Are patients with liver cirrhosis (liver scarring) immunocompromised?

From the Guidelines

Liver cirrhosis patients are indeed immunocompromised, with a higher risk of infections due to cirrhosis-associated immune-deficiency syndrome, as evident in the most recent study from 2024 1.

Key Points

• Cirrhosis causes immune dysfunction through multiple mechanisms, including impaired protein synthesis, reduced neutrophil function, complement deficiencies, and altered gut barrier function.
• Patients with cirrhosis have higher rates of bacterial infections, with spontaneous bacterial peritonitis, urinary tract infections, pneumonia, and cellulitis being particularly common.
• The severity of immune dysfunction typically correlates with the degree of liver damage, with those having decompensated cirrhosis (marked by complications like ascites, encephalopathy, or variceal bleeding) at highest risk.
• Infection prevention is crucial in these patients, and healthcare providers should maintain a high index of suspicion for infections, as symptoms may be subtle or atypical.
• Vaccination against pneumococcal disease, influenza, and hepatitis A and B is recommended for cirrhosis patients to reduce infection risk, as supported by studies such as 1.

Infection Risk and Prevention

• The risk of infection is further increased by invasive procedures, line and catheter placement, and the presence of multi-drug-resistant (MDR) organisms, as noted in 1.
• A careful screening for infection is recommended before initiating therapy, repeatedly during treatment, and during the follow-up period, especially in high-risk groups such as younger male patients, those with alcohol-associated cirrhosis, and those with a high MELD score.
• The use of corticosteroids in severe alcoholic hepatitis may increase the risk of infection, but the development of infection depends more on the response to corticosteroid treatment rather than the treatment itself, as discussed in 1.

Vaccination and Immune Response

• Vaccination is a priority for patients with chronic liver disorders, including cirrhosis, and should be done early in the course of the underlying disease, as the timing of vaccination is a significant factor in determining its effectiveness, as suggested in 1.
• The extent of the vaccine-induced immune response may be suboptimal in patients with decompensated cirrhosis, liver malignancies, and liver transplant patients due to their underlying disease and medications, highlighting the need for careful consideration and monitoring.

From the Research

Immunocompromised State in Liver Cirrhosis Patients

• Liver cirrhosis patients are considered immunocompromised due to their increased susceptibility to infections 2, 3.
• The severity of immune dysfunction in cirrhosis patients is dynamic and progressive, associated with the deterioration of liver function 3.
• Patients with cirrhosis have a higher risk of developing infections, particularly those with gastrointestinal hemorrhage, with bacterial infections occurring in 32-34% of hospitalized patients 2.

Infection Risks and Vaccination

• Common infections in cirrhosis patients include spontaneous bacterial peritonitis (SBP), urinary tract infections, and pneumonia 2.
• Vaccination is recommended for patients with chronic liver disease, including hepatitis A, hepatitis B, influenza, pneumococcus, and SARS-CoV-2 4, 5.
• Despite recommendations, vaccination coverage in cirrhosis patients remains poor, with inadequate access to healthcare and lack of information on vaccine safety being contributing factors 4, 5.

Immune Response and Liver Damage

• Dysfunctional immune responses, including both innate and adaptive immunity, contribute to liver damage in cirrhosis patients 6.
• The innate immune system plays a crucial role in responding to liver insults, and its activation can predict survival in patients with acute on chronic liver failure 6.
• Understanding the immune response in cirrhosis patients is essential for developing effective treatment strategies and improving patient outcomes 6.