Hepatitis E virus-related cirrhosis in kidney- and kidney-pancreas-transplant recipients

Hepatitis E virus infection in Latin America: a review

Data reported during recent years reveal the complex picture of the epidemiology of hepatitis E virus (HEV) infection in Latin America. Whereas in countries like Argentina and Brazil is almost identical to the characteristic of most countries from North America and Europe, HEV in the Caribbean and Mexico involves the water-borne, non-zoonotic viral genotypes responsible for epidemics in Asia and Africa. Nevertheless, Latin America has been considered a highly endemic region for hepatitis E in the scientific literature, a generalization that ignores the above complexity. In addition, reports from isolated Amerindian communities, which display well known, important and very specific epidemiological features for hepatitis B and D virus infections are neither taken into account when considering the epidemiology of hepatitis E in the region. This review updates compilation of the available information for the HEV infection, both among humans and other mammals, in Latin America, discusses the strengths and the weaknesses of our current knowledge, and identifies future areas of research.

Hepatitis E virus infection as a new probable cause of de novo membranous nephropathy after kidney transplantation

Hepatitis E virus (HEV) has been identified as a cause of chronic viral hepatitis in immunocompromised patients. Some glomerular diseases were found to be associated with this infection. We report the first case, to our knowledge, of a kidney transplant recipient who developed an HEV infection and de novo membranous nephropathy (MN) concomitantly. The patient displayed a hepatic cytolysis first and a nephrotic syndrome occurred 3 months later. HEV infection was diagnosed upon positive polymerase chain reaction on plasma and stool samples, and renal allograft biopsy revealed de novo MN. Typical causes of MN were definitively excluded. A 3-month course of ribavirin monotherapy allowed the patient to mount a sustained viral response that was rapidly followed by complete remission of the nephrotic syndrome. The chronology of the onset and remission of both diseases is highly suggestive of a causal relationship between hepatitis E and MN.

Hepatitis E virus infection in a liver transplant recipient in the United States: a case report

BACKGROUND

Chronic infection with hepatitis E virus (HEV) has recently been recognized in immunocompromised or immunosuppressed individuals.

CASE REPORT

We report a case of concurrent HEV and human herpes virus-6 (HHV-6) infection, documented by serum HEV RNA and HHV-6 DNA, in an orthotopic liver transplant (OLT) recipient in the United States, where HEV genotype 3 infection, although prevalent, is considered to be self-limited and almost always asymptomatic. The coinfection was accompanied by elevated serum aminotransaminases, liver biopsies demonstrating chronic hepatitis, and the presence of HEV RNA in the tissue. After lowering of immunosuppressive therapy and 2 courses of valganciclovir, sequential clearance of the viruses and normalization of the serum aminotransaminases were observed.

CONCLUSIONS

HEV infection can lead to chronic hepatitis in OLT recipients, and evaluation of this virus should be considered in immunosuppressed individuals with unexplained liver test abnormalities.

Hepatitis E: current status

Acute hepatitis E is a very common disease in developing countries, to the point that, according to World Health Organization estimates, one third of the world's population has been exposed to HEV. It also causes outbreaks in refugee camps or after natural disasters such as floods or earthquakes. Sporadic cases of acute hepatitis have been observed in practically all European countries and other developed geographical areas, not only in travelers from endemic countries but also in people with no risk factors. But, lately, new aspects of this infection are appearing in industrialized countries such as the possibility of the disease becoming chronic in transplant patients, the immunocompromised in general, and even in patients with previous liver disease who are immunocompetent. In this comprehensive review, we summarize the current knowledge on HEV infection.

Epidemiology and management of chronic hepatitis E infection in solid organ transplantation: a comprehensive literature review

Hepatitis E virus (HEV) infection has emerged as a global public health issue. Although it often causes an acute and self-limiting infection with low mortality rates in the western world, it bears a high risk of developing chronic hepatitis in immunocompromised patients with substantial mortality rates. Organ transplant recipients who receive immunosuppressive medication to prevent rejection are thought to be the main population at risk for chronic hepatitis E. Therefore, there is an urgent need to properly evaluate the clinical impact of HEV in these patients. This article aims to review the prevalence, infection course, and management of HEV infection after solid organ transplantation by performing a comprehensive literature review. In addition, an in-depth emphasis of this clinical issue and a discussion of future development are also presented.

Clinical implications of chronic hepatitis E virus infection in heart transplant recipients

BACKGROUND

Recent reports have shown that hepatitis E virus (HEV) infection can become chronic in solid-organ transplant recipients, but few studies have systematically investigated the clinical consequences of this chronic HEV infection in solid-organ transplant (SOT) recipients.

METHODS

We have undertaken an in-depth study of 6 chronic HEV-infected heart transplant recipients to gain further insight into the clinical, biochemical and virologic presentation of this disorder.

RESULTS

In 6 patients (2.3%) chronic HEV infection, genotype 3, was identified. Immunosuppression in these patients was tacrolimus-based, combined with either everolimus or prednisolone and/or mycophenolate mofetil. Median follow-up after case detection was 26 months (range 21 to 40 months). All chronic HEV cases had elevated liver enzyme values. IgM antibodies at presentation were positive in 2 of 6 (33%) patients. Liver histology in 4 of 6 (67%) patients showed advanced fibrosis within 2 years after infection. One patient spontaneously cleared the HEV infection: 1 after dose reduction of immunosuppressive therapy and 3 during ribavirin therapy. One patient has yet to clear the virus and remains on ribavirin therapy.

CONCLUSIONS

Chronic HEV infection in heart transplant (HTx) recipients may lead to rapid fibrosis of the liver. We advise additional HEV RNA screening in solid-organ transplant recipients with elevated liver enzymes, because antibody production is often delayed, as demonstrated in these patients. Dose reduction of immunosuppressive therapy should be the first intervention strategy to achieve viral clearance in chronic HEV-infected immunocompromised patients. Ribavirin treatment should be considered in cases of chronic HEV.

