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Markakis GE, Papatheodoridis GV, Cholongitas E. Epidemiology and treatment of hepatitis E in the liver transplantation setting: A literature review. J Viral Hepat 2022; 29:698-718. [PMID: 35644040 DOI: 10.1111/jvh.13709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 02/01/2022] [Accepted: 05/10/2022] [Indexed: 12/09/2022]
Abstract
Hepatitis E virus (HEV) is a common cause of acute hepatitis in developing countries, but it can also take a chronic course especially in immunocompromised patients. Its epidemiology after liver transplantation (LT) is hard to assess and treatment options are still explored. Between 2009 and 2020, literature reporting HEV prevalence and treatment in LT recipients was searched and a synthesis was attempted. Sixteen studies reported HEV prevalence in consecutive LT patients: HEV RNA positivity ranged between 0%-1.4% and 0%-7.7% for Western and Eastern cohorts, respectively. In studies published between 2009-2014 and 2015-2020, HEV RNA positivity ranged between 0.35%-1.3% (all European) and 0%-7.7% (European: 0%-1.4%), respectively. Five studies evaluated HEV prevalence in LT recipients with abnormal liver enzymes: HEV RNA positivity was 2.9% in studies published between 2009 and 2014 and from 3.5% to 20% in studies published between 2015 and 2020. Twenty-seven studies reported HEV treatment in LT recipients: sustained virologic response was achieved in 15% by immunosuppression reduction alone and in 83% of cases by ribavirin regiments. Chronic HEV infection is affecting LT recipients, mostly those with abnormal liver enzymes and in Eastern countries. HEV diagnoses should be based on PCR techniques. Successful treatment can be achieved with ribavirin in most cases.
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Affiliation(s)
- George E Markakis
- Department of Gastroenterology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George V Papatheodoridis
- Department of Gastroenterology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Ankcorn M, Said B, Morgan D, Elsharkawy AM, Maggs J, Ryder S, Valliani T, Gordon F, Abeysekera K, Suri D, McPherson S, Galliford J, Smith B, Pelosi E, Bansal S, Bethune C, Sheridan D, Vine L, Tedder RS, Ijaz S, Zuckerman M, Dalton H, Healy B, Donati M, Bicknell K, Evans C, Poller B, Smit E, Halsema C, Williams E, Raza M, McGann H, Irving W, Douthwaite S, Ch'ng CL, McCaughey C, Irish D. Persistent Hepatitis E virus infection across England and Wales 2009-2017: Demography, virology and outcomes. J Viral Hepat 2021; 28:420-430. [PMID: 33073452 DOI: 10.1111/jvh.13424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/20/2020] [Accepted: 10/02/2020] [Indexed: 01/11/2023]
Abstract
The first clinical case of persistent HEV infection in England was reported in 2009. We describe the demography, virology and outcomes of patients identified with persistent HEV infection in England and Wales between 2009 and 2017. A series of 94 patients with persistent HEV infection, defined by HEV viraemia of more than 12 weeks, was identified through routine reference laboratory testing. Virology, serology and clinical data were recorded through an approved PHE Enhanced Surveillance System. Sixty-six cases (70.2%) were transplant recipients, 16 (17.0%) had an underlying haematological malignancy without stem cell transplantation, six (6.4%) had advanced HIV infection, five (5.3%) were otherwise immunosuppressed, and one patient (1.1%) had no identified immunosuppression. Retrospective analysis of 46 patients demonstrated a median 38 weeks of viraemia before diagnostic HEV testing. At initial diagnosis, 16 patients (17.0%) had no detectable anti-HEV serological response. Of 65 patients treated with ribavirin monotherapy, 11 (16.9%) suffered virological relapse despite undetectable RNA in plasma or stool at treatment cessation. Persistent HEV infection remains a rare diagnosis, but we demonstrate that a broad range of immunocompromised patients are susceptible. Both lack of awareness and the pauci-symptomatic nature of persistent HEV infection likely contribute to significant delays in diagnosis. Diagnosis should rely on molecular testing since anti-HEV serology is insufficient to exclude persistent HEV infection. Finally, despite treatment with ribavirin, relapses occur even after cessation of detectable faecal shedding of HEV RNA, further emphasising the requirement to demonstrate sustained virological responses to treatment.
