Does Cirrhosis Lower the Immune System?
Yes, cirrhosis profoundly impairs immune function through a complex process called Cirrhosis-Associated Immune Dysfunction (CAID), creating what has been described as "the world's most common immunodeficiency syndrome," which directly increases infection risk approximately 10-fold and infection-related mortality by more than 20-fold compared to the general population. 1, 2, 3
The Mechanism of Immune Dysfunction
Cirrhosis creates a paradoxical immune state with two simultaneous problems:
Systemic inflammation occurs due to bacterial translocation from the gut, where increased intestinal permeability allows gut-derived bacterial products (particularly lipopolysaccharides/endotoxin) to enter systemic circulation 1, 2
Immunodeficiency develops from deterioration of antimicrobial recognition and elimination in macrophages, impaired antigen presentation in monocytes, and compromised neutrophil function 1, 2, 4
All host defense systems become compromised, including the acute phase response, macrophage function, neutrophil function, and lymphocyte function 3
Clinical Impact on Infection Risk
The immune dysfunction translates directly into devastating clinical outcomes:
Bacterial infections cause approximately a 4-fold increase in mortality in cirrhotic patients regardless of etiology 1
The incidence of specific infections increases more than 10-fold: spontaneous bacterial peritonitis, bacteremia, urinary tract infections, pneumonia, meningitis, tuberculosis, and liver abscess 3
Mortality from each infectious episode is 3-10 times higher than in non-cirrhotic patients 3
In alcoholic cirrhosis specifically, infection rates reach 20-65% during follow-up, with infections accounting for 24% of all deaths 1
Alcoholic Cirrhosis: A Particularly High-Risk Population
Patients with alcoholic cirrhosis and active alcohol use face even greater immunological compromise:
Active alcoholism increases infection rates to 22.5% versus 6% in non-active drinkers following acute events 5
Alcohol abuse increases liver inflammation through translocation of gut-derived bacterial products, contributing to multiorgan failure and high mortality 1
Bacterial overgrowth, dysbiosis, and increased translocation combine with impaired innate and adaptive immunity 1
Practical Clinical Implications
Recognition and Monitoring
Suspect infection in any cirrhotic patient with unexpected clinical deterioration, as systemic response and classical symptoms are usually weakened 3
Screen for infections before initiating any immunosuppressive therapy (such as corticosteroids for other conditions) 1
Monitor repeatedly during treatment and follow-up periods 1
Infection Prevention Strategies
Vaccination is critical due to the immunodeficiency state: pneumococcal (PCV13 followed by PPSV23), hepatitis A and B, and annual influenza vaccines are strongly recommended 6
Consider pneumococcal revaccination after 5 years, as immune responses wane more quickly in cirrhotic patients 6
Antibiotic prophylaxis is efficacious for specific high-risk situations: variceal bleeding, recurrent peritonitis, and very low protein ascites 3
Treatment Considerations
Start broad-spectrum antibiotics on suspicion of infection without waiting for culture results, using large doses while avoiding aminoglycosides 3
Be aware that multi-drug resistant bacteria are increasingly common, making infection management more challenging 7
The flora tends to be opportunistic in nature when positive isolates are obtained 3
Key Clinical Pitfall
Never underestimate the infection risk in cirrhotic patients—what might be a minor infection in a healthy individual can rapidly progress to sepsis and death in someone with cirrhosis. The combination of increased susceptibility to infection and decreased ability to mount appropriate immune responses creates a perfect storm for life-threatening complications. 1, 7, 3