Chronic hepatitis e virus infection and treatment

It is now well accepted that hepatitis E virus (HEV) infection can induce chronic hepatitis and cirrhosis in immunosuppressed patients. Chronic genotype-3 HEV infections were first reported in patients with a solid-organ transplant. Thereafter, cases of chronic HEV infection have been reported in patients with hematological disease and in those who are human immunodeficiency virus (HIV)-positive. HEV-associated extra-hepatic manifestations, including neurological symptoms, kidney injuries, and hematological disorders, have been also reported. In transplant patients, reducing the dosage of immunosuppressive drugs allows the virus to be cleared in some patients. In the remaining patients, as well as hematological patients and patients who are HIV-positive, anti-viral therapies, such as pegylated interferon and ribavirin, have been found to be efficient in eradicating HEV infection. This review summarizes our current knowledge of chronic HEV infection, its treatment, and the extra-hepatic manifestations induced by HEV.

Hepatitis E virus infection

PURPOSE OF REVIEW

The spectrum of hepatitis E virus (HEV) infection has changed over the past 2 years, especially in the developed world. Herein, we review the progress made in studying the epidemiology, hepatic, and extrahepatic manifestations, and the treatment of HEV infection, over the past 2 years.

RECENT FINDINGS

HEV infection is an underdiagnosed disease because of the use of low-sensitivity serological assays. In addition to the four known genotypes, other new genotypes have also been recently described. HEV infection is not only a self-limiting disease but it can also evolve to chronic hepatitis and cirrhosis in organ transplant patients, hematological patients receiving chemotherapy, and HIV patients. HEV can also cause extrahepatic manifestations, such as neurological symptoms, kidney injury, and hematological disorders. Pegylated interferon and ribavirin have been found to effectively treat HEV infection.

SUMMARY

HEV is a worldwide disease that can cause hepatic and extrahepatic manifestations.

Performance of two commercial assays for detecting hepatitis E virus RNA in acute or chronic infections

We assessed the performance of the Ceeram and Altona assays, the first two commercially available hepatitis E virus (HEV) RNA assays, using serial dilutions of 4 HEV-positive reference samples (genotypes 3a, 3c, 3e, and 3f). Both assays provided good analytical sensitivity and high reproducibility for detecting genotype 3 HEV RNA.

Virus host protein interaction network analysis reveals that the HEV ORF3 protein may interrupt the blood coagulation process

Hepatitis E virus (HEV) is endemic worldwide and a major cause of acute liver disease in developing countries. However, the molecular mechanisms of liver pathology and clinical disease are not well understood for HEV infection. Open reading frame 3 (ORF3) of HEV encodes a small phosphoprotein, which is assumed to be involved in liver pathology and clinical disease. In this study, the interactions between the HEV ORF3 protein and human proteins were investigated using a stringent, high-throughput yeast two-hybrid (Y2H) analysis. Thirty two proteins were shown to interact with genotype 1 ORF3, 28 of which have not been reported previously. These novel interactions were evaluated by coimmunoprecipitation of protein complexes from transfected cells. We found also that the ORF3 proteins of genotype 4 and rabbit HEV interacted with all of the human proteins identified by the genotype 1 ORF3 protein. However, the putative ORF3 protein derived from avian HEV did not interact with the majority of these human proteins. The identified proteins were used to infer an overall interaction map linking the ORF3 protein with components of the host cellular networks. Analysis of this interaction map, based on functional annotation with the Gene Ontology features and KEGG pathways, revealed an enrichment of host proteins involved in complement coagulation, cellular iron ion homeostasis and oxidative stress. Additional canonical pathway analysis highlighted the enriched biological pathways relevant to blood coagulation and hemostasis. Consideration of the clinical manifestations of hepatitis E reported previously and the results of biological analysis from this study suggests that the ORF3 protein is likely to lead to an imbalance of coagulation and fibrinolysis by interacting with host proteins and triggering the corresponding pathological processes. These results suggest critical approaches to further study of the pathogenesis of the HEV ORF3 protein.

Hepatitis E seroprevalence in recipients of renal transplants or haemodialysis in southwest England: a case-control study

Locally acquired HEV infection is increasingly recognized in developed countries. Anti-HEV IgG seroprevalence has been shown to be high in haemodialysis patients in a number of previous studies, employing assays of uncertain sensitivity. The aim of this study was to investigate anti-HEV IgG seroprevalence in recipients of haemodialysis and renal transplants compared to a control group using a validated, highly sensitive assay. Eighty-eight patients with functioning renal transplants and 76 receiving chronic haemodialysis were tested for HEV RNA and anti-HEV IgG and IgM. Six hundred seventy controls were tested for anti-HEV IgG. Anti-HEV IgG was positive in 28/76 (36.8%) of haemodialysis and 16/88 (18.2%) of transplant patients. HEV RNA was not found in any patient. 126/670 (18.8%) of control subjects were anti-HEV IgG positive. After adjusting for age and sex, there was a significantly higher anti-HEV IgG seroprevalence amongst haemodialysis patients compared to controls (OR = 1.97, 95% CI = 1.16-3.31, P = 0.01) or transplant recipients (OR = 2.63, 95% CI = 1.18-6.07, P = 0.02). Patients with a functioning transplant showed no difference in anti-HEV IgG seroprevalence compared to controls. The duration of haemodialysis or receipt of blood products were not significant risk factors for HEV IgG positivity. Patients receiving haemodialysis have a higher seroprevalence of anti-HEV IgG than both age- and sex-matched controls and a cohort of renal transplant patients. None of the haemodialysis patients had evidence of chronic infection. The reason haemodialysis patients have a high seroprevalence remains uncertain and merits further study.

