Vaccination gaps and infection risk at dialysis initiation

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.