Vaccination in Chronic Liver Disease: An Update.
Name:
Publisher version
Date
2021-12-08Journal
Journal of Clinical and Experimental HepatologyPublisher
ElsevierType
ArticleMetadata
Show full item recordSee at
https://doi.org/10.1016/j.jceh.2021.12.003http://www.ncbi.nlm.nih.gov/pmc/articles/pmc8710401/
Abstract
Patients with chronic liver disease (CLD) with or without cirrhosis remain at risk of developing hepatic decompensation when infected with viral or bacterial pathogens. The Advisory Committee on Immunization Practices (ACIP) currently recommends vaccination in CLD against hepatitis A virus (HAV), hepatitis B virus (HBV), influenza, pneumococcus, herpes zoster, tetanus, diphtheria, pertussis, and SARS-CoV-2. Inactivated vaccines are preferred over live attenuated ones, especially in transplant recipients where live vaccines are contraindicated. As the severity of the liver disease progresses, vaccine efficacy declines, and therefore, vaccines should be ideally administered early in the disease course for optimal immune response. Despite the strong recommendations, overall vaccination coverage in CLD remains poor; however, it is encouraging to note that in recent years coverage against influenza and pneumococcus has shown some improvement. Inadequate access to healthcare, lack of information on vaccine safety, poor financial reimbursement for healthcare providers, and vaccine misinformation are often responsible for low immunization rates. This review summarizes the impact of vaccine-preventable illness in those with CLD, updated vaccine guidelines, seroconversion rates in the vaccinated, and barriers faced by healthcare professionals in immunizing those with liver disease.Rights/Terms
© 2021 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.Keyword
ACIP, Advisory Committee on Immunization PracticesACLF, acute on chronic liver failure
ALD, alcohol-related liver disease
CLD, Chronic liver disease
CLIF-C, Chronic Liver Failure Consortium
DAA, direct-acting antiviral drugs
HAV, hepatitis A virus
HBV, hepatitis B virus
HCV, hepatitis C virus
LT, liver transplantNAFLD, nonalcoholic fatty liver diseaseSARS-CoV-2SOFA, sequential organ failure assessmentchronic liver diseaseimmunizationvaccines
Identifier to cite or link to this item
http://hdl.handle.net/10713/17622Scopus Count
Collections
Related items
Showing items related by title, author, creator and subject.
-
Prevalence of chronic liver disease in patients with COVID-19 and their clinical outcomes: a systematic review and meta-analysisAbnormal liver enzymes are seen in 20% of hospitalized patients with COVID-19. The etiology of elevated liver enzymes is thought to be multifactorial including medications and underlying liver disease. The true prevalence and clinical significance of underlying chronic liver diseases (CLD) in COVID-19 remains poorly defined. In this systematic review and meta-analysis, we included 74 clinical studies that were identified after a thorough literature search across three databases. The prevalence of CLD patients (73 studies, 24,299 patients) was 3% among all COVID-19 patients. The prevalence of CLD patients was similar in COVID-19 positive and negative population (pooled OR 0.79 [95% CI 0.60, 1.05], p = 0.10). The presence of CLD was significantly associated with more severe COVID-19 infection (pooled OR 1.48 [95% CI 1.17, 1.87], p = 0.001) and overall mortality (pooled OR 1.78 [95% CI 1.09, 2.93], p = 0.02). Additionally, there was a non-significant trend noted for increased ICU admissions and need for invasive mechanical ventilation among COVID-19 patients with CLD. To date, the clinical importance of chronic liver diseases among COVID-19 infection has remained undefined. In this novel systematic review and meta-analysis, the presence of underlying chronic liver disease was significantly associated with more severe COVID-19 infections and mortality.
