What vaccinations are recommended post orthotopic liver transplant (OLT)?

From the Guidelines

Vaccination after liver transplantation should be initiated 2-6 months post-transplant with inactivated vaccines, including influenza, pneumococcal (PCV13 followed by PPSV23), hepatitis B, and Tdap, as recommended by the 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host 1. The timing of vaccination is crucial, and patients should wait until immunosuppression reaches maintenance levels before receiving vaccines. Some key points to consider include:

• Influenza vaccine can be administered ≥1 month after transplant during a community influenza outbreak 1
• PCV13 should be administered 2 to 6 months after SOT if not administered before SOT, with the timing based on the patient’s degree of immunosuppression 1
• For SOT patients aged ≥2 years, 1 dose of PPSV23 should be administered 2 to 6 months after SOT, with the timing based on the patient’s degree of immunosuppression, and ≥8 weeks after indicated doses of PCV13 1
• HepB vaccine should be considered for chronic HepB-infected recipients 2 to 6 months after liver transplant in an attempt to eliminate the lifelong requirement for HepB immune globulin (HBIG) 1
• Live vaccines such as MMR, varicella, and live attenuated influenza are typically contraindicated due to the risk of vaccine-strain infection in immunosuppressed patients 1
• Vaccination response may be suboptimal due to immunosuppressive medications like tacrolimus, mycophenolate mofetil, and prednisone, which are necessary to prevent organ rejection but diminish immune responses to vaccines 1
• Patients should always consult their transplant team before receiving any vaccine, as individual circumstances may require personalized vaccination schedules. It is also important to note that household members should be fully vaccinated to create a protective cocoon around the transplant recipient. Overall, vaccination after liver transplantation requires careful consideration of the patient's immunosuppressed state and the potential risks and benefits of different vaccines.

From the Research

Vaccination Post Liver Transplant

• Vaccination is a major preventive measure against specific infectious risks in liver transplant recipients, such as invasive pneumococcal diseases, influenza, and viral hepatitis A and B 2.
• Inactivated or killed-type vaccinations are preferable in patients with cirrhosis, as live attenuated vaccinations are contraindicated after transplantation 3, 2.
• The timing of vaccination post-transplant should be taken into account, with inactivated vaccines able to be administered starting at 3 months post-transplant, except for influenza which can be given as early as one month 4.
• Vaccines demonstrate superior immunogenicity when given earlier in the course of liver disease and prior to transplant 5.
• Specific vaccines, including pneumococcal, influenza, hepatitis B, HPV, and meningococcal vaccines, are discussed in the context of liver transplant recipients 4.

Recommended Vaccines

• Influenza vaccination: yearly inactivated influenza vaccinations should be provided to those with chronic liver disease, although its effectiveness may be reduced in patients with cirrhosis and in the early post-liver transplant setting 3, 5.
• Pneumococcal vaccination: standard guidelines for the administration of Pneumovax23 for immunocompromised hosts apply to patients with chronic liver disease, although its effectiveness may decline after liver transplantation 3, 4.
• Hepatitis B vaccination: early-stage chronic liver disease patients should receive conventional hepatitis B series, while cirrhotics benefit from a double-dose hepatitis B vaccination at standard intervals 3, 5.
• Hepatitis A vaccination: its effectiveness wanes in cirrhosis, and should if possible be given before the development of cirrhosis 3, 5.

Considerations

• Immunization in liver transplant recipients raises several issues, including the dynamics of immunosuppression, which makes timing of immunization challenging, and the contraindication of live attenuated vaccines after transplantation 2.
• Vaccines tolerance is poorly known in cirrhotic patients, and more data are needed to confirm the effectiveness of certain vaccines in this population 3, 2.