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

Table 1 Characteristics of available pneumococcal vaccines

Vaccine (brand)	Serotypes covered	Recommended adult use	Clinical notes in CLD/LT
PPSV23 (Pneumovax 23®, Merck)	1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, 33F	Adults ≥ 19 years with risk factors; given after PCV15 (≥ 1 year later; min 8 weeks if immunocompromised); not needed after PCV20/21	Broadest coverage but short-lived immunity and rapid titer decline post-LT. Used mainly to broaden coverage after conjugate vaccine
PCV13 (Prevnar 13®, Pfizer)	1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F	Option if higher-valency PCVs unavailable	Early LT data showed better response than PPSV23, but immunity wanes quickly
PCV15 (Vaxneuvance®, Merck)	PCV13 + 22F, 33F	Adults ≥ 19 years: One dose, then PPSV23 ≥ 1 year later (min 8 weeks if immunocompromised)	Broader coverage and stronger immunogenicity than PCV13
PCV20 (Prevnar 20®, Pfizer)	PCV13 + 8, 10A, 11A, 12F, 15B, 22F, 33F	Adults ≥ 19 years: Single dose; no PPSV23 needed	Broadest coverage Preferred single-dose option for CLD/LT. Limited durability data post-LT
PCV21 (Capvaxive™, Merck)	PCV21 + 15A, 15C, 16F, 23A, 23B, 24F, 31, 35B

CLD: Chronic liver disease; LT: Liver transplantation.

Table 2 Recommended influenza vaccines in chronic liver disease patients/Liver transplantation recipients

Vaccine (brand)	Recommended adult use	Clinical notes in CLD/LT
High-dose inactivated trivalent influenza vaccine (HD-IIV3) or adjuvanted inactivated influenza vaccine (aIIV3)	Adults ≥ 19 years should receive one dose before the onset of seasonal influenza epidemic. In case of planned LT, vaccine should be given at least 2 weeks prior to or at least one month following LT	Standard-dose inactivated trivalent influenza vaccine (IIV3) might be considered, although HD-IIV3 is preferred due to increased immunogenicity. Can be co-administered with other respiratory vaccines

CLD: Chronic liver disease; LT: Liver transplantation.

Table 3 Coronavirus disease 2019 vaccines (adult)-recommended use and clinical notes in chronic liver disease/Liver transplantation

Vaccine (brand)	Recommended adult use	Clinical notes in CLD/LT
Pfizer–BioNTech (Comirnaty®; mRNA)	Updated/seasonal dose(s) per national guidance for adults	Preferred platform for most CLD/LT due to strong effectiveness and safety experience. Responses may be attenuated and additional boosters often needed
Moderna (Spikevax®; mRNA)
AstraZeneca (Vaxzevria®; viral vector)	Where available/used: 2-dose primary series per local policy; boosters typically with an updated vaccine	Generally not first-line for immunocompromised patients. Heterologous boosting with mRNA may improve breadth of responses

CLD: Chronic liver disease; LT: Liver transplantation.

Table 4 Vaccines approved for prevention of herpes zoster in chronic liver disease patients/Liver transplantation recipients

Vaccine (brand)	Recommended adult use	Clinical notes in CLD/LT
LZV (Zostavax®, Merck)	Adults ≥ 50 years who are at increased risk for HZ a single intramuscular dose is given at least 4 weeks prior to LT	LZV is no longer available in the United States and EU. Contraindicated after LT. Not recommended for CLD patients
RZV (Shingrix®, GSK)	Adults ≥ 19 years who are at increased risk for HZ; two intramuscular doses (1 to 6, but ideally 1 to 2 months apart). Indicated for CLD patients with Child-Pugh scores B and C	Can be administered following LT, although vaccination should be timed > 3 months post-LT. Waning immunity warrants further investigation regarding the need of booster dosing

HZ: Herpes zoster; CLD: Chronic liver disease; LT: Liver transplantation; LZV: Live zoster vaccine; RZV: Recombinant zoster vaccine.

Table 5 Currently recommended hepatitis A virus and hepatitis B virus vaccines in patients with chronic liver disease and liver transplantation recipients

Vaccine (brand)	Recommended adult use	Clinical notes in CLD/LT
Hepatitis A
Havrix® (inactivated HAV)	2 doses: 0 and 6-12 months	Prefer pre-LT when feasible. Consider post-vaccination anti-HAV: Check ~1-2 months after dose 2; if anti-HAV < 20 mIU/mL, give an additional dose and recheck
Vaqta® (inactivated HAV)	2 doses: 0 and 6-18 months
Hepatitis B
Engerix-B® (recombinant HBsAg)	3 doses: 0, 1, 6 months	Consider double-dose 40 µg per dose and/or additional doses due to lower response. Prefer completion pre-LT; if post-LT, vaccinate once immunosuppression is stable. Check anti-HBs 1-2 months after last dose; if < 10 IU/L, revaccinate/boost
Recombivax HB® (recombinant HBsAg)	3 doses: 0, 1, 6 months
HBVaxPro® (recombinant HBsAg)	3 doses: 0, 1, 6 months
Fendrix® (HBsAg + adjuvant; “enhanced” vaccine)	4 doses: 0, 1, 2, 6 months	Often more immunogenic in poor responders. May be considered off-label for CLD/LT candidates depending on local policy
Heplisav-B® (CpG-adjuvanted; TLR9 agonist)	2 doses: 0, 1 month	Highly immunogenic and simplifies completion pre-LT. Availability varies by country/region
Hepatitis A and B combination
Twinrix® (HAV/HBV combination)	3 doses: 0, 1, 6 months (accelerated schedules exist)	Useful when both HAV and HBV vaccination are indicated

HAV: Hepatitis A virus; HBV: Hepatitis B virus; HBsAg: Hepatitis B surface antigen; CLD: Chronic liver disease; LT: Liver transplantation; Anti-HAV: Antibody to hepatitis A virus; Anti-HBs: Antibody to hepatitis B surface antigen; TLR9: Toll-like receptor 9.

Table 6 Currently approved respiratory syncytial virus vaccines in chronic liver disease patients/Liver transplantation recipients

Vaccine (brand)	Recommended adult use	Clinical notes in CLD /LT
RSVpreF (Abrysvo®, Pfizer), RSVpreF3 OA (Arexvy®, GSK), mRNA-1345 (mRESVIA®, Moderna)	A single i.m. dose in adults with CLD aged 60-74 years prior to RSV season; a single intramuscular dose to adults undergoing LT at least 2 weeks prior to LT, or at least 6 months afterwards	No recommendations on booster dosing are yet available

RSV: Respiratory syncytial virus; RSVpreF: Respiratory syncytial virus prefusion F protein vaccine; RSVpreF3 OA: Respiratory syncytial virus prefusion F protein vaccine (adjuvanted, older adults formulation); CLD: Chronic liver disease; LT: Liver transplantation.