Infection with hepatitis E virus in kidney transplant recipients in southeastern France

Hepatitis E virus (HEV) is an emerging cause of acute hepatitis in Europe, particularly in southern France, and HEV is a new causative agent of chronic hepatitis and cirrhosis in immunocompromised patients. However, the data regarding HEV infection after kidney transplantation are still scarce with respect to the clinical issues that have been raised, and no study has specifically focused on kidney transplant recipients. This study described the clinical features and outcomes of HEV infections in a cohort of kidney transplant recipients living in southeastern France. The epidemiological, clinical, and virological characteristics of HEV infections diagnosed by PCR over a 53-month period were retrospectively analyzed in a cohort of 1,350 kidney transplant recipients monitored at the Marseille University Hospital. Sixteen HEV infections were diagnosed, all of which were autochthonous and involved genotype 3 viruses (HEV-3). Chronic infections occurred in 80% of these patients and resolved in half of the cases after a median time of 39 months. The rate of HEV clearance was 54% after a decrease in the dose of immunosuppressants. One patient developed liver cirrhosis 14 months after infection and experienced acute rejection after a decrease in the dose of immunosuppressants. Autochthonous HEV-3 infections in kidney transplant recipients progress to chronicity in most cases and might be complicated by early liver cirrhosis. Chronic HEV infection can resolve following the reduction of immunosuppressive therapy, but ribavirin may be required if reduction of the immunosuppressant dose is not associated with HEV clearance or is inappropriate for the patient management.

[Hepatitis E: molecular virology, epidemiology and pathogenesis]

Hepatitis E represents a significant proportion of enteric transmitted liver diseases and poses a major public health problem, mainly associated with epidemics due to contamination of water supplies, especially in developing countries. Hepatitis E virus (HEV) is responsible for self-limiting acute liver oral-faecal infections. In industrialised countries, acute hepatitis E is sporadic, detected in travellers from endemic areas but also in sporadic cases with no risk factors. HEV is a non-enveloped virus with a single-stranded RNA genome classified into 4 genotypes and a single serotype. Genotypes 1 and 2 only infect humans, and are predominant in the developing countries, while 3 and 4 are predominant in industrialised countries, and also infect other species of mammals, especially pigs, and multiple evidence classifies HEV as a zoonotic agent. Some HEV chronic infections have recently been reported in kidney and liver transplant patients. The mortality rate of HEV infection is greater than hepatitis A. In addition to faecal-oral transmission, parenteral transmission of HEV has also been reported. Several vaccines are currently in development. The severity of this infection in some groups of patients, especially pregnant women, and the occurrence of chronic hepatitis, even with progression to cirrhosis, have raised interest in the application of interferon and/or ribavirin therapy.

[Hepatitis E: scale of the problem in Spain]

Hepatitis E virus (HEV) infection is one of the most frequent causes of acute hepatitis worldwide. However, in Spain, HEV causes only a tiny number of cases of acute hepatitis, the most prevalent cause being hepatitis A. Most cases of HEV in Spain are "imported", being acquired through travel to areas where this infection is endemic. Nevertheless, in the last few years a growing number of "autochthonous cases" have been reported in persons with no history of travelling to HEV-endemic areas. The prevalence of IgG antibodies against HEV, indicating exposure to this virus, is approximately 0.6-7.3% in the general population in Spain and is 19% in persons with risk factors such as exposure to pigs.

Emerging viral diseases in kidney transplant recipients

Viruses are the most important cause of infections and a major source of mortality in Kidney Transplant Recipients (KTRs). These patients may acquire viral infections through exogenous routes including community exposure, donor organs, and blood products or by endogenous reactivation of latent viruses. Beside major opportunistic infections due to CMV and EBV and viral hepatitis B and C, several viral diseases have recently emerged in KTRs. New medical practices or technologies, implementation of new diagnostic tools, and improved medical information have contributed to the emergence of these viral diseases in this special population. The purpose of this review is to summarize the current knowledge on emerging viral diseases and newly discovered viruses in KTRs over the last two decades. We identified viruses in the field of KT that had shown the greatest increase in numbers of citations in the NCBI PubMed database. BKV was the most cited in the literature and linked to an emerging disease that represents a great clinical concern in KTRs. HHV-8, PVB19, WNV, JCV, H1N1 influenza virus A, HEV, and GB virus were the main other emerging viruses. Excluding HHV8, newly discovered viruses have been infrequently linked to clinical diseases in KTRs. Nonetheless, pathogenicity can emerge long after the discovery of the causative agent, as has been the case for BKV. Overall, antiviral treatments are very limited, and reducing immunosuppressive therapy remains the cornerstone of management.

Acute risk for hepatitis E virus infection among HIV-1-positive pregnant women in central Africa

BACKGROUND

Hepatitis E virus (HEV), an enterically transmitted pathogen, is highly endemic in several African countries. Pregnant women are at particularly high risk for acute or severe hepatitis E. In Gabon, a central African country, the prevalence of antibodies to HEV among pregnant women is 14.1%. Recent studies have demonstrated unusual patterns of hepatitis E (chronic hepatitis, cirrhosis) among immunodeficient patients.

FINDINGS

We investigated the prevalence of antibodies to HEV among pregnant women infected with HIV-1 or HTLV-1 in Gabon. Of 243 samples collected, 183 were positive for HIV-1 and 60 for HTLV-1; 16 women (6.6%) had IgG antibodies to HEV. The seroprevalence was higher among HIV-1-infected women (7.1%) than HTLV-1-infected women (5.0%). Moreover, the HIV-1 viral load was significantly increased (p ≤ 0.02) among women with past-HEV exposure (1.3E+05 vs 5.7E+04 copies per ml), whereas no difference was found in HTLV-1 proviral load (9.0E+01 vs 1.1E+03 copies per ml).

CONCLUSIONS

These data provide evidence that HIV-1-infected women are at risk for acute or severe infection if they are exposed to HEV during pregnancy, with an increased viral load.

Chronic hepatitis E virus infection is specifically associated with an interferon-related transcriptional program

BACKGROUND

Hepatitis E virus (HEV) is a new causative agent of chronic hepatitis in solid organ transplant recipients. Clinical studies suggest that the occurrence and persistence of chronic HEV infection are related to the immunological status of patients.

