Vaccine efficacy in CKD patients not on dialysis: a systematic review and meta-analysis

Patients with chronic kidney disease (CKD) have increased infection risk, contributing to higher rates of hospitalization and mortality. While vaccines can prevent or reduce the severity, data primarily focus on dialysis-dependent patients. This meta-analysis aimed to evaluate vaccine efficacy in non-dialysis CKD patients (CKD-ND).

We systematically searched the MEDLINE, Embase, Scopus and OVID databases through April 2025 for randomized controlled and observational studies reporting the vaccine efficacy in stage 1-5 CKD-ND patients. Efficacy was assessed using laboratory markers (seroconversion, antibody titres) and clinical outcomes. The quality of the studies was assessed by ROBINS-I V2 and RoB2. A random effects model was used to estimate pooled effect size with 95% confidence interval.

Twenty-eight studies involving >500 000 participants were included covering hepatitis B virus (HBV), COVID-19, influenza, herpes zoster, pneumococcus and human papillomavirus (HPV) vaccines. Most studies were graded fair quality. Ten studies on HBV vaccination revealed a pooled seroconversion rate of 80% that decreased to 60% at 12 months post-vaccination. For COVID-19, the pooled anti-spike immunoglobulin G titre was 228.39 BAU/ml, with a reduced risk of COVID-19 infection following a boosting dose. Two doses of the influenza vaccine yielded higher seroconversion rates than a single dose, but the antibody levels declined over time, indicating waning immunity. The zoster vaccine showed a pooled adjusted hazard ratio of 0.74 for herpes zoster incidence compared with those who were unvaccinated. Pneumococcal vaccine elicited a modest transient response and was associated with reduced Streptococcus pneumoniae hospitalization and community-acquired pneumonia risk. The HPV vaccine demonstrated 100% seroconversions, although with lower HPV neutralizing antibody levels.

Vaccination in CKD-ND patients is associated with a high rate of seroconversion and seroprotection across multiple vaccines. However, these surrogate markers may not fully reflect clinical effectiveness. Further studies are needed to evaluate the impact of vaccination on demonstrated clinical outcomes, particularly infection-related morbidities and mortalities.