Chronic hepatitis E in heart transplant recipients

Chronic courses of infections with the hepatitis E virus (HEV) have been described in patients after liver and kidney transplantation. We here aimed to study the role of HEV infections in heart transplant recipients.

Methods: In a prospective approach, 274 heart transplant recipients were tested for serological and virological markers of HEV infection. In addition, 137 control patients undergoing cardiac surgery (bypass, cardiac valve, aneurysmata) were studied cross-sectionally. 537 healthy subjects served as controls. All patients were tested for HEV RNA (in-house-PCR) and anti-HEV-IgG (Diasorin/ Abbott ELISA). Healthy controls were only tested for IgG and subsequently for HEV RNA if anti-HEV tested positive.

Results: The HEV seroprevalence rate in healthy controls was 2% (n=11) while 11% of heart transplant recipients tested anti-HEV positive (n=31; p <0.0001, chi square test). Non-transplant patients undergoing cardiac surgery showed an anti-HEV prevalence of 7% (n=10; p=0.0002 vs. healthy controls). Four HTx patients (1.5%) were chronically infected with HEV and had biochemical (AST> 200 U/l) and histological evidence of severe liver disease. Ribavirin treatment was successful with a sustained biochemical and virological response in 3 patients while one cirrhotic patient developed resistance to ribavirin with a 3-log increase of HEV RNA levels during continued RBV treatment after an initial partial virological response.

Conclusion: Chronic hepatitis E is a rare event in heart transplant recipients in a non-endemic country. However, HEV infections occur and chronic courses are associated with progressive liver disease. Ribavirin treatment is recommended, but continued monitoring is necessary as resistance to ribavirin may develop. Future studies need to investigate possible reasons why patients undergoing cardiac surgery show higher HEV seroprevalence rates.

HEV - Hepatitis E - heart transplantation