METHODS

We used whole-genome microarray and quantitative reverse transcription polymerase chain reaction (qRT-PCR) to compare the transcriptional profiles of whole blood from 8 kidney transplant recipients with chronic HEV infection and 8 matched kidney transplant recipients without HEV infection.

RESULTS

We found that 30 genes in HEV-infected patients were upregulated, compared with those in control patients, as determined by microarray analysis. In contrast, no genes were downregulated. The 30 upregulated genes included 25 interferon-stimulated genes. Increased expression of the genes that encode IFIT1, IFI44L, RSAD2, EPSTI1, and ISG15 was confirmed by qRT-PCR. Interestingly, the expression levels of these genes were associated with the persistence of HEV infection.

CONCLUSIONS

Increased expression of interferon-stimulated genes may favor the persistence of an HEV infection. Whether the expression of interferon-stimulated genes is a marker of ongoing viremia or independent prognostic marker of HEV clearance needs further investigations.

CLINICAL TRIALS REGISTRATION

NCT01090232.

Serological evidence for a hepatitis e virus-related agent in goats in the United States

Hepatitis E virus (HEV) causes an important public health disease in many developing countries and is also endemic in some industrialized countries. In addition to humans, strains of HEV have been genetically identified from pig, chicken, rat, mongoose, deer, rabbit and fish. While the genotypes 1 and 2 HEV are restricted to humans, the genotypes 3 and 4 HEV are zoonotic and infect humans and other animal species. As a part of our ongoing efforts to search for potential animal reservoirs for HEV, we tested goats from Virginia for evidence of HEV infection and showed that 16% (13/80) of goat sera from Virginia herds were positive for IgG anti-HEV. Importantly, we demonstrated that neutralizing antibodies to HEV were present in selected IgG anti-HEV positive goat sera. Subsequently, in an attempt to genetically identify the HEV-related agent from goats, we conducted a prospective study in a closed goat herd with known anti-HEV seropositivity and monitored a total of 11 kids from the time of birth until 14 weeks of age for evidence of HEV infection. Seroconversion to IgG anti-HEV was detected in seven of the 11 kids, although repeated attempts to detect HEV RNA by a broad-spectrum nested RT-PCR from the faecal and serum samples of the goats that had seroconverted were unsuccessful. In addition, we also attempted to experimentally infect laboratory goats with three well-characterized mammalian strains of HEV but with no success. The results indicate that a HEV-related agent is circulating and maintained in the goat population in Virginia and that the goat HEV is likely genetically very divergent from the known HEV strains.

Hepatitis E virus quasispecies and the outcome of acute hepatitis E in solid-organ transplant patients

Hepatitis E virus (HEV) infections are responsible for chronic hepatitis in immunocompromised patients, and this can evolve to cirrhosis. Like all RNA viruses, HEV exists as a mixture of heterogeneous viruses defining quasispecies. The relationship between the genetic heterogeneity described as a quasispecies, cytokine secretion, and the outcome of acute hepatitis in immunocompromised patients remains to be elucidated. We cloned and sequenced the region encoding the M and P capsid domains of HEV from eight solid-organ transplant (SOT) patients with acute HEV infection who subsequently cleared the virus and from eight SOT patients whose infection became chronic. We analyzed the cytokines and chemokines in the sera of these SOT patients by multianalyte profiling. The nucleotide sequence entropy and genetic distances were greater in patients whose infections became chronic. A lower K(a)/K(s) ratio was associated with the persistence of HEV. The patients who developed chronic infection had lower serum concentrations of interleukin-1 (IL-1) receptor antagonist and soluble IL-2 receptor. Increased concentrations of the chemokines implicated in leukocyte recruitment to the liver were associated with persistent infection. Those patients with chronic HEV infection and progressing liver fibrosis had less quasispecies diversification during the first year than patients without liver fibrosis progression. Great quasispecies heterogeneity, a weak inflammatory response, and high serum concentrations of the chemokines involved in leukocyte recruitment to the liver in the acute phase were associated with persistent HEV infection. Slow quasispecies diversification during the first year was associated with rapidly developing liver fibrosis.

Cirrhosis due to chronic hepatitis E infection in a child post-bone marrow transplant

Chronic hepatitis E virus (HEV) infection occurs in immunosuppressed adults. We detected HEV ribonucleic acid in serum of an adolescent patient who had undergone bone marrow transplantation and subsequently presented with persistently increased aminotransferases and histologic chronic hepatitis, and eventually developed cirrhosis. Phylogenetic analysis revealed these HEV strains were similar to swine genotype 3a, suggesting a possible zoonosis.

[Hepatitis E. Current perspectives]

Infection with hepatitis E virus (HEV) is highly prevalent in developing countries and the WHO estimates one third of the world population has had contact with the virus. Its diagnosis and epidemiology are well known in endemic countries but, recently, there have been sporadic cases in developed countries in patients with no history of travel. Currently in these countries, hepatitis E is considered a zoonosis yet there remain to be known other routes of transmission. Another interesting aspect is that HEV can cause chronic hepatitis in transplanted patients, other immunocompromised patients and even in immunocompetent people. There have also been reported cases of fulminant hepatitis and other extrahepatic manifestations. The diagnosis is based on serological studies and detection of viral RNA in blood and feces. The vaccine is a good option to prevent this infection that affects a large number of people in deprived geographical areas but unfortunately it is not available yet.

The epidemiology of hepatitis E virus infections in developed countries and among immunocompromised patients

Hepatitis E virus (HEV) is an important cause of acute hepatitis in humans worldwide, both as epidemic and sporadic disease. Since the virus was identified in 1983, epidemics have occurred regularly in many countries across South and Southeast Asia when seasonal floods have contaminated drinking water supplies and in Africa during humanitarian crises among refugee populations without access to clean water. In addition, sporadic cases and small clusters of HEV infections have been recognized throughout the world in developed countries over the past couple of decades. This review will focus on emerging evidence of HEV infection as an under-recognized pathogen in Europe, the USA and other industrialized countries. We will discuss some of the issues associated with the recognition, diagnosis and treatment of these sporadic cases. We will also summarize the recent literature on autochthonous HEV infection among populations in developed countries in industrialized Europe, the USA, Japan and other industrialized Asian countries. We will review recent reports of acute and chronic HEV infections among transplant recipients and other immunocompromised individuals including HIV/AIDS patients.

