ARTICLE IN PRESS

THE JOURNAL OF PEDIATRICS • www.jpeds.com ORIGINAL

ARTICLES
Prospective Study of Live Attenuated Vaccines for Patients with
Nephrotic Syndrome Receiving Immunosuppressive Agents
Koichi Kamei, MD, PhD1, Isao Miyairi, MD, PhD2, Kenji Ishikura, MD, PhD1, Masao Ogura, MD1, Kensuke Shoji, MD2,
Takanori Funaki, MD2, Reiko Ito, MD3, Katsuhiro Arai, MD, PhD4, Jun Abe, MD, PhD5, Toshinao Kawai, MD, PhD6,
Masafumi Onodera, MD, PhD6, and Shuichi Ito, MD, PhD7

Objective To conduct a prospective study to evaluate the immunogenicity and safety of live attenuated vaccines
in patients with nephrotic syndrome receiving immunosuppressive agents.
Study design Patients with nephrotic syndrome receiving immunosuppressive agents with negative or border-
line antibody titers (virus-specific IgG levels <4.0) against measles, rubella, varicella, and/or mumps fulfilling the
criteria of cellular and humoral immunity were enrolled. Virus-specific IgG levels were measured using an enzyme
immunoassay. The primary endpoint was the seroconversion rate (ie, achievement of virus-specific IgG levels ≥4.0)
at 2 months after vaccination. Virus-specific IgG levels at 1 year, breakthrough infections (wild-type infections), and
adverse events were also evaluated.
Results A total of 116 vaccinations were administered to 60 patients. Seroconversion rates were 95.7% for measles,
100% for rubella, 61.9% for varicella, and 40.0% for mumps. More patients with a borderline antibody titer before
vaccination achieved seroconversion than those with negative antibody titer, with statistical significance after vari-
cella and mumps vaccination. The rate of patients who maintained seropositivity at 1 year after vaccination was
83.3% for measles, 94.1% for rubella, 76.7% for varicella, and 20.0% for mumps. No patient experienced break-
through infection. No serious adverse events, including vaccine-associated infection, were observed.
Conclusion Immunization with live attenuated vaccines may be immunogenic and is apparently safe in our cohort
of patients with nephrotic syndrome receiving immunosuppressive agents if their cellular and humoral immuno-
logic measures are within clinically acceptable levels. (J Pediatr 2017;■■:■■-■■).
Trial Registration UMIN-CTR UMIN 000007710.

V
iral infections, such as measles and varicella, cause serious complications in children receiving immunosuppressive agents.
Varicella is especially known to cause fatal, viscerally disseminated infections in patients on immunosuppression. These
children have a much higher mortality rate than healthy children.1-6 There is a 1969 case report of a 4-year-old boy with
nephrotic syndrome who died from measles pneumonia during cyclophosphamide treatment.7 The severity of infection is re-
portedly less severe in already immunized patients compared with nonimmunized patients.4 There is also a risk of disease re-
currence, such as relapse of nephrotic syndrome, after such viral infections. Therefore, long-lasting protection conferred by
vaccination is desirable for these vaccine-preventable diseases.
In Japan, the combined measles and rubella (MR) vaccine is administered routinely at age 1 year and 5-6 years. The vari-
cella vaccine is now also routinely administered twice at age 1 year, although it was voluntary before October 2014. The mumps
vaccine is still voluntary. Most children in Japan receive the MR vaccine; however, the rates of varicella and mumps immuni-
zation are relatively low.
Live vaccines are generally contraindicated for use in patients receiving immu-
nosuppressive agents, who are considered at greater risk for serious viral infec-
tion from the vaccine strains.8 In Japan, the use of live vaccines is listed as a
contraindication on the package insert of every immunosuppressive agent, in-
From the 1Division of Nephrology and Rheumatology,
cluding cyclosporine, tacrolimus, mycophenolate mofetil, mizoribine, azathio- National Center for Child Health and Development, Tokyo;
2Division of Infectious Diseases, National Center for Child
prine, and everolimus. In these patients, administration of live vaccines requires Health and Development, Tokyo; 3Department of General
previous discontinuation of immunosuppressive agents, putting them at an un- Pediatrics, National Center for Child Health and
Development, Tokyo; 4Division of Gastroenterology,
acceptable risk of recurrence of their original disease, such as relapse of ne- National Center for Child Health and Development, Tokyo;
5Department of Allergy and Immunology, National
phrotic syndrome. Immunization with live vaccines in selected patients who Research Institute for Child Health and Development,
Tokyo; 6Department of Human Genetics, National
Research Institute for Child Health and Development,
Tokyo; and 7Department of Pediatrics, Yokohama City
University, Yokohama
This study is funded and supported by a grant from the
EIA Enzyme immunoassay National Center for Child Health and Development (24-
10). The authors declare no conflicts of interest.
MR Measles and rubella
NCCHD National Center for Child Health and Development 0022-3476/$ - see front matter. © 2017 Elsevier Inc. All rights
PHA Phytohemagglutinin reserved.
https://doi.org10.1016/j.jpeds.2017.12.061

