Risk of Herpes Zoster in Patients Treated With Long-term Hemodialysis: A Matched Cohort Study

doi:10.1053/j.ajkd.2011.10.049

American Journal of Kidney Diseases

Volume 59, Issue 3, March 2012, Pages 428-433

https://doi.org/10.1053/j.ajkd.2011.10.049 Get rights and content

Background

The risk of herpes zoster in the dialysis population relative to the general population is not known. The aim of this study was to perform a population-based cohort study to investigate the risk of herpes zoster after the initiation of hemodialysis therapy in patients with end-stage renal disease (ESRD) in Taiwan, a country with the highest incidence of ESRD in the world.

Study Design

Matched cohort study.

Setting & Participants

Data were obtained from the Taiwan National Health Insurance Research Database. 843 patients who were beginning hemodialysis therapy in 1999-2003 were included as the study cohort and 3,372 patients without ESRD matched for age and sex were included as a comparison cohort. A multivariate frailty Cox proportional hazard regression model was used to adjust for confounding and compare the 6-year herpes zoster–free survival rate between these 2 cohorts.

Predictors

Hemodialysis.

Outcomes

Herpes zoster.

Results

Mean years of follow-up were 4.73 and 5.49 for the hemodialysis and comparison cohorts, respectively. 868 patients developed herpes zoster throughout the study period, 294 from the hemodialysis cohort and 574 from the comparison cohort. The incidence rate of herpes zoster (73.34 events/1,000 person-year) was significantly higher in the hemodialysis cohort than in the control cohort (31.03 events/1,000 person-years). After adjusting for potential confounders, the adjusted HR of herpes zoster was 1.98 (95% CI, 1.72-2.27).

Limitations

We expect that some patients with mild zoster chose not to seek medical help.

Conclusions

We conclude that patients treated with long-term hemodialysis are at an increased risk of herpes zoster compared with the general population.

Section snippets

Data Source

The National Health Insurance (NHI) program, which provides compulsory universal health insurance, was implemented in Taiwan on March 1, 1995. Under the NHI, 98% of the island's population receives all forms of health care services, including outpatient services, inpatient care, Chinese medicine, dental care, childbirth, physical therapy, preventive health care, home care, and rehabilitation for chronic mental illness. In cooperation with the Bureau of NHI, the National Health Research

Results

There were 843 patients in our hemodialysis cohort who were compared with 3,372 selected matched controls. Table 1 lists the distribution of demographic characteristics and selected medical conditions of study participants. Patients treated with long-term hemodialysis therapy had a significant higher rate of diabetes. There was no significant difference in the distribution of SLE, breast cancer, liver cancer, and lymphoma/leukemia between these 2 cohorts.

Table 2 lists the distribution of herpes

Discussion

In this population-based cohort study, after adjusting for potential confounders, we found that patients treated with long-term hemodialysis were 1.98 times more likely than the general population to experience herpes zoster during the 6-year follow-up period (HR, 1.98; 95% CI, 1.72-2.27). To our knowledge, this study is the first cohort study to investigate the risk of herpes zoster in patients treated with long-term hemodialysis.

Patients of older age or who are immunocompromised, have

Acknowledgements

This study is based in part on data from the NHI Research Database provided by the Bureau of NHI, Department of Health, and managed by NHRIs. The interpretation and conclusions contained herein do not represent those of the Bureau of NHI, Department of Health, or NHRIs.

Support: This study was supported in part by a grant from the National Science Council, Executive Yuan, Taiwan (NSC-97-2314-B-037-006-MY3).

Financial Disclosure: The authors declare that they have no other relevant financial