The PSAP motif within the ORF3 protein of an avian strain of the hepatitis E virus is not critical for viral infectivity in vivo but plays a role in virus release

The ORF3 protein of hepatitis E virus (HEV) is a multifunctional protein important for virus replication. The ORF3 proteins from human, swine, and avian strains of HEV contain a conserved PXXP amino acid motif, resembling either Src homology 3 (SH3) cell signaling interaction motifs or "late domains" involved in host cell interactions aiding in particle release. Using an avian strain of HEV, we determined the roles of the conserved prolines within the PREPSAPP motif in HEV replication and infectivity in Leghorn male hepatoma (LMH) chicken liver cells and in chickens. Each proline was changed to alanine to produce 8 avian HEV mutants containing single mutations (P64, P67, P70, and P71 to A), double mutations (P64/67A, P64/70A, and P67/70A), and triple mutations (P64/67/70A). The results showed that avian HEV mutants are replication competent in vitro, and none of the prolines in the PXXPXXPP motif are essential for infectivity in vivo; however, the second and third prolines appear to aid in fecal virus shedding, suggesting that the PSAP motif, but not the PREP motif, is involved in virus release. We also showed that the PSAP motif interacts with the host protein tumor suppressor gene 101 (TSG101) and that altering any proline within the PSAP motif disrupts this interaction. However, we showed that the ORF2 protein expressed in LMH cells is efficiently released from the cells in the absence of ORF3 and that coexpression of ORF2 and ORF3 did not act synergistically in this release, suggesting that another factor(s) such as ORF1 or viral genomic RNA may be necessary for proper particle release.

Low risk of hepatitis E virus reactivation after haematopoietic stem cell transplantation

BACKGROUND

Hepatitis E virus (HEV) is an emerging cause of acute hepatitis in industrialized countries. HEV infection can evolve to chronic hepatitis in immunocompromised patients. Additionally, HEV reactivation after haematopoietic stem cell transplantation has been reported.

OBJECTIVE

To assess the prevalence of anti-HEV antibodies in patients who underwent haematopoietic stem cell transplantation in south-western France and the risk of HEV reactivation after transplantation.

STUDY DESIGN

We have investigated the prevalence of anti-HEV antibodies in 88 patients who underwent allogenic or autologous haematopoietic stem cell transplantation with two anti-HEV IgG assays and have evaluated the risk of HEV reactivation in pretransplant seropositive patients by testing for HEV RNA in blood samples collected after stem cell transplantation.

RESULTS

While only 11 patients (12.5%) tested positive for anti-HEV IgG with the Adaltis assay, 32 patients (36.4%) tested positive for anti-HEV IgG with the Wantai assay before transplantation. Three anti-HEV IgG positive patients were also anti-HEV IgM positive. Plasma HEV RNA was negative in all the patients before transplantation. We looked for HEV reactivation in pretransplant seropositive patients by testing 89 blood samples for HEV RNA 1, 3 and 6 months after transplantation. We detected no reactivation. Similarly, we detected no HEV RNA in pretransplant seronegative patients after transplantation.

CONCLUSION

Despite strong immunosuppression, the risk of HEV reactivation after stem cell transplantation appears to be very low.

Transfusion-transmitted hepatitis E: is screening warranted?

Hepatitis E virus (HEV) is an emerging infectious threat to blood safety. In recent years, there have been a number of publications delineating this threat by providing evidence of the transmissibility of this virus through transfusions. The extent of transmission and its clinical relevance are issues under debate at present. HEV usually causes a self-limiting illness which subsides in a few weeks barring a few cases where fulminant hepatic failure occurs. The virus poses a risk of higher morbidity and mortality in pregnant females, patients with pre-existing liver disease and solid organ transplant recipients. As these categories of patient often require repeated transfusions or massive transfusions, they are exposed to a greater risk of transmission of HEV. At present, there is little evidence to advocate universal screening for this virus but considering that there is no definitive treatment for HEV induced hepatitis, selective screening should be advocated in blood products for high risk recipients in endemic areas.

Progress in research of chronic hepatitis E

Hepatitis E caused by hepatitis E virus (HEV) has long been considered as an acute self-limiting disease. But in recent years, cases which progress to chronic liver disease mainly in immunocompromised patients have been detected, such as organ transplant recipients and patients with human immunodeficiency virus infection. Studies indicate that chronic HEV hepatitis may result in cirrhosis and end-stage liver disease. Since clearance of the virus depends on the development of specific immunity, lowering the immunosuppressive medication is generally recommended. Ribavirin, interferon-alpha-2a and interferon-alpha-2b were found to be effective in patients with chronic HEV infection.

Chronic Hepatitis E as a cause for cryptogenic cirrhosis in HIV

Chronic Hepatitis E infection (HEV) is reported in immunocompromised patients. A 45-year-old HIV-infected man had no cause found for a persistent transaminitis which predated commencement of antiretroviral therapy. Hepatic elastography and liver biopsy revealed cirrhosis. In 2010, he tested positive for HEV IgM/IgG antibodies. Plasma HEV RNA was detected. Archived samples revealed HEV viraemia since 2000. A 24-week course of pegylated interferon was commenced and HEV RNA became undetectable at week 4 until week 27 post treatment cessation. Chronic HEV infection should be considered in HIV patients as a cause for unexplained transaminitis and cryptogenic liver cirrhosis.

Hepatitis E virus infection as a cause of acute hepatitis in Southern Italy

BACKGROUND

Hepatitis E virus (HEV) is a major cause of acute hepatitis in developing countries, whereas it is not considered a major health problem in Western World.

AIMS

To investigate the spread of HEV and its possible role in causing acute hepatitis in Southern Italy.

