Z Gastroenterol 2019; 57(01): e38
DOI: 10.1055/s-0038-1677144
2. Clinical Hepatology, Surgery, LTX
Georg Thieme Verlag KG Stuttgart · New York

Hepatitis E is a frequent cause of severe acute liver injury – a tertiary referral center experience

S Quickert
1   Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Friedrich Schiller University, Jena, Germany
,
PA Reuken
1   Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Friedrich Schiller University, Jena, Germany
,
M Rose
2   Department of Clinical Chemistry and Laboratory Medicine, Jena University Hospital, Jena, German
,
K Boden
2   Department of Clinical Chemistry and Laboratory Medicine, Jena University Hospital, Jena, German
3   Dianovis GmbH Greiz, Germany
,
A Stallmach
1   Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Friedrich Schiller University, Jena, Germany
,
T Bruns
1   Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Friedrich Schiller University, Jena, Germany
4   The Integrated Research and Treatment Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
04 January 2019 (online)

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Background:

The four major causes of severe acute liver injury (ALI) is are hypoxic hepatitis, drug-induced liver injury (DILI), hepatobiliary obstruction, and viral hepatitis. Available systematic studies have shown that ALI with highly elevated liver transaminase levels (ALT or AST ≥500 or ≥1000 IU/L) is related to acute viral hepatitis A to D in 10 – 15% cases, while acute Hepatitis E virus (HEV) infection has been attributed in less than 1% of cases.

Aims: To investigate the frequency and characteristics of acute HEV infection among hospitalized patients with severe liver injury.

Methods:

We performed a database analysis to identify all episodes with at least one ALT or AST serum/plasma concentration ≥1000 IU/L (≥16.67µkat/L) recorded between July 2013 and June 2018 in our department. Two investigators independently performed chart reviews to identify and evaluate cases of HEV-associated ALI. Cases were classified as confirmed HEV infections, when HEV-RNA was detected in plasma using a sensitive commercial assay (Mikrogen Amplicube HEV 2.0).

Results:

Within a five-year period, a total of 247 patients experienced an episode of severe ALI. Acute HEV infection was identified as the cause in 37 (15%) of severe ALI cases. The diagnosis of HEV infection among patients with severe ALI increased during the study period from 8.4% to 19.9% (2013 – 2015: 9/106, 2016 – 2018: 28/141; P = 0.02). HEV infection was a common cause of severe ALI in patients on the general gastroenterology wards but less frequently identified in patients on ICU (22.5% vs. 4.8%; P = 0.0001). Patients with HEV-related ALI often demonstrated serological characteristics of autoimmune liver disease (78.2% ANA+, 43.5% SMA+) and histological characteristics suggestive of DILI (6/7), which may confuse diagnosis. Seventeen out of 37 patients (45.9%) received antiviral therapy. Five (13.5%) patients died from liver-related causes and one (2.7%) patient received a liver transplant within 90 days after diagnosis. Pre-existing cirrhosis was a predictor of short-term mortality.

Conclusions:

This study confirms viral hepatitis E as frequent and increasing cause of severe ALI in a German tertiary referral center. These data should increase the clinicians' awareness and support timely screening for acute HEV infection in patients presenting with severe ALI.