Clinics and Research in Hepatology and Gastroenterology
Mini reviewVaccination in adult liver transplantation candidates and recipients
Introduction
Chronic liver disease is associated with an overall impairment of the immune system, referred as cirrhosis-associated immune dysfunction syndrome, leading to an increased risk of infections which represent a major cause acute liver decompensation and mortality [1], [2]. Liver transplantation (LT) currently represents the main therapeutic option for end-stage liver disease and localized hepatocellular carcinoma. The risk of infection increases in the pre-transplantation period with the severity of liver disease, and is maximal during the 6 first months post-LT due to intensive immunosuppressive drugs regimens used to prevent graft rejection [3]. In addition, to maintain the global health status of cirrhotic patients and LT recipients as in general population, vaccination represents a pivotal preventive measure against infections of particular concern in this population, including invasive pneumococcal diseases (IPD), influenza or viral hepatitis A (VHA) and B (VHB). However, current guidelines rely on very little data regarding vaccine efficacy and effectiveness in this specific population [4], [5], [6], [7]. Additionally, the establishment of immunization schedules is challenging, having to take into account the balance between a decreased efficacy of vaccines in immunosuppressed hosts, an accelerated loss of antibody titers, the dynamics of immunosuppression in the peri-transplantation period, and the contraindication of live attenuated vaccines after LT.
The present review summarizes the rational for immunization in the peri-LT period, focusing on risk evaluation and available data regarding vaccine efficacy in this specific population.
Section snippets
Immune status of patients with chronic liver disease and after transplantation
Cirrhosis–and a fortiori liver failure–is associated with an overall dysfunction of the immune response [2], responsible for an increased infection risk, related to:
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a destruction and shunt of the intrahepatic reticuloendothelial system, impeding bacterial and toxin clearance;
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a disturbed innate immunity, with impairment of mobilization, phagocytic functions and half-life of neutrophils and monomacrophagic cells, and of hepatic synthesis of the components of the complement system; and
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a
General principles of vaccination in the setting of solid organ transplantation
With respect to vaccine-preventable diseases, patients awaiting LT share issues of all immunosuppressed hosts:
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an increased incidence and severity of several vaccine-preventable infections requiring specific immunization recommendations;
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a decreased immunogenicity of vaccines and an accelerated loss of protection, which may require specific vaccination schedules with additional booster doses; and
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a contraindication of live attenuated vaccines after transplantation given the risk of active
Invasive pneumococcal diseases
IPD are more frequent and more severe in cirrhotic patients [23], [24]. Lower respiratory tract infections are the third leading cause of infection in this population, the main etiologic agent being Streptococcus pneumoniae. Community-acquired pneumonia during cirrhosis is more frequently bacteremic, multi-lobar, associated with neurological, renal or multi-organ failure, and complicated by septic shock [25]. Globally, the mortality rate is 2 times higher than in the general population. Beyond
Conclusion
Chronic liver disease patients and LT recipients are at increased risk of infections, some of them being preventable by vaccination, especially IPD, influenza, viral hepatitis A and B, measles and chickenpox and HZ. National and international guidelines have been released regarding immunization of LT candidates and recipients. However, knowledge on vaccine response in this specific population is scarce and there is a need for specific trials evaluating vaccine efficacy. While the tolerance of
Disclosure of interest
The authors declare that they have no competing interest.
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Cited by (12)
Liver Transplantation for the Nonhepatologist
2023, Medical Clinics of North AmericaInfluenza vaccination adherence after liver transplantation: A collateral benefit of the COVID-19 pandemic (results of a patients’ survey)
2022, Clinics and Research in Hepatology and GastroenterologyAn Essential Guide for Managing Post-Liver Transplant Patients: What Primary Care Physicians Should Know
2022, American Journal of MedicineCitation Excerpt :Live-attenuated vaccines such as measles, mumps, rubella, varicella-zoster, herpes-zoster, yellow fever, and tuberculosis are contraindicated after liver transplantation, given the risk of active vaccine-induced infection.14 Other vaccinations are encouraged in liver-transplanted patients (Table 1).15,16 The classic signs or symptoms of infection may be absent in liver-transplanted patients
Italian association for the study of the liver position statement on SARS-CoV2 vaccination
2021, Digestive and Liver DiseaseCitation Excerpt :In kidney transplant recipients, vaccination against influenza with the adjuvanted A(H1N1) 2009 the pandemic vaccine was associated with an increase in the anti-HLA antibodies, with no increase in the acute rejection rate. Certain case series have suggested an association between adjuvanted influenza vaccination and acute rejection, although these observations have not been confirmed in larger studies [12]. The most debatable post-transplant immunization decision is regarding whether live vaccines could ever be safely administered in a post-transplant setting.
Advances in Rejection Management: Prevention and Treatment
2021, Clinics in Liver DiseaseCitation Excerpt :We know that antigen-dependent immune responses can lead to allograft rejection.54 Therefore, there is a theoretic risk of vaccination-induced graft rejection.55 There have been conflicting data, mostly in the kidney transplant population, that vaccination against influenza has been associated with an increase in anti-HLA antibodies that would theoretically increase the risk of rejection.56,57