METHODS

Four hundred and thirty patients observed from April to December 2009 were studied and grouped as follows: 55 individuals with acute hepatitis (AH), 33 of whom cryptogenic; 321 individuals with chronic liver diseases (CLD), (278 Italians and 43 immigrants); 54 individuals without liver disease (control-group). Serum samples from all cases were tested for IgG anti-HEV antibodies and those positive to this test as well as all AH cases were also tested both for IgM anti-HEV and HEV RNA.

RESULTS

Two of 33 (6%) cryptogenic AH cases were associated with HEV infection as shown by positive IgM anti-HEV test. Both these patients had not travelled to areas at high HEV endemicity. HEV RNA was not found in any sample tested. IgG anti-HEV antibodies were detected in 5.7% of Italians with CLD and 3.7% of the control-group. No immigrant was found positive for any HEV marker.

CONCLUSION

Autochthonous HEV infection is present in Southern Italy where it may cause AH.

Potential risk of zoonotic transmission from young swine to human: seroepidemiological and genetic characterization of hepatitis E virus in human and various animals in Beijing, China

The aim of this study was to further investigate the prevalence of infection and genotype of hepatitis E virus (HEV) among different species of animals, people whose works are related to pigs and the general population in the suburb of Beijing, China. Serum and faecal samples were collected from 10 animal species and humans. Anti-HEV was detected by enzyme immunoassays (EIA); HEV RNA was amplified by reverse transcription-nested polymerase chain reaction (RT-nPCR) method. PCR products were cloned and sequenced. The isolated swine HEV sequences were analysed phylogenetically. The positive rates of serum anti-HEV in swine, cattle, milk cow, horse, sheep, donkey, dog, duck, chicken, pig farm workers and slaughterhouse workers, and general population were 81.17% (802/988), 25.29% (66/261), 14.87% (40/269), 14.29% (40/280), 9.30% (53/514), 0 (0/25), 0 (0/20), 2.53% (8/316), 3.03% (7/231), 58.73% (37/63), 35.87% (66/184) and 20.06% (538/2682), respectively. The anti-HEV prevalence in adult swine (≥ 6 months) and younger swine (≤ 3 months) was 91.49% (591/646) and 61.7% (211/342), respectively. The positive rate of HEV RNA in young swine faeces was 47.94% (93/194). All 93 isolates from the younger swine shared 87.8-100% nucleotide homology with each other and had identities of 75.6-78.9%, 73.9-76.1%, 76.4-80.6% and 83.1-95.0% with the corresponding regions of genotypes 1-4 HEV, respectively. Phylogenetic analysis showed that all HEV isolates belong to genotype 4, subgenotype 4d. These results suggest a potential risk of zoonotic transmission of HEV from younger swine to farmers who rear pigs.

Role of hepatitis E infection in acute on chronic liver failure in Egyptian patients

BACKGROUND

The vast majority of patients who are referred to a specialist hepatological centre suffer from acute deterioration of their chronic liver disease. Yet, this entity of acute on chronic liver failure remains poorly defined.

AIM

The aim of the present study was to highlight the occurrence of hepatitis E viraemia by nested reverse transcriptase polymerase chain reaction (RT-PCR) in patients with acute on chronic liver failure.

MATERIALS AND METHODS

The study included 100 patients with acute on chronic liver disorders admitted to Mansoura University Hospital, Egypt. Blood samples were obtained from patients and sera were separated. Sera were subjected to a study of viral hepatitis markers for hepatitis A by IgM, for hepatitis B by S antigen and core IgM and for hepatitis C virus by IgG and RT-PCR for HCV. Liver function tests were evaluated including alanine transaminase, aspartate transaminase and bilirubin total and direct by an autoanalyser. Study for hepatitis E virus (HEV) was performed using a molecular technique. Nested RT-PCR was performed for each serum sample.

RESULTS

HEV RNA was detected in the sera of 13 patients (13%) of the patients with chronic liver disorders. The majority of the positive cases were among patients with cirrhosis (29.9%) followed by patients with HCC (15.4%). On multirisk analysis for the factors associated with the presence of HEV viraemia, younger age < 45 years and lower albumin level < 3.5 g/dl were significantly (P = 0.04, P = 0.03) associated with HEV viraemia.

DISCUSSION

From this study it appears that HEV viraemia is a common cause of acute on chronic liver disorders in Egypt.

CONCLUSION

There is no effective vaccine is available against HEV, mass awareness and preventive measures are important to the related.

Viral hepatitis in solid organ transplantation other than liver

Transplantation is the best treatment for end-stage organ failure. Hepatitis virus infections, mainly hepatitis B virus (HBV) and hepatitis C virus (HCV) infections still constitute a major problem because they are common in allograft recipients and are a significant cause of morbidity and mortality after transplantation. Recently, hepatitis E virus infection has been added as an emergent cause of chronic hepatitis in organ transplantation. The prevalence of HBV and HCV infections has markedly decreased in patients who are candidates for transplantation since the introduction of screening, hygiene and prevention measures, including systematic screening of blood and organ donations, use of erythropoietin, compliance with universal hygiene rules, segregation of HBV-infected patients from non-infected patients and systematic vaccination against HBV. A liver biopsy is preferable to non-invasive biochemical and/or morphological tests of fibrosis to evaluate liver fibrosis before and even after transplantation. Treatment with entecavir or tenofovir is indicated in HBV-infected dialyzed patients who have moderate or severe disease (≥A2 or F2 on the Metavir scale) in preparation for renal transplantation. Due to the risks of severe reactivation, fibrosing cholestatic hepatitis or histological deterioration after transplantation, systematic use of nucleoside or nucleotide analogues shortly before or at the time of transplantation is recommended (tenofovir or entecavir are preferable to lamivudine) in all patients, whatever the baseline histological evaluation. In HCV-infected dialyzed patients who are not candidates for renal transplantation, the indication for antiviral therapy is limited to significant fibrosis (fibrosis ≥2 on the Metavir scale). Treatment must be proposed to all candidates for renal transplantation, whatever their baseline histopathology, and interferon-α should be used as monotherapy. After transplantation, interferon-α is contraindicated but may be used in patients for whom the benefits of antiviral treatment clearly outweigh the risks, especially that of allograft rejection. All cirrhotic patients, notably after solid organ transplantation, should be screened for hepatocellular carcinoma. Sustained suppression of necro-inflammation may result in regression of cirrhosis, which in turn may lead to decreased disease-related morbidity and improved survival. Finally, due to the high mortality after renal transplantation, active (namely without sustained viral suppression) cirrhosis should be considered a contraindication to kidney transplantation, but an indication to combined liver-kidney transplantation; on the contrary, inactive (namely with sustained viral suppression) compensated cirrhosis may permit renal transplantation alone. Organ transplantations other than kidney (cardiac or pulmonary transplantations) involve the same diagnosis and therapeutic issues.