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THE JOURNAL OF PEDIATRICS • www.jpeds.com
demonstrate stable disease activity under immunosuppres-
sive therapy and normal immunologic parameters may be a
possible solution to this dilemma.
A number of several case series examining immunization
using live attenuated vaccines in patients on immunosuppres-
sive therapy, mainly solid organ transplant recipients, have been
published to date.9-20 No life-threatening adverse events were
reported. However, to the best of our knowledge, there are no
published data on immunization with live vaccines for pa-
tients on immunosuppressive agents for nephrotic syn-
drome. Therefore, we conducted a prospective study to examine
the immunogenicity and safety of live attenuated vaccines for
patients with nephrotic syndrome receiving immunosuppres-
sive agents.
Methods
This prospective study was performed between May 2011 and
January 2017 at the National Center for Child Health and De-
velopment (NCCHD) in Tokyo, Japan. The study was regis-
tered under the University Hospital Medical Information
Network Clinical Trials Registry (UMIN-CTR: UMIN
000007710). The study was performed in accordance with the
Declaration of Helsinki and was approved by the Ethics Com-
mittee of the NCCHD (approval no. 452). An intramural com-
mittee for live attenuated vaccines for patients receiving
immunosuppressive agents, consisting of medical doctors in
the Divisions of Infectious Diseases, Immunology, Nephrol-
ogy and Rheumatology, and Gastroenterology and the De-
partment of General Pediatrics, was established in April 2011
at the NCCHD and since then has been convened once a month
to discuss patient eligibility and the monitoring of vaccine safety
and immunogenicity. This prospective study of live attenu-
ated vaccines for children with nephrotic syndrome receiv-
ing immunosuppressive agents was conducted under the
supervision of this committee.
Inclusion criteria for eligible patients are listed in Table I.
Virus-specific antibody titers were measured using a commer-
cially available enzyme immunoassay (EIA) (Denka Seiken,
Tokyo, Japan) for measles, rubella, varicella, and mumps. Nega-
tive (−), borderline (±), and positive (+) antibody titers were
defined based on EIA measured IgG values of <2.0, 2.0-3.9, and
≥4.0. These cutoff values for IgG levels were determined by the
manufacturer based on conversion from international units
using World Health Organization standard substances. 26
The conversion formulas were as follows: measles, EIA
values × 45 = international values (mIU/mL); rubella, EIA
values × 2.3 = international values (IU/mL); varicella, EIA values
× 45 = international values (mIU/mL). The relationship between
virus-specific antibody titers and clinical efficacy (preven-
tion of infection) suggested for healthy children is shown in
Table II (available at www.jpeds.com).27
We used a freeze-dried live attenuated MR vaccine (Schwartz
FF strain for measles and the TO-336 strain for rubella; Takeda,
Osaka, Japan), a freeze-dried live attenuated varicella vaccine
(Oka strain; Biken, Osaka, Japan), and a freeze-dried live at-
tenuated mumps vaccine. For cases with a history of adverse
2 Kamei et al
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Volume ■■ • ■■ 2017
Table I. Inclusion criteria for patients with nephrotic
syndrome