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Affiliation(s)
- Michael Ankcorn
- Blood Borne Virus Unit, Virus Reference Department, National Infection Service, Public Health England, London, UK.,Transfusion Microbiology, National Health Service Blood and Transplant, London, UK
| | - Bengü Said
- Emerging Infections and Zoonoses, National Infection Service, Public Health England, London, UK
| | - Dilys Morgan
- Emerging Infections and Zoonoses, National Infection Service, Public Health England, London, UK
| | | | - James Maggs
- Department of Gastroenterology, Buckinghamshire Healthcare NHS Trust, Buckinghamshire, UK
| | - Stephen Ryder
- Department of Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Talal Valliani
- North Bristol Liver Unit, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Fiona Gordon
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kushala Abeysekera
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Deepak Suri
- Department of Hepatology, University College London Hospitals, London, UK
| | - Stuart McPherson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, & Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Jack Galliford
- Department of Nephrology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Belinda Smith
- Department of Hepatology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Emanuela Pelosi
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sanjay Bansal
- Department of Paediatric Hepatology, Gastroenterology & Nutrition Center, King's College Hospital NHS Foundation Trust, London, UK
| | - Claire Bethune
- Department of Immunology and Allergy, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - David Sheridan
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Louisa Vine
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Richard S Tedder
- Blood Borne Virus Unit, Virus Reference Department, National Infection Service, Public Health England, London, UK.,Transfusion Microbiology, National Health Service Blood and Transplant, London, UK.,Department of Medicine, Imperial College London, London, UK
| | - Samreen Ijaz
- Blood Borne Virus Unit, Virus Reference Department, National Infection Service, Public Health England, London, UK
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Hepatitis E Virus Capsid Antigen (HEV-Ag) - A practical diagnostic biomarker in the HEV outbreak scenario. J Clin Virol 2020; 134:104692. [PMID: 33316568 DOI: 10.1016/j.jcv.2020.104692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The increased global incidence of hepatitis E virus (HEV) infections, warrants accurate and affordable diagnostics across different geographical regions. The soluble and highly conserved HEV open reading frame 2 (ORF2) capsid antigen (HEV-Ag) is detectable in self-limited acute enteric hepatitis by HEV-Ag ELISA which is a promising serological assay in settings where HEV-RNA testing is not feasible. Our aim was to assess the HEV-Ag biomarker in an HEV outbreak in a low income country. METHODS A prospective single center longitudinal study during HEV outbreaks in the Chittagong, Bangladesh region between October 2018 and October 2019 was conducted based on recruitment of acute jaundice cases with clinical signs and symptoms of suspect HEV infections. Acute HEV infection was defined as a positive test result for anti-HEV IgM antibodies. RESULTS Forty four of the 51 enrolled enteric hepatitis cases (86 %) were confirmed HEV by anti-HEV IgM ELISA at day 0 hospital entry. The anti-HEV-IgM and IgG were positive in all patients and did not reveal significant differences; neither between the time points day 0 and follow-up hospitalization on day 2-6 or day 7-10 nor between RNA-positive (n = 36) versus RNAnegative (n = 8) HEV groups. The HEV-Ag positivity was higher in viral RNA-positive (29/36, 81 %) than the viral RNA-negative (1/8, 12 %) group, p < 0.001 and the HEV-Ag levels positively correlated with viremia, r = 0.77, p < 0.0001. All non-HEV cases; n = 7 tested negative anti-HEV IgM and HEV-Ag and 5 of 7 (71 %) tested anti-HAV IgM positive. CONCLUSIONS The HEV-Ag ELISA is a reliable and practical diagnostic tool in this acute HEV outbreak.
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Hepatitis E virus infection in liver transplant recipients: a descriptive literature review. Eur J Gastroenterol Hepatol 2020; 32:916-922. [PMID: 32091436 DOI: 10.1097/meg.0000000000001682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hepatitis E virus infection has been recognized as a rising hepatotropic viral infection in the developing countries but overlooked in the developed countries, due to its lower prevalence. However, hepatitis E virus prevalence is on rise in the liver transplant recipients due to immunosuppression, which needs prompt recognition by healthcare practitioners. Hepatitis E virus infection is commonly believed to be transmitted via an animal host; but in the post-liver transplant patients, it can also be acquired via blood and blood products transfusion and autochthonous route. Previous studies have shown the significance of hepatitis E virus infection in post-liver transplant, as the patients at a high risk of progressing to chronic hepatitis and cirrhosis. Pediatric patients are at higher risk of hepatitis E virus infection post-liver transplant. Specific hepatitis E virus genotypes have the potential for greater severity. The clinical manifestation of hepatitis E virus can also present as extrahepatic features which need high level of suspicion for early recognition and treatment. Treatment options of hepatitis E virus range from immunosuppressive drug minimization, ribavirin therapy to novel direct-acting antiviral regimens. Herein, we aim to explore epidemiology, prevalence, risk factor, diagnosis, and management of hepatitis E virus infection giving special attention to liver transplant recipients.
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