Acute hepatitis E virus infection is a relevant cause of decompensation and acute-on-chronic liver failure in patients with liver cirrhosis

Background: Hepatitis E virus (HEV) infections typically remain asymptomatic in most immunocompetent individuals. However, patients with pre-existing liver disease face an increased risk of suffering from acute-on-chronic liver failure.

Aims: This study seeks to explore the prevalence and consequences of HEV infection in individuals with liver cirrhosis. By examining this relationship, the research aims to clarify how acute HEV infection may influence disease progression and severity in this vulnerable population.

Methods: We established a large cohort of patients with advanced liver cirrhosis, and measured anti-HEV-IgG (n=332) to explore the prevalence of past HEV infection and the susceptibility for future infections in this patient group. Next, we examined 249 sera from 184 cirrhotic patients obtained during individual episodes of acute hepatic decompensation for anti-HEV-IgM and HEV-RNA in order to analyze the relevance of acute HEV infection as triggering event. Finally, we retrospectively analyzed all consecutive patients who were hospitalized in Hannover Medical School, northern Germany, due to acute HEV infection between 2014 and 2024 to analyze the course of the infection in this vulnerable group.

Results: The prevalence of anti-HEV-IgG in patients with advanced liver cirrhosis was found to be 32.8% (109 out of 332). Among the 249 sera obtained during acute hepatic decompensation, two samples were positive for HEV-RNA, with one case remaining unrecognized during hospitalization. Furthermore, ten patients, including both HEV-RNA positive patients, tested positive for anti-HEV-IgM, suggesting recent HEV infection. This amounts to 4% (10/249) of hospitalizations due to acute hepatic decompensation being linked to recent HEV infection in our cohort. Over the past decade, 32 patients with liver cirrhosis who were hospitalized due to acute HEV infection were identified. Among these patients, 16 (50%) experienced acute-on-chronic liver failure (ACLF), resulting in five fatalities (31.3%) and three individuals (18.8%) requiring liver transplantation for survival.

Conclusions: These results delineate, that patients with advanced liver cirrhosis are at risk of acute HEV infection and acute HEV infection is a relevant cause leading to ACLF with high mortality in these patients.

 

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Publication History

Article published online:
04 September 2025