1. Patients with nephrotic syndrome, aged ≥1 y
2. Negative or borderline antibody titer against 1 or more of measles, rubella,
varicella, and mumps
3. Current treatment with 1 or 2 immunosuppressive agents (CsA, Tac, MMF,
or MZR)
4. Normal cellular immunity
CD4+ cells ≥500/mm3*
Normal lymphocyte blast transformation by phytohemagglutinin
(stimulation index ≥101.6)†
5. Serum IgG level‡ ≥300 mg/dL§
6. Recovery of normal B-cell count in patient with a history of rituximab
treatment
7. No steroid use or prednisolone <1 mg/kg/d or <2 mg/kg/2 d
8. Trough levels of Tac¶ <10 ng/mL
9. Trough levels of CsA** <100 ng/mL
10. Remission of nephrotic syndrome for >6 mo
11. Difficulty discontinuing immunosuppressive agents due to relapse of
nephrotic syndrome
12. Written informed consent obtained from patients or families
CsA, cyclosporine; MMF, mycophenolate mofetil; MZR, mizoribine; Tac, tacrolimus.
*Cutoff value was adapted from the Centers for Disease Control and Prevention recommendation,21
which shows the CD4 lymphocyte counts under no evidence of immunosuppression.
†Cutoff value provided by the manufacturer.
‡Serum IgG level assessed as described previously.22
§Cutoff value determined as described previously,23 which shows a 95% range of IgG level of
patients aged 1 year.
The criteria in ‡ and § were established in July 2013,when we encountered a renal transplant
recipient with chickenpox caused by a varicella vaccine strain, as indicated by her low cellu-
lar and humoral immunity (CD4 cell count of 511/mm3, PHA stimulation index of 91.1, and serum
IgG level of 208 mg/dL).
¶Tac level assessed as described previously.24
**The method of assessing CsA level was described by Morelle et al.25.
events due to the MR vaccine, a positive antibody titer for
rubella but a negative or borderline titer for measles, we used
the freeze-dried live attenuated measles vaccine (Schwartz FF
strain; Takeda). For the mumps vaccine, we used the Torii strain
(Takeda) until October 2012 and then, because the immuno-
genicity of that strain proved unsatisfactory in our study, in
November 2012 our institute changed to the Hoshino strain
(Kitasato Daiichi Sankyo, Saitama, Japan).
Written informed consent was obtained from each pa-
tient’s guardian for patients aged <15 years, from each patient
and his or her guardian for patients aged 15-20 years, or from
each patient aged ≥20 years who had achieved remission, was
free of relapse of nephrotic syndrome for >6 months, and
showed a negative or borderline antibody titer against measles,
rubella, varicella, and/or mumps. The following parameters were
assessed: CD4 cell count, lymphocyte blast transformation by
phytohemagglutinin (PHA), and serum IgG level. In patients
with a history of rituximab treatment, CD19 or CD20 cell count
was measured as well. If these measurements met the inclu-
sion criteria (Table I), the committee members discussed the
indications for vaccination. After the committee’s approval was
obtained, vaccination was administered. Each vaccination was
decided as single dose in this study protocol.
Antibody titers were examined at 2 months after vaccina-
tion. A positive antibody titer (virus-specific IgG level ≥4.0)
was defined as seroconversion (seropositivity; responder), and
a borderline or negative antibody titer (virus-specific IgG
level <4.0) was defined as a nonresponder. Initial vaccination
■■ 2017 ORIGINAL ARTICLES

