Course and treatment of chronic hepatitis E virus infection in lung transplant recipients

OBJECTIVE: Persistent hepatitis E virus (HEV) infections have been described in various transplant cohorts. However, the frequency and the course of HEV infection in lung transplant recipients (Lu-Tr) are not well defined.

METHODS: We retrospectively analyzed serum from 95 Lu-Tr for HEV RNA and anti-HEV immunoglobulin-G (IgG) (with the MP assay). Anti-HEV seroprevalence was compared to that of 537 healthy individuals. Prospective HEV screening was subsequently initiated in Lu-Tr.

RESULTS: Elevated liver enzymes were observed in 44/95 (46.3%) patients. Anti-HEV IgG was present in 5/95 patients (5.3%), revealing a slightly higher prevalence compared to controls (2%, 11/537; P = 0.07). Chronic HEV infection with detectable viral replication was confirmed by polymerase chain reaction in 3 (3.2%) patients, all of whom demonstrated clinical and biochemical features of active liver disease (maximum alanine aminotransferase [ALTmax ] 89, 215, and 270 IU/L, respectively). One patient had died from multi-organ failure in combination with liver cirrhosis before HEV diagnosis. Two additional patients with chronic hepatitis E were identified during prospective screening (ALTmax 359 and 318 IU/L). All patients still alive commenced ribavirin therapy for 5 months, with dose adjustment (400-600 mg/day) according to renal function and hemoglobin level. Sustained resolution of HEV infection occurred in 2 patients. One patient is still under treatment, and the fourth died from graft failure considered unrelated to ribavirin therapy.

CONCLUSION: Chronic hepatitis E should be considered in the differential diagnosis of elevated liver enzymes, which are commonly seen in Lu-Tr. We observed 1 case of end-stage liver cirrhosis and death in an HEV-infected subject, who was not treated with ribavirin. Given this potentially devastating consequence, ribavirin therapy of persistent HEV infection appears to be acceptably safe and effective in Lu-Tr. However, larger prospective studies are warranted.