Not just another shot: Tailoring vaccination in the era of modern liver transplantation

Abstract

Infections remain a leading cause of morbidity and mortality in patients with cirrhosis and liver transplantation (LT). Vaccination is underutilized despite proven benefits, and responses are often blunted by cirrhosis-associated immune dysfunction and post-transplant immunosuppression. This review synthesizes current evidence and recent advances in vaccination strategies for adult LT recipients, emphasizing optimal timing, novel vaccine platforms, and precision vaccinology. We discuss emerging data on coronavirus disease 2019, respiratory syncytial virus, and new pneumococcal and hepatitis B vaccines, highlight strategies to overcome immunogenicity gaps, and address implementation barriers. A practical roadmap and clinician-focused algorithms are proposed to integrate vaccination into the continuum of LT care.

Keywords: Vaccination; Liver transplantation; Immunosuppression; Precision vaccinology; Vaccine immunogenicity

Core Tip: Vaccination remains an underused preventive strategy in patients with cirrhosis and liver transplant recipients, despite a substantial burden of vaccine-preventable infections. Vaccine immunogenicity declines with advancing liver disease and is further reduced after transplantation due to immunosuppression, making early, pre-transplant immunization particularly important. Optimizing vaccine timing, formulation, and follow-up can support better integration of vaccination into standard liver transplant care. Novel vaccine platforms may improve immune responses in immunosuppressed patients, but their role in liver transplant recipients requires validation in dedicated clinical studies.