Chronic Hepatitis E in Heart Transplant Recipients

Abstract

Chronic courses of hepatitis E virus (HEV) infections have been described in immunosuppressed patients. We aimed to study the role of HEV infections in heart transplant recipients (HTR). 274 HTR were prospectively screened for HEV infection using an anti-HEV-IgG ELISA and HEV-PCR. In addition, 137 patients undergoing cardiac surgery (non-HTR) and 537 healthy subjects were studied cross-sectionally. The anti-HEV-IgG seroprevalence was 11% in HTR, 7% in non-HTR and 2% in healthy controls (HTR vs. healthy controls p<0.0001; non-HTR vs. healthy controls p<0.01). Anti-HEV tested positive in 4.0% in control cohorts of other immunocompromised patients (n = 474). Four HTR (1.5%) were chronically infected with HEV as shown by HEV-PCR and all four patients had liver transaminases of >200 IU/L and histological or clinical evidence of advanced liver disease. In three patients ribavirin treatment was successful with a sustained biochemical and virological response while treatment failed in one cirrhotic patient after ribavirin dose reduction. Heart transplant recipients and patients undergoing cardiac surgery have an increased risk for HEV infections. Chronic hepatitis E may explain elevated liver enzymes in heart transplant recipients. Treatment of HEV infection with ribavirin is effective but the optimal dose and duration of ribavirin therapy remains to be determined.

Hepatitis E Virus Infection

“…Although the majority of chronic HEV cases are diagnosed in the transplant population (13,(222)(223)(224)(225)(226)(227)(228), several chronic cases have also been observed in patients coinfected by HIV (229) and in hematological patients treated with anticancer chemotherapy (230). All chronic HEV cases were observed in patients infected by HEV genotype 3.…”

“…However, interferon cannot be used after kidney, heart, or lung transplantation, because it increases the risk of acute rejection (294). Hence, short courses of ribavirin monotherapy have been used, producing promising and very interesting results, in both adults and pediatric organ transplant patients (Table 4) (41,222,226,227,241,254,282,(295)(296)(297). Further large studies are needed to confirm these preliminary observations.…”

A Mutation in the Hepatitis E Virus RNA Polymerase Promotes Its Replication and Associates With Ribavirin Treatment Failure in Organ Transplant Recipients

“…The patient died of hepatic decompensation as described previously. 9 The second patient is a female lung/kidney/bone-marrow-recipient who underwent two consecutive RBV treatments of 4 and 7 months respectively. 10 Although at the end of each treatment period, HEV RNA status was negative, viral RNA was detected again shortly after stopping therapy.…”

Hepatitis E virus infection

“…Although the majority of chronic HEV cases are diagnosed in the transplant population (13,(222)(223)(224)(225)(226)(227)(228), several chronic cases have also been observed in patients coinfected by HIV (229) and in hematological patients treated with anticancer chemotherapy (230). All chronic HEV cases were observed in patients infected by HEV genotype 3.…”

“…However, interferon cannot be used after kidney, heart, or lung transplantation, because it increases the risk of acute rejection (294). Hence, short courses of ribavirin monotherapy have been used, producing promising and very interesting results, in both adults and pediatric organ transplant patients (Table 4) (41,222,226,227,241,254,282,(295)(296)(297). Further large studies are needed to confirm these preliminary observations.…”