Table III. Patient characteristics

Mumps
Mumps vaccine
Measles Varicella vaccine (Hoshino
Characteristics Total MR vaccine vaccine vaccine (Torii strain) strain)
Patients, n 60 31 2 44 10 14
Male sex, n (%) 41 (68.3) 20 (64.5) 2 (100.0) 26 (59.1) 5 (50.0) 6 (42.9)
History of infection before the study entry, n (%) Measles: 0 (0.0) 0 (0.0) 6 (13.6) 0 (0.0) 0 (0.0)
Rubella: 0 (0.0)
History of vaccination before the study entry, n (%) Measles: 30 (96.8) 2 (100.0) 28 (63.6) 3 (30.0) 11 (78.6)
Rubella: 28 (90.3)
Vaccinations, n 116 33 2 57 10 14
Initial vaccination in this study, n (%)* 97 (83.6) 31 (93.9)‡ 1 (50.0) 44 (77.2)¶ 10 (100.0) 11 (78.6)**
Revaccination in this study, n (%)† 19 (16.4) 2 (6.1) 1 (50.0) §
13 (22.8) 0 (0.0) 3 (21.4)††
Age at vaccination, y, median (range) 8 (1-24) 9 (1-20) 6 (4-8) 7 (2-24) 8 (4-16) 12 (2-19)
CD4 cell count at vaccination, × mm3, mean ± SD 1055.6 ± 435.5 1078.8 ± 478.8 1021, 2235 1045.0 ± 414.6 1125.7 ± 406.5 912.2 ± 351.5
PHA stimulation index at vaccination, mean ± SD 342.1 ± 182.6 311.6 ± 119.1 437.6, 440.1 340.3 ± 183.8 281.7 ± 79.2 450.9 ± 301.5
Serum IgG at vaccination, mg/dL, mean ± SD 788.6 ± 286.3 750.7 ± 263.1 620, 788 779.6 ± 299.0 947.0 ± 283.5 877.8 ± 313.4
Immunosuppressive agents/antimetabolite agents, n (%)
Calcineurin inhibitors (CsA, Tac) 36 (31.0) 9 (27.3) 1 (50.0) 17 (29.8) 4 (40.0) 5 (35.7)
Antimetabolite agents (MMF, MZR) 50 (43.1) 15 (45.5) 1 (50.0) 26 (45.6) 2 (20.0) 6 (42.9)
Calcineurin inhibitors + antimetabolite agents 30 (25.9) 9 (27.3) 0 (0.0) 14 (24.6) 4 (40.0) 3 (21.4)
Steroid use at vaccination, n (%) 4 (3.4) 2 (6.1) 0 (0.0) 2 (3.5) 0 (0.0) 0 (0.0)

*Initial vaccination means the first vaccination during the study period.
†Revaccination means the second or third vaccination of the same virus due to primary or secondary vaccine failure.
‡In 31 patients who received the MR vaccine, 23 patients had negative antibody and 19 patients had borderline antibody against measles and rubella, who were enrolled in the seroconversion
analysis.
§One patient received MR vaccine as initial vaccination and measles vaccine as second vaccination due to adverse event of MR vaccine (transient fever).
¶Two patients who received varicella vaccine could not be enrolled in the seroconversion analysis as they were immunized too recently.
**One patient who received Hoshino mumps vaccine could not be enrolled in the seroconversion analysis as they were immunized too recently.
††Three patients received Torii strain as initial vaccination and Hoshino strain as second vaccination for mumps vaccine.

