vaccine&#44;<span class="elsevierStyleSup">15&#44;16</span> guideline which is currently being followed in our Service&#46;</p><p class="elsevierStylePara">Despite the current controversy as to the effectiveness of the HB vaccine in HD patients&#44; due to the reduced efficiency of the vaccine and the low incidence of infection by the HB virus&#44; its use has become generalised in this population of patients&#46;<span class="elsevierStyleSup">17</span> In our experience&#44; 54&#46;4&#37; of the vaccinated patients developed immunity&#44; a figure similar to that shown in other studies&#46;<span class="elsevierStyleSup">8&#44;18</span> Even in the protocols that include four double doses of vaccine in months 0&#44; 1&#44; 2 and 6&#44; the seroconversion results obtained are not optimal either and oscillate between 58 and 80&#37;&#46;<span class="elsevierStyleSup">8&#44;19</span> This insufficient response to the HB vaccine is related to deficiency in immunocompetence&#44; characteristic of advanced chronic renal disease&#46;<span class="elsevierStyleSup">4&#44;5</span> Other modulating factors that negatively affect this response have been identified&#44; such as age&#44; diabetes&#44; malnutrition&#44; erythropoietin deficiency and suitability and duration of dialysis&#44; among others&#46;<span class="elsevierStyleSup">19&#44;20</span> The lack of response of our patients was related to age&#44; the percentage of responding patients decreasing the higher the patient age&#46; In contrast&#44; other factors&#44; such as the presence of diabetes&#44; did not influence the response in this population&#46;</p><p class="elsevierStylePara">In patients who did not respond to the initial vaccination&#44; revaccination was recommended with three additional vaccine doses&#44; obtaining a response in 40-50&#37; of the patients&#44;<span class="elsevierStyleSup">8</span> although in some studies these were much lower&#46;<span class="elsevierStyleSup">7</span> Intradermal injection has proven to be useful as a revaccination method in non-responding patients&#44; although it poses technical problems in its administration&#46;<span class="elsevierStyleSup">12</span> There is speculation that the non-responding patients to the initial vaccine could have developed cellular immunity without humoral immune response and that revaccination could be able to induce humoral immunity in this population&#46;<span class="elsevierStyleSup">21</span></p><p class="elsevierStylePara">The guide to viral infections in haemodialysis by the Spanish Society of Nephrology &#40;SEN&#41;<span class="elsevierStyleSup">2</span> recommends the administration of a second vaccine guideline in patients who have not responded to vaccination &#40;AcHbs &#60; 10UI&#47;L&#41;&#46; If there is still no response&#44; the patients are then definitively considered non-responding patients&#44; and there is no evidence that non-responding patients with both guidelines applied have a higher rate of subsequent response&#46; Our results show that the establishment of a booster dose administration protocol in patients without initial response allows for immunisation in a large number of patients&#46; Thus&#44; with this protocol&#44; with the first dose&#44; a quarter of the non-responding patients were immunised and the administration of new booster doses obtained new immunisations&#44; even after five booster doses&#46;</p><p class="elsevierStylePara">One third of our responding patients loss immunological memory in the first year&#44; a similar result to other studies&#46;<span class="elsevierStyleSup">8&#44;19</span> he antibody titre immediately after completing vaccination is the major predictive factor of immunity maintenance in these patients&#46;<span class="elsevierStyleSup">19&#44;22</span> Thus&#44; 75&#37; of the patients with antibodies &#62; 1&#44;000UI&#47;ml maintained seroprotection four years after vaccination&#44; while this percentage was less in patients with lower antibody titres&#46; A striking fact in our study was not finding significant differences in the maintenance of immunological memory among patients with initial titres between 11-99 and 100-999UI&#47;ml&#46; An antibody titre of 100UI&#47;ml is considered as the necessary threshold to maintain adequate immunological protection in immunocompromised patients&#46;<span class="elsevierStyleSup">13</span> In our study&#44; in the long-term&#44; this titre did not offer greater seroprotection than inferior titres&#44; which suggests that other factors&#44; independent of the initial vaccination response&#44; could influence in the maintenance or loss of immunological memory&#46;</p><p class="elsevierStylePara">Current recommendations in the follow-up of vaccinated patients against HB suggest carrying out annual anti-HB antibody tests&#44;<span class="elsevierStyleSup">16</span> although there is no unanimity in relation to the frequency of these tests&#46; Indeed&#44; there is great variability in the frequency of these tests in different dialysis services&#46;<span class="elsevierStyleSup">23</span> Furthermore&#44; due to the elevated percentage of patients who lose their immunological memory and that the loss of antibodies can be premature&#44; it has been suggested that it may be useful in these patients to perform more frequent tests&#44; 6-12 months after vaccination&#46;<span class="elsevierStyleSup">24</span> In our study&#44; annual antibody testing makes the elapsed time between the last vaccine dose and the determination of the antibody rate very variable and those patients classified as non-responding&#44; in reality&#44; could be responding patients with a low rate of antibodies and fast disappearance of this rate&#46; Indeed&#44; our results show that biannual testing could facilitate detection of a large number of patients who could benefit from a biannual booster dose instead of an annual one and&#44; moreover&#44; would expedite correct identification of the vaccination response in