Chronic hepatitis e infection resulting in graft failure in a liver transplant tourist

Hepatitis E, usually an acute hepatitis in the immunocompetent, has a chronic form described in immunocompromised hosts. We report the clinical course and outcome of an adult liver transplant recipient whose posttransplant period was complicated by chronic hepatitis E, Epstein-Barr virus infection, and cellular rejection of the graft.

Microbial safety in xenotransplantation

PURPOSE OF REVIEW

As clinical trials are in progress involving porcine islet cell transplantation, microbial safety remains a key issue. Therefore, in the context of pig-to-human xenotransplantation, we provide an overview of the recent progress in the studies of relevant viruses including well known problematic viruses, such as herpesviruses and porcine endogenous retroviruses (PERV) in addition to some emerging issues regarding other pathogens.

RECENT FINDINGS

The ability of herpesvirus to infect across species barriers is probably underestimated and requires monitoring and control of both xenograft donors and recipients for latent infection. Exclusion from donors and recipient monitoring for other exogenous pathogens including newly identified Parvovirus-4 are warranted. The availability of the swine whole genome sequence may help to characterize and select donor animals with less PERV infectivity. Rigorous PERV monitoring in both clinical and preclinical xenotransplantation experiments must be included in clinical protocols.

SUMMARY

A wide range of pathogens, both viruses and bacteria, pose potential safety problems in xenotransplantation, highlighting the importance of prescreening of the donor animals, and careful monitoring and follow-up of the patients.

The molecular epidemiology of hepatitis E virus infection

Molecular characterization of various hepatitis E virus (HEV) strains circulating among humans and animals (particularly swine, deer and boars) in different countries has revealed substantial genetic heterogeneity. The distinctive four-genotype distribution worldwide of mammalian HEV and varying degrees of genetic relatedness among local strains suggest a long and complex evolution of HEV in different geographic regions. The population expansion likely experienced by mammalian HEV in the second half of the 20th century is consistent with an extensive genetic divergence of HEV strains and high prevalence of HEV infections in many parts of the world, including developed countries. The rate and mechanisms of human-to-human transmission and zoonotic transmission to humans vary geographically, thus contributing to the complexity of HEV molecular evolution.

Factors associated with chronic hepatitis in patients with hepatitis E virus infection who have received solid organ transplants

BACKGROUND & AIMS

Hepatitis E virus (HEV) infection can cause chronic hepatitis in recipients of solid organ transplants. However, the factors that contribute to chronic infection and the outcomes of these patients are incompletely understood. We performed a retrospective analysis of data from 17 centers from Europe and the United States that described the progression, outcomes, and factors associated with development of chronic HEV infection in recipients of transplanted solid organs.

METHODS

We studied data from 85 recipients of solid organ transplants who were infected with HEV. Chronic HEV infection was defined by the persistent increases in levels of liver enzymes and polymerase chain reaction evidence of HEV in the serum and/or stool for at least 6 months.

RESULTS

Fifty-six patients (65.9%) developed chronic hepatitis. Univariate analysis associated liver transplant, shorter times since transplant, lower levels of liver enzymes and serum creatinine, lower platelet counts, and tacrolimus-based immunosuppressive therapy (rather than cyclosporin A) with chronic hepatitis. On multivariate analysis, the independent predictive factors associated with chronic HEV infection were the use of tacrolimus rather than cyclosporin A (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.49-1.97; P = .004) and a low platelet count at the time of diagnosis with HEV infection (OR, 1.02; 95% CI, 1.001-1.1; P = .04). Of patients with chronic hepatitis, 18 (32.1%) achieved viral clearance after the dose of immunosuppressive therapy was reduced. No HEV reactivation was observed after HEV clearance.

CONCLUSIONS

HEV infection causes chronic hepatitis in more than 60% of recipients of solid organ transplants. Tacrolimus therapy is the main predictive factor for chronic hepatitis. Dose reductions of immunosuppressive therapy resulted in viral clearance in more than 30% of patients.

Clinical and epidemiological aspects of a hepatitis E outbreak in Bangui, Central African Republic

Background

Outbreaks of hepatitis E frequently occur in tropical developing countries during the rainy season due to overflowing drains, short-circuiting of networks of clean water and use of contaminated water from wells. Hepatitis E virus (HEV) infections are usually accompanied by general symptoms of acute liver disease. This study was conducted to define the clinical and epidemiological aspects of the HEV outbreak that occurred in May 2004 in Bangui.

Methods

Blood samples were collected from 411 patients aged 1-87 years, most of whom presented with jaundice, asthenia or signs of uncomplicated malaria, for a transversal study from June 2004 to September 2005. Patients were recruited at 11 health care centres, including two referral hospitals, after they had given informed consent. The diagnosis of HEV was made with a commercial ELISA test to detect IgM and/or IgG antibodies. HEV RNA was amplified by RT-PCR to confirm the presence of the viral genome.