-
Implementation of NECPAL and Chronic Liver Disease Screening Tools in Transplant UnitProblem & Purpose: Liver disease is often associated with high symptom burden and long hospital course, subsequently leading to decreased quality of life. For patients considered unsuitable for transplantation, the alternative treatment options are supportive management and palliative care (PC). The most significant barrier to early PC is the failure to identify patients who may benefit. Currently, transplant health care professionals have limited PC education, as well as understanding of primary PC and PC service flow. The purpose of this quality improvement (QI) project is to identify non-transplantable liver disease patients’ unidentified unmet PC needs, utilizing two validated tools (Necesidades Paliativas [Palliative. Needs]) (NECPAL) and Chronic Liver Disease Questionnaire (CLDQ), and integrate them within routine nursing care activities in the transplant unit. Method: This DNP project was integrated into a Quality Improvement (QI) project guided by the MAP-IT (Mobilize-Assess-Plan-Implement-Track) QI process model. Over a 12-week period, nurses and nurse practitioners (NPs) completed the tools for every non-transplantable liver disease patient. The NECPAL screening tool was used to identify patients in need of PC, and was completed by the NPs. The CLDQ tool was completed by the bedside nurse and was used to assist with identifying symptoms and quality of life. Results: A total of five nurse practitioners and ten staff nurses received education and training on the NECPAL and CLDQ tools from the DNP student project leader. Sixteen non-transplant liver disease patients ages ranging 29 to 68, median age 52, majority (69%) female participated. Percentage of patients who completed the CLDQ and reported symptoms of unmet needs an average of 80%. The most symptoms reported were abdominal bloating and discomfort, worry, and family impact. The percentage of both screening tools goal 100% average (50%, n=9) were completed by the nurses and NPs. The percentage of patients completing the NECPAL an average of 60%, indicated a need for integration of palliative care. The unintended barriers included change in medical director, nurses completing one of the two screening tools, and patients deeming nontransplantable on the transplant service admitted to other units. Conclusions: Implementation of NECPAL and CLDQ tools identified multiple unmet PC needs in non-transplantable liver disease patients. Nurses and nurse practitioners voiced confidence and ease in use of the tools identifying symptoms and clinical indicators for the identification of unmet palliative care needs and to promote incorporation into routine nursing care in liver disease patients who were deemed non-transplantable.
-
Analysis of antibody responses after COVID-19 vaccination in liver transplant recipients and those with chronic liver diseasesBackground & Aims: Liver transplant (LT) recipients or other immunocompromised patients were not included in the registration trials of vaccine studies against SARS-CoV-2. Although clinical efficacy of COVID vaccines in immunocompromised patients was unknown, many societies had recommended vaccination of this highly vulnerable patient population. Methods: In this prospective study, we determined antibody (Ab) response to spike protein, 4 weeks after the 2nd dose of mRNA vaccines or after the single dose of Johnson & Johnson vaccine, in LT recipients and those with chronic liver diseases (CLD) with and without cirrhosis. Results: Of the 233 patients enrolled so far, 62 had LT, 79 had cirrhosis (10 decompensated) and 92 had CLD without cirrhosis. Ab titers were defined as undetectable (<0.40 U/mL), suboptimal (0.40 - 250 U/mL) and adequate (>250 U/mL). Of the 62 patients who had LT, Ab levels were undetectable in 11 patients and suboptimal (median titer 17.6, range 0.47 - 212 U/mL) in 27 patients. Among 79 patients with cirrhosis, 3 had undetectable Ab and 15 had suboptimal (median titer 41.3, range 0.49 - 221 U/L) response. Of the 92 patients without cirrhosis, four had undetectable Ab and 19 had suboptimal (median titer 95.5, range 4.9 - 234 U/L) Ab response. Liver transplantation, use of 2 or more immunosuppression medications and vaccination with a single dose of Johnson & Johnson vaccine were associated with poor immune response on multivariable analysis. No patient had any serious adverse events. Conclusions: Poor antibody response after SARS-CoV-2 vaccination was seen in 61% of LT recipients and 24% of those with CLD.
