Hepatitis E and Acute-on-Chronic Liver Failure

Abstract

Hepatitis E virus (HEV) is the most common cause of acute viral hepatitis (AVH) globally. It causes large scale epidemics of AVH across the low-and middle income countries in Asia and Africa, and also causes sporadic cases of AVH in the same geographical region. AVH due to HEV is usually an acute, self-limiting illness, similar in clinical presentation to AVH caused by hepatitis A virus (HAV). When HEV causes AVH in patients of chronic liver disease it may worsen rapidly to a syndrome called acute-on-chronic liver failure (ACLF) leading to very high mortality. Acute deterioration of liver function in a patient with compensated chronic liver disease is the characteristic feature of ACLF. The typical disease course of patients with ACLF is the appearance of organ failure, which progresses to multi-organ failure and death. Many publications have reported HEV as one of the leading causes for ACLF from Asia and Africa, where HEV is endemic. The mortality rate of HEV-related ACLF (HEV-ACLF) ranges from 0% to 67% with a median being 34%. These patients require admission in the intensive care unit and they benefit from a team approach of clinicians with expertise in both hepatology and critical care. The goals of treatment are to prevent further deterioration in liver function, reverse precipitating factors, and support failing organs. Liver transplantation is required in selected patients to improve survival and quality of life. One preliminary report suggests that ribavirin may be an effective and safe drug for treatment of HEV-ACLF however this requires validation in large trials. ( J CLIN EXP HEPATOL 2013;3:225-230)

Review article: hepatitis E—a concise review of virology, epidemiology, clinical presentation and therapy

“…to 75%) with a median short-term mortality rate of 34% (range: 0%-100%). 58 One study from India reported a 70% 12-month mortality rate in patients with HEV infection superimposed upon chronic liver disease and interestingly, HEV infection was associated with a higher mortality rate than decompensation due to any other cause. 64 However, a study from South-East England suggested that there are 80 000-100 000 infections per year in England, the majority of which are asymptomatic.…”

Acute-on-chronic liver failure: recent update

“…It is important to note that this is not always easy to discern. In the Asian subcontinent, HBV reactivation is a significant precipitant of ACLF, while superimposed HEV is a major cause of ACLF in India [39][40] . As well as viral infection, bacterial and fungal infections may also result in bacterial translocation and therefore contribute toward the development of the SIRS.…”

Combating the wrath of viral hepatitis in India

“…HEV infection is attributable not only as a common cause of acute liver failure in India but also to worsening liver function in patients with underlying chronic liver disease, an entity termed as acute-on-chronic liver failure (ACLF)34. During an epidemic, women in the late trimester of pregnancy are infected more frequently (12-20%) than non-pregnant women and men (2-4%)35.…”