was defined as the first vaccination in this study. Patients were
followed up for at least 1 year after vaccination, and long-
term maintenance of seropositivity was assessed by measur-
ing antibody titer at 1 year after vaccination in seroconverted
patients. Adverse events after vaccination were monitored by
clinic visits or phone calls. Any event occurring within 1 month
after vaccination was recorded as an adverse event. All events
with evidence of association with vaccination were also con-
sidered adverse events, regardless of the time after vaccina-
tion. All adverse events were categorized as grade 1-5 using the
Common Terminology Criteria for Adverse Events version 4.0
and were discussed by the committee.
Patients who failed to respond to the first study vaccine dose
(nonresponders) or who became seronegative at 1 year after
a positive response at 2 months (secondary vaccine failure) were
offered additional doses of vaccine. Nonresponders after initial
vaccination could be revaccinated up to 3 times. Secondary
vaccine failure was defined as seroconversion after vaccina-
tion followed by a borderline or negative antibody titer on sub-
sequent testing. The limit on the number of vaccinations for
secondary vaccine failure was not determined. Immunologic
analysis (Table I) was examined again before revaccination, and
the indications for revaccination were also decided by
committee.
The primary endpoint of this study was the seroconversion
rate at 2 months after the initial vaccination in this study. The
secondary endpoints included the antibody titers at 1 year after
vaccination, evaluation of immunogenicity of revaccination
for nonresponders or patients with secondary vaccine failure,
breakthrough infections, and adverse events. Breakthrough in-
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fection was defined as infection of wild-type strain after vac-
cination. All of these data were analyzed separately for each
virus.
Statistical Analyses
We evaluated the primary endpoint by the rates of patients who
achieved seroconversion for each virus. Comparisons between
responders and nonresponders were analyzed using the Mann–
Whitney U test for continuous variables and the Fisher exact
test for categorical variables. Antibody titers at 1 year after vac-
cination were compared with those at 2 months. All data were
analyzed using JMP version 11.0 (SAS Institute Japan, Tokyo,
Japan). Statistical significance was established at P < .05.
Results
A total of 116 vaccinations were administered to 60 patients
between May 2011 and January 2017 (Table III). The vari-
cella vaccine was the most frequently administered. There were
97 initial vaccinations and 19 revaccinations. Four patients were
on low-dose steroid therapy.
Seroconversion rates after the initial vaccination are shown
in Table IV. Thirty-two patients received either the MR vaccine
(31 patients) or measles vaccine (1 patient) as the initial vac-
cination. Among them, the number of patients with border-
line or negative antibody titer for measles and rubella was 23
and 19, respectively. Three patients (2 with varicella and 1 with
mumps) who were immunized too recently were excluded from
this analysis. The seroconversion rates were 95.7% for measles,
100% for rubella, 61.9% for varicella, and 40.0% for mumps.
3
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Table IV. Seroconversion rates after the initial vaccination in this study
Variables Measles Rubella Varicella Mumps (Total) Mumps (Torii strain) Mumps (Hoshino strain)
Vaccinations, n 23 19 42 20 10 10
Seropositivity, n (%) 22 (95.7) 19 (100) 26 (61.9) 8 (40.0) 4 (40.0) 4 (40.0)
Vaccine failure, n (%)
Borderline (±) 1 (4.3) 0 (0.0) 8 (19.0) 5 (25.0) 1 (10.0) 4 (40.0)
Negative (−) 0 (0.0) 0 (0.0) 8 (19.0) 7 (35.0) 5 (50.0) 2 (20.0)
Antibody titers after vaccination
Mean ± SD 36.7 ± 72.6 29.8 ± 23.3 8.9 ± 11.9 3.5 ± 3.5 3.5 ± 4.4 3.6 ± 2.6
Median (range) 15.6 (3.2-329.0) 23.1 (4.6-80.2) 5.6 (<2.0-58.1) 3.5 (<2.0-11.2) 1.8 (<2.0-11.2) 3.6 (<2.0-8.1)