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This is a retrospective population-based study. RZV-vaccinated patients at Bari Policlinico General Hospital vaccination clinic from October 1st, 2021, to March 31st, 2023, were enrolled. Subjects were screened for reason of RZV eligibility and baseline chronic pathologies. AEFIs occurred in the first 7-days post-vaccination period were collected, and baseline disease flare-ups and post-vaccination HZ episodes were assessed via a 3-month follow-up.
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Twelve patients who completed the vaccination cycle(2.43%) had at least one HZ episode by the long-term follow-up.
The study demonstrates RZV safety in a significant number of high-risk patients. Hence, RZV should be actively offered as part of tailored vaccination programs to decrease the burden of HZ in fragile populations.
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The impact of herpes zoster (HZ) on patients’ quality of life and the introduction of zoster vaccination for HZ prevention,46 raised the awareness of the importance of HZ prophylaxis and possible adjuvants to enhance treatment and vaccination efficacy.47 A potential adjunctive measure is vitamin D, which may lower the incidence of HZ.48-50 Primary varicella zoster virus (VZV) infection is followed by immunity and a state of viral latency, which if switched towards viral reactivation, leads to HZ.47
Vitamin D is an important cornerstone in the immunologic cascade of many skin infections, systemic infections with cutaneous presentations, and other infectious dermatologic diseases where infections could be a culprit. Vitamin D supplementation is proposed as a protective measure against their occurrence and exacerbation, especially with the emergence of several viral pandemics in recent years. Vitamin D plays a key role in the maintenance of a balanced immunologic profile which could be reflected by a lowered incidence and morbidity of infections. Vitamin D screening and supplementation in patients with deficiencies or insufficiencies should be a part of the dermatologic approach to patients with these diseases.
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These infections were selected because the defective epidermal barrier seen in psoriasis might be expected to put these patients at greater risk of seven of the infectious complications examined: bacteremia, septicemia, SIRS, cellulitis, conjunctivitis, fungemia, and onychomycosis. Herpes zoster was also chosen as an outcome because both kidney failure and psoriasis are reported to increase the risk of Herpes zoster infection, and we wished to determine whether psoriasis enhances susceptibility to this infection in ESRD patients.35,36 Finally, there is some thought that psoriasis may be associated with pericarditis,37 with occasional case reports of psoriasis patients on biologic treatment presenting with pericarditis.38,39
Psoriasis impairs the quality of life of approximately 7.5 million Americans and is associated with serious comorbidities. Because of chronic vascular access and epidermal dysfunction, end-stage renal disease (ESRD) patients with psoriasis may be at greater risk for infection, and psoriasis treatment could affect this risk.
A retrospective cohort analysis was performed using the United States Renal Data System from 2004-2011 to investigate the association of psoriasis with infections common to ESRD patients, as well as the effect of psoriasis treatment on infection risk as well as mortality.
A total of 8,911 psoriasis patients were identified. Psoriasis was associated with a significantly increased risk for all queried infections, especially cellulitis (adjusted relative risk = 1.55), conjunctivitis (1.47), and onychomycosis (1.36). Psoriasis treatment (systemic, local, and light) was associated with a significantly decreased risk of some infections. Psoriasis treatment was also correlated with a significantly decreased risk of mortality, with systemic therapies (biologics and other immunosuppressants) showing the greatest reduction (adjusted hazard ratio = 0.55).
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Patients in need of long-term renal replacement therapy (RRT) are known to be at increased risk of herpes zoster, occurring when the latently present varicella-zoster virus (VZV) reactivates. In this study we investigated immunity to VZV in patients receiving RRT, with the aim of better understanding the mechanism behind the increased risk.
Patients treated for at least three months with hemodialysis or peritoneal dialysis, and matched healthy controls (HC) were included. Cellular immunity to varicella-zoster virus (VZV) was studied using an interferon-γ (IFNγ) enzyme-linked immunospot (ELISpot) assay, flow-cytometric analysis of cytokine production and a proliferation assay. Humoral immunity was determined by measuring immunoglobulin (Ig)G antibody levels to VZV using an in-house glycoprotein enzyme-linked immunosorbent assay (ELISA). Multiple regression was used to assess variables of influence on measures of cellular and humoral immunity to VZV in patients receiving RRT.
Similar numbers of IFNγ spot-forming cells and levels of VZV-IgG were found in 97 patients and 89 HC. Age and transplantation history were negatively associated with cellular immunity (p = 0.001 and p = 0.012, respectively) while treatment modality, gender and urea levels were not. No variables were found to be associated with VZV-IgG levels.
Increased incidence of herpes zoster in patients receiving RRT cannot be explained by intrinsic defects of cellular or humoral immunity to VZV as measured by the methods used in this study, although older age and previous transplantation were associated with decreased cellular immunity to VZV. Herpes zoster susceptibility might be caused by a diminished function of otherwise capable T cells in a uremic environment.
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To systematically review studies examining risk factors for herpes zoster (HZ).
We performed a literature search using PubMed, EMBASE, and Web of Science for articles published from January 1, 2003, to February 1, 2017. A random-effects model was used to summarize the risk ratio (RR) or odds ratio (OR) and 95% CI.
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: Originally published online December 19, 2011.

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Original InvestigationDialysisRisk of Herpes Zoster in Patients Treated With Long-term Hemodialysis: A Matched Cohort Study

Background

Study Design

Setting & Participants

Predictors

Outcomes

Results

Limitations

Conclusions

Section snippets

Data Source

Results

Discussion

Acknowledgements

Am J Kidney Dis

Lancet

J Neurol Sci

Kidney Int

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

J Infect

Clin Neurol Neurosurg

Lancet Infect Dis

Kidney Int

Maintenance dialysis population dynamics: current trends and long-term implications

J Am Soc Nephrol

USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States

Am J Kidney Dis

Epidemiological features and costs of herpes zoster in Taiwan: a national study 2000 to 2006

Acta Derm Venereol

Clinical and molecular pathogenesis of varicella virus infection

Viral Immunol

Neurologic complications of the reactivation of varicella-zoster virus

N Engl J Med

Granulomatous angiitis of the nervous system in cases of herpes zoster and lymphosarcoma

Neurology

Varicella-zoster virus infections of the nervous system: clinical and pathologic correlates

Arch Pathol Lab Med

Aspects of immune dysfunction in end-stage renal disease

Clin J Am Soc Nephrol

Inflammation in atherosclerosis

Nature

Risk of myocardial infarction and stroke after acute infection or vaccination

N Engl J Med

Chronic infections and the risk of carotid atherosclerosis: prospective results from a large population study

Circulation

Original Investigation
Dialysis
Risk of Herpes Zoster in Patients Treated With Long-term Hemodialysis: A Matched Cohort Study