these non-responding patients&#46;</p><p class="elsevierStylePara">To sum up&#44; in our experience&#44; the administration of three double doses of recombinant vaccine against HB immunises half of the HD patients&#46; Age is a determining factor in the initial response to vaccination&#46; One third of the patients lose their immunological memory in the first year of follow-up&#46; The antibody titre after completing the vaccination protocol is a predictor of the maintenance of this memory&#46; The administration of booster doses immunises one fourth of the non-responding patients and biannual testing can be of use to better control and manage vaccinations in this population&#46;<br></br></p><p class="elsevierStylePara"><a href="grande&#47;41118078&#95;t1&#95;pag417&#46;jpg" class="elsevierStyleCrossRefs"><img src="41118078_t1_pag417.jpg" alt="Initial response to the hepatitis B vaccine"></img></a></p><p class="elsevierStylePara">Table 1&#46; Initial response to the hepatitis B vaccine</p><p class="elsevierStylePara"><a href="grande&#47;41118078&#95;t2&#95;pag418&#46;jpg" class="elsevierStyleCrossRefs"><img src="41118078_t2_pag418.jpg" alt="Additional booster doses in non-responding patients"></img></a></p><p class="elsevierStylePara">Table 2&#46; Additional booster doses in non-responding patients</p><p class="elsevierStylePara"><a href="grande&#47;41118078&#95;f1&#95;pag418&#46;jpg" class="elsevierStyleCrossRefs"><img src="41118078_f1_pag418.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p>"
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        "resumen" => "<p class="elsevierStylePara">La respuesta inmunitaria a la vacuna de la hepatitis B &#40;HB&#41; est&#225; impedida en los pacientes en hemodi&#225;lisis &#40;HD&#41;&#44; y la persistencia de la inmunidad&#44; la eficacia de la revacunaci&#243;n y la periodicidad de la realizaci&#243;n de controles serol&#243;gicos no est&#225;n bien definidas&#46; Presentamos la experiencia de un protocolo de vacunaci&#243;n de la HB con tres dosis intramusculares de 40 &#956;g de vacuna recombinante &#40;Engerix&#174;-B&#41; en un grupo de 136 pacientes atendidos en una unidad de HD a lo largo de 18 a&#241;os&#46; Se realizaron controles anuales de anticuerpos anti-HB en todos los pacientes&#44; y semestrales en 31&#59; y se administraba anualmente una dosis doble de vacuna a los pacientes que no respond&#237;an o cuando los niveles de anticuerpos descend&#237;an por debajo de 10 UI&#47;ml&#46; Setenta y cuatro pacientes &#40;54&#44;4&#37;&#41; presentaron seroconversi&#243;n&#44; mientras que 62 pacientes no respondieron&#46; La edad de los pacientes era superior en el grupo de no respondedores&#44; pero no se observaron diferencias en el sexo ni en la etiolog&#237;a de la enfermedad renal&#46; Un 32&#37; de los pacientes respondedores perdi&#243; la memoria inmunol&#243;gica al primer a&#241;o de la vacunaci&#243;n&#44; y tan s&#243;lo un 18&#37; de los pacientes permaneci&#243; inmunizado a los seis a&#241;os&#46; El t&#237;tulo de anticuerpos inmediatamente despu&#233;s de completar la vacunaci&#243;n fue predictor del mantenimiento de la memoria inmunol&#243;gica&#58; un 75&#37; de los pacientes con t&#237;tulos de anticuerpos &#62;1&#46;000 UI&#47;ml mantuvo la seroprotecci&#243;n a los tres a&#241;os en comparaci&#243;n con un 47&#37; con t&#237;tulos entre 100-999 &#40;p &#61; 0&#44;08&#41;&#44; y un 34&#37; con t&#237;tulos entre 11-99 &#40;p &#61; 0&#44;02&#41;&#46; La administraci&#243;n de dosis de refuerzo fue efectiva en un 24&#37; de los pacientes no respondedores&#44; y un 69&#37; manten&#237;a la respuesta inmunol&#243;gica al final del primer a&#241;o&#46; Las dosis de refuerzo repetidas en pacientes no respondedores a una primera dosis consiguieron nuevas seroconversiones en un 19&#44;6&#37; de los pacientes&#46; La pr&#225;ctica de controles semestrales podr&#237;a haber permitido administrar dosis de recuerdo antes del per&#237;odo anual en un 16&#37; de los pacientes respondedores&#46; En conclusi&#243;n&#44; nuestros resultados demuestran que un protocolo de vacunaci&#243;n de la HB con un seguimiento serol&#243;gico regular y dosis de refuerzo sucesivas consigue una aceptable seroprotecci&#243;n en los pacientes en hemodi&#225;lisis&#46;</p>"
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        "resumen" => "Hemodialysis &#40;HD&#41; patients have an impaired response to hepatitis B &#40;HB&#41; vaccines&#44; and the persistence of immunity&#44; the efficacy of revaccination and the periodicity of postvaccination testing are not well defined&#46; We present the experience during 18 years in an outpatient dialysis center of 136 HD patients who completed a HB vaccination program consisting in 3 doses of 40 &#956;g intramuscular recombinant B vaccine &#40;Engerix-B&#41;&#46; In all patients anti-HBs titers were determined annually and in 31 patients every 6 months&#46; Nonresponders patients and responders patients that lost their antibodies &#40; <10 ui ml received annually a booster double dose of vaccine seventy-four patients 54 4 developed immunity and the remaining 62 were considered nonresponders when compared both groups gender etiology chronic kidney disease did not differ between two nevertheless significantly older than responders after 1 year followup 32 had no detectable anti-hbs levels only 18 remained immunoreactive 6 years afer vaccination peak titer immediately completion schedule was found to be major predictor maintaining immunity: 75 with titers greater 1000 iu 3 47 100-999 p="0&#46;02&#41;&#46;" 34 11-99 administration additional doses effective in 24 69 them seropositive at end 1-year follow up repeated first afforded seroconversion 19 performing post-vaccination testing every six months it would have allowed give 16 responder before annual period conclusion: this current study demonstrates that hb regular serological affords an acceptable seroprotection hd</10>"
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