For the mumps vaccine, seroconversion rates were the same
for the Torii and Hoshino strains.
Because most patients seroconverted after the measles and
rubella vaccines, the comparison between responders and
nonresponders were analyzed in the varicella and mumps vac-
cinations (Table V; available at www.jpeds.com). Patients with
borderline antibody titers before vaccination were more likely
to have seroconverted compared with those with negative an-
tibody titers for both the varicella and mumps vaccination, with
statistical significance (P = .005 and .049, respectively). There
were no other statistically significant factors.
A total of 19 revaccinations were performed for
nonresponders and patients with secondary vaccine failure. Ten
revaccinations were performed for nonresponders (MR, 1; vari-
cella, 8; mumps, 1). One patient who did not acquire anti-
body against measles and mumps after initial MR and mumps
vaccines against measles and mumps did not seroconvert for
either again. Seroconversion was achieved in 4 of 8 varicella
revaccinations. Overall, the seroconversion rate after revacci-
nation for nonresponders was 40% (4 out of 10 cases). For sec-
ondary vaccine failure, 9 revaccinations were performed (MR,
3; varicella, 4; mumps, 2). The seroconversion rate for pa-
tients with secondary vaccine failure was 78% (7 out of 9 cases).
Including revaccination, the number of seroconversions was
24 for measles, 20 for rubella, 32 for varicella, and 10 for
mumps. Among these, 18, 17, 30, and 10 patients, respec-
tively, could be evaluated in the antibody titers at 1 year after
vaccination (Table VI). Patients with a virus-specific IgG
level ≥10.0 at 2 months remained seropositive at 1 year at a
much higher rate compared with those with a virus-specific
IgG level <10.0 for each virus.
No patient experienced a breakthrough infection after vac-
cination during the study period.
Adverse events occurring within 1 month of vaccination are
listed in Table VII (available at www.jpeds.com). Sixteen pa-
tients suffered from 19 adverse events. Most events were rela-
tively mild (grade 1, 13 events; grade 2, 6 events), and the
relationship with the vaccination was unclear in most cases.
Nephrotic syndrome recurred in 2 patients (1.7% of all vac-
cinations), at 16 and 22 days after vaccination, respectively. No
patient developed any infection due to the vaccine strains after
vaccination. No serious adverse events were observed.
Discussion
In this prospective study, we evaluated the immunogenicity and
safety of live attenuated vaccines for patients with nephrotic
syndrome receiving immunosuppressive agents. The
seroconversion rates were 95.7% for measles, 100% for rubella,
61.9% for varicella, and 40.0% for mumps. No breakthrough
infections occurred in our cohort, and no serious adverse events
were observed, including infection with the vaccine strain. To
the best of our knowledge, this is the first study of live attenu-
ated vaccines in patients with nephrotic syndrome using im-
munosuppressive agents.
Our seroconversion rates for measles and rubella were similar
to those in the general population (90%-95%).28 However, our
seroconversion rates for varicella (61.9%) and mumps (40.0%)
were much lower that the reported rates of 80%-85% in the
general population after single doses.28 A likely reason for our
higher rate of nonresponders is the use of immunosuppres-
sion. Regarding mizoribine, and antiviral effect (ie, inhibi-
tion of some viruses, such as hepatitis B and C and
cytomegalovirus) has been reported.29,30 However, to our knowl-
edge, there are no data on immunogenicity after vaccination
under mizoribine. Although not a statistically significant
finding, there appears to be a trend toward lower seroconversion
rates among seronegative individuals given varicella or mumps
vaccine if they were receiving antimetabolic agents at the time
of immunization (P = .06). However, given that patients using

Table VI. Preservation of antibody 1 year after vaccination in seropositive patients

Measles Rubella Varicella Mumps
Antibody titer Positive antibody Positive antibody Positive antibody Positive antibody
2 mo after 1 y after 1 y after 1 y after 1 y after
vaccination Patients, n vaccination, n (%) Patients, n vaccination, n (%) Patients, n vaccination, n (%) Patients, n vaccination, n (%)
<10.0 3 1 (33.3) 3 2 (66.7) 17 11 (64.7) 7 1 (14.3)
≥10.0 15 14 (93.3) 14 14 (100.0) 13 12 (92.3) 3 1 (33.3)
Total 18 15 (83.3) 17 16 (94.1) 30 23 (76.7) 10 2 (20.0)