Results

The most frequent clinical signs found were jaundice (93.4%), vomiting (50.7%), hepatalgia (47.4%), hepatomegaly (30.9%) and asthenia (26.8%), which are the general clinical signs of hepatic disease. Acute hepatitis E was found in 213 patients (51.8%) who were positive for HEV IgM antibodies. The IgG anti-HEV seroprevalence during this outbreak was high (79.5%). The age group 18-34 years was more frequently infected (91.2%) than those aged 1-17 (78.0%) or over 34 (64.9%) (p < 10^-6). RT-PCR performed on 127 sera from the 213 IgM-HEV-positive patients was amplified, and the presence of the viral genome was found in 65 samples.

Conclusion

Although no specific clinical signs exist for hepatitis E infection, people presenting with jaundice, vomiting, hepatalgia, asthenia, hepatomegaly or distended abdomen with no signs of uncomplicated malaria in tropical developing countries should be sent to a laboratory for testing for hepatitis E.

[Prevention of virus hepatitis A to E]

Infection with hepatitis viruses can lead to acute hepatitis with the risk of developing liver failure. Chronic viral hepatitis may evolve into liver cirrhosis and hepatocellular carcinoma. Thus, prevention of viral hepatitis and its sequels is essential. Vaccination against hepatitis A is successful in almost all individuals. Protective antibodies maintain for at least 20 years. Booster vaccinations are not necessary. Since the introduction of hepatitis A vaccines, the incidence of new HAV-infections has declined significantly. Hepatitis B vaccines are safe and highly effective. Special populations such as dialysis patients or immunocompromised patients require special vaccine schedules. New vaccines with improved adjuvants are currently being tested in clinical trials. So far there is no hepatitis C vaccine on the horizon. Prophylaxis of HCV-infections relies primarily on hygiene measures. Early therapy of acute hepatitis C can prevent chronic hepatitis C. HDV-infection can only be established if HBsAg is present. Thus, prevention of hepatitis B or elimination of HBsAg means prevention of hepatitis delta. Hepatitis E vaccines have been evaluated in phase III studies. The development of HEV vaccines becomes more relevant since chronic HEV infections have been reported in immunosuppressed individuals.

[Hepatitis E virus: A new entity]

Hepatitis E virus (HEV) is a RNA enterically transmitted virus that causes large waterborne epidemics of acute hepatitis E in endemic regions (Asia and Africa). Sporadic hepatitis E is an emerging disease in developed countries such as France. The majority of acute hepatitis E in France is indigenous (non travel-associated) and is due to infection with HEV genotype 3. Diagnosis is made on the presence of specific serum antibodies and on viral RNA detection in serum or stools. Characteristic pathological signs of acute hepatitis E are severe intralobular necrosis, polymorph inflammation and acute cholangitis in portal tract with numerous neutrophils. Severe forms of hepatitis are associated with underlying chronic liver disease such alcoholic disease. In immunocompetent patients, HEV causes acute resolutive hepatitis and there is no chronic evolution. Conversely, chronic hepatitis E is frequent in immunocompromised patients with a risk of rapid evolution to cirrhosis. Histologic lesions of chronic hepatitis E are similar to those observed in patients chronically infected with hepatitis C virus with dense lymphocytic portal infiltrate, constant peacemeal necrosis and fibrosis.

Ribavirin therapy inhibits viral replication on patients with chronic hepatitis e virus infection

BACKGROUND & AIMS

Hepatitis E virus (HEV) infection can evolve to chronic hepatitis in immunocompromised patients. Pegylated α-interferon can effectively treat chronic HEV infection after liver transplantation but is contraindicated for kidney transplantation. We assessed the antiviral effect of ribavirin monotherapy in patients with chronic HEV infection following kidney transplantation.

METHODS

In a pilot study performed at Toulouse University Hospital, 6 patients that received kidney transplants who were positive for HEV RNA (infected with HEV for 36.5 months; [range, 11-46 months]) were given ribavirin monotherapy for 3 months. Ribavirin was given at 600-800 mg/day in 2 separate doses, based on the patient's ability to clear creatinine.

RESULTS

Median serum concentration of HEV RNA at baseline was 5.77 log copies/mL (range, 4.35-7.35 log copies/mL). Three months after ribavirin therapy commenced, HEV RNA was undetectable in serum samples from all patients. A sustained virologic response was observed in 4 patients; the other 2 patients relapsed at 1 and 2 months after ribavirin therapy ended. At the end of the study, all patients had normal levels of alanine and aspartate aminotransferase. Anemia was the main side effect caused by ribavirin therapy.

CONCLUSIONS

Ribavirin monotherapy inhibits the replication of HEV in vivo and might induce a sustained virological response in patients with chronic HEV infections. Further studies are required to determine the optimal duration of ribavirin therapy.

Hepatitis E virus excretion can be prolonged in patients with hematological malignancies

BACKGROUND

Hepatitis E virus (HEV) is transmitted via the fecal-oral route and locally acquired sporadic hepatitis E can occur in Western countries. Chronic hepatitis E virus infections have been recently described in solid organ transplant recipients. There is little data on the evolution of hepatitis E in patients immunocompromised for other reasons.

OBJECTIVES

The aim of this study was to evaluate the clinical course of hepatitis E in patients immunocompromised because of hematological malignancies.

STUDY DESIGN

Starting on November 2003, all patients in the Toulouse University Hospital Hematology Department with unexplained elevated transaminases were tested for hepatitis E using viral RNA detection in serum or stools and serology.

RESULTS

Acute hepatitis E was diagnosed in six middle-aged hematology patients. All cases were autochthonous. HEV strains were genotype 3. All patients had a significant increase of transaminases (6-95 upper limit normal) and only two had HEV IgG. Five patients were asymptomatic and one had jaundice. Transmission of HEV occurred between two patients who had overlapping stays in the hematology ward. All five evaluable patients ultimately cleared their HEV but viremia was prolonged over 6 months in three patients and specific treatment had to be postponed in two patients.

CONCLUSION

Screening for HEV should be carried out routinely in hematology patients with elevated transaminases, and patient-to-patient transmission is a concern. Further studies are required to determine whether management of malignancy, particularly stem-cell transplantation should be adapted to HEV status.