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Immunizations for patients with chronic liver disease

Raymond S Koff, MD
Section Editor
Sanjiv Chopra, MD, MACP
Deputy Editors
Jennifer Mitty, MD, MPH
Kristen M Robson, MD, MBA, FACG


The management of patients with liver disease has changed dramatically in the last 25 years, leading to improved outcomes and survival. Prevention of liver disease has also improved. As an example, hepatitis A and B vaccines have reduced the incidence of acute viral hepatitis [1]. Furthermore, hepatitis B vaccines have resulted in a decline in the sequelae of chronic hepatitis B virus infection, and, despite the absence of a specific hepatitis D vaccine, a marked decrease in hepatitis D infections in the United States. Although not yet FDA approved, a hepatitis E vaccine may become available in the future [2]. Despite these advances, chronic liver disease from multiple etiologies continues to be a prevalent health problem in the United States.

In one sense, patients with chronic liver disease are no different from the general population. Both groups require appropriate immunizations in order to maintain their general health status. However, for some individuals with chronic liver disease due to the bloodborne pathogens, shared risk factors may result in dual infections with hepatitis B and C or exposure to hepatitis A. Data suggest that the prevalence of hepatitis A infection is higher in patients with chronic liver disease than in the general population [3]. Furthermore, in patients with chronic liver disease or in recipients of liver transplants, the superimposition of another acute disease (hepatitis virus superinfection, influenza, and pneumococcal infection) may result in higher morbidity and mortality than in individuals without pre-existing liver disease.

The impact of hepatitis viruses, pneumococcal disease, and influenza infection in the patient with chronic liver disease will be discussed here. Efficacy of preventive vaccines will also be discussed. For further information regarding general safety and efficacy issues related to these vaccines, please see appropriate topics. (See "Hepatitis A virus infection: Prevention" and "Hepatitis B virus vaccination" and "Seasonal influenza vaccination in adults" and "Pneumococcal vaccination in adults" and "Meningococcal vaccines".)


Studies of the impact of vaccine-preventable infections (hepatitis A and B, influenza, and pneumococcal disease) in chronic liver disease have been largely restricted to patients with chronic hepatitis B and C, alcoholic liver disease, compensated and decompensated cirrhosis, and liver transplant recipients.

Data on the impact of acute viral hepatitis A and B, influenza, and pneumococcal infection on other liver diseases are sparse. Fatty liver and non-alcoholic steatohepatitis, hereditary hemochromatosis, primary biliary cholangitis, autoimmune hepatitis, primary sclerosing cholangitis, alpha-1 antitrypsin deficiency, Wilson's disease, and granulomatous liver disease have received little attention. In one study of 225 patients with autoimmune liver diseases, all achieved seroconversion followed hepatitis A vaccination while 76 percent developed seroprotective levels of surface antibodies (anti-HBs) following hepatitis B vaccine [4]. Both immunosuppressive therapy and advanced liver disease were common in nonresponders [4]. Other systemic disorders that may involve the liver (eg, celiac disease and cystic fibrosis) also have not been extensively studied. Nonetheless, HAV and HBV vaccinations have been recommended by one European group for individuals with cystic fibrosis, either at the time of diagnosis of cystic fibrosis or when liver involvement is recognized [5].

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Literature review current through: Nov 2017. | This topic last updated: Apr 24, 2017.
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