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mizoribine and mycophenolate mofetil showed a similar trend,
we believe that this is due not to the antiviral effect of
mizoribine itself, but rather to the inhibitory effect of B cells
by antimetabolic agents. Our observations suggest that re-
peated varicella and mumps vaccinations may be required for
this population. In general, 2 doses of varicella and mumps
vaccinations are recommended for healthy children.31 Because
patients who had borderline antibody titers before vaccina-
tion seroconverted at a high rate after vaccination even for vari-
cella and mumps, we believe that 2 doses of vaccination should
be recommended for varicella and mumps for patients on im-
munosuppressive therapy.
We examined the longevity of the seropositive status of pa-
tients over a 1-year period. We found that antibody titers waned
in approximately one-third of seroconverted patients by 1 year
after vaccination. Secondary vaccine failure is likely due to many
factors, such as the use of immunosuppressive agents as well
as treatment for a primary disease (eg, steroids, rituximab).
In patients receiving immunosuppressive agents, monitoring
antibody titers against these viruses is necessary when con-
sidering revaccination for those with waned immunity. Current
vaccines should be improved for patients to ensure a high an-
tibody titer, especially against varicella and mumps.
The indications for vaccination should always be consid-
ered in the context of risk and benefit. Although measles and
rubella are relatively rare in Japan, varicella and mumps are
still common, and protection from these vaccine-preventable
diseases is crucial for patients receiving immunosuppressive
therapy. According to previous studies, as well as our present
work, vaccine-associated infection is rare, and its dangers are
theoretical. Because patients receiving immunosuppressive
agents require long-term use and remain at high risk for severe
infections, our results suggest that the relatively low risk of com-
plications from live vaccines may be acceptable if the pa-
tients’ primary disease activity is stable and his or her cellular
and humoral immunologic parameters, such as CD4 cell count,
PHA stimulation index, and serum IgG levels, are within clini-
cally acceptable levels.
This study has several limitations. First, the kinds and doses
of immunosuppressive agents differed among the patients.
Evaluation of the immunogenicity and safety of live attenu-
ated vaccines during the use of each immunosuppressive agent
will require another prospective trial with a fixed immuno-
suppressive therapy protocol. Second, we did not assess cel-
lular immunity before and after vaccination. The screening of
virus-specific CD8+ cytotoxic T cells before immunization was
not done. Most subjects were immunized with measles vaccine
and rubella before enrollment. These subjects may have virus-
specific CD8+ T-cell immunity even though their concentra-
tions of anti-virus antibodies measured by EIA were below the
limit of detection. The presence of these virus-specific T cells
elicited by previous immunization could influence the overall
safety profile seen following immunization with the live at-
tenuated strains. Moreover, we did not assess T cell re-
sponses to vaccine antigens. Virus-specific T cell responses are
needed to facilitate virus clearance after infections, and they
might be decreased in patients receiving cyclosporine or
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ORIGINAL ARTICLES
tacrolimus. Third, we did not monitor vaccine virus viremia
or vaccine virus shedding in the immediate postimmunization
period. In a previously reported series, none of the 10 chil-
dren with symptomatic human immunodeficiency virus type
1 infection who received measles, mumps, and rubella immu-
nization experienced persistent viremia or infection after
immunization.32 However, rubella vaccine virus is reportedly
shed in the oropharynx even in healthy individuals in the post-
vaccination period, and shedding might be increased or pro-
longed in those receiving immunosuppressive therapy. Fourth,
the clinical efficacy of these vaccinations has not been veri-
fied, because this study was not a placebo-controlled trial. More-
over, we did not have data about the patients’ exposure to
infection, such as varicella and mumps. Given that vaccine ef-
fectiveness was evaluated solely by antibody titer, informa-
tion on clinical efficacy is limited in this study, although no
patients developed breakthrough infections after vaccina-
tion. Fifth, the persistence of seropositivity at 1 year after vac-
cination might be strongly affected by immunosuppressive
treatment against the primary disease during the same period.
Sixth, the number of patients in our study was relatively small
to ensure safety, although we did not observe any vaccine-
related infections. The small sample size prevented a com-
plete safety assessment of low-frequency adverse events. The
condition under immunosuppressive therapy can lead to un-
derestimation of even common adverse reactions, such as fever
and rash. One recent review found that 1.0% of patients with
immune-mediated inflammatory diseases, 7.3% of solid organ
transplant recipients, and 10.5% of bone marrow transplant
recipients suffered from vaccine-related varicella after vari-
cella vaccination.33 Another large, multicenter study is needed
to evaluate the safety of live vaccines using more immuno-
logic parameters.
In conclusion, immunization with live attenuated vaccines
may be immunogenic and is apparently safe in our cohort of
patients with nephrotic syndrome receiving immunosuppres-
sive agents who have cellular and humoral immunologic pa-
rameters within clinically acceptable ranges. No life-threatening
adverse events occurred in our cohort, although a longer ob-
servation period is needed to assess safety, such as reactogenicity
of live vaccines. Considering the expected benefits and ac-
ceptable risks, patients who require long-term immunosup-
pressive agents can be immunized with these live vaccines if
their disease activity is stable. ■
We thank all the participants and physicians in charge for their con-
tributions to this study.
Submitted for publication Jun 13, 2017; last revision received Dec 4, 2017;
accepted Dec 20, 2017
Reprint requests: Koichi Kamei, MD, PhD, Division of Nephrology and
Rheumatology, National Center for Child Health and Development, 2-10-1,
Okura, Setagaya-ku, Tokyo 157-8535, Japan. E-mail: kamei-k@ncchd.go.jp.
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■■ 2017 ORIGINAL ARTICLES

Table II. Suggested virus-specific antibody titers corre-

sponding to clinical efficacy (prevention of disease or in-
fection) in healthy children
Levels protective Levels protective
Viruses against disease against infection
Measles
EIA ≥4.0 ≥16.0
IU ≥120 ≥800
Rubella
EIA ≥4.0 ≥16.0
IU ≥15 ≥60
Varicella
EIA ≥4.0 ≥16.0
Mumps
EIA ≥4.0 ≥16.0

Table V. Comparison of responders and nonresponders after varicella and mumps vaccine
Varicella (n = 42), antibody titers after Mumps (n = 20), antibody titers after
vaccination (EIA of IgG) vaccination (EIA of IgG)
≥4.0 (responders; <4.0 (nonresponders; ≥4.0 (responders; <4.0 (nonresponders;
Characteristics n = 26) n = 16) P value n = 8) n = 12) P value
Male sex, n (%) 13 (50.0) 12 (75.0) .19 3 (37.5) 7 (58.3) .65
Age at vaccination, y, median (IQR) 8 (2-14) 6 (3-20) .49 6.5 (3-13) 11 (2-18) .10
Receipt of calcineurin inhibitor, n (%) 18 (69.2) 10 (62.5) .74 7 (87.5) 8 (66.7) .60
Receipt of antimetabolic agent, n (%) 13 (50.0) 13 (81.3) .06 2 (25.0) 9 (75.0) .06
Receipt of 2 immunosuppressants, n (%) 5 (19.2) 7 (43.8) .16 1 (12.5) 5 (41.7) .32
Receipt of steroids, n (%) 2 (7.7) 0 (0.0) .52 0 (0.0) 0 (0.0)
CD4 cell count at vaccination, × mm3, median (IQR) 1108.7 ± 420.9 1054.8 ± 453.9 .60 1150.5 ± 338.1 984.6 ± 425.8 .25
PHA stimulation index at vaccination, median (IQR) 356.1 ± 207.5 365.9 ± 182.7 .60 401.2 ± 268.1 379.1 ± 275.5 1.00
Serum IgG at vaccination, mg/dL, median (IQR) 825.9 ± 233.7 630.5 ± 262.9 .06 962.4 ± 354.9 725.3 ± 144.2 .27
History of vaccination or infection, n (%) 21 (80.8) 11 (68.8) .46 5 (62.5) 6 (50.0) .67
Antibody titer before vaccination, n (%)
Borderline (virus-specific IgG, 2.0-3.9) 17 (65.4) 3 (18.8) .005 3 (37.5) 0 (0.0) .049
Negative (virus-specific IgG, <2.0) 9 (34.6) 13 (81.3) 5 (62.5) 12 (100.0)

Table VII. Adverse events

Mumps vaccine Mumps vaccine
MR vaccine Measles vaccine Varicella vaccine (Torii strain) (Hoshino strain)
Events (n = 33) (n = 2) (n = 57) (n = 10) (n = 14)
Fever 1 1 2 1
Fever and cough 2
Fever and rash 1
Cough and nasal discharge 2
Relapse of nephrotic syndrome 1 1
Transient proteinuria 1 1
Rash 2*
Neck pain 1
Parotitis 1 1

*Not resembling varicella rash.

Prospective Study of Live Attenuated Vaccines for Patients with Nephrotic Syndrome Receiving 6.e1
Immunosuppressive Agents
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