title: Clinical implications of chronic hepatitis E virus infection in heart transplant recipients.
abstract: BACKGROUND
  Recent reports have shown that hepatitis E virus (HEV) infection can become chronic in solid-organ transplant recipients, but few studies have systematically investigated the clinical consequences of this chronic HEV infection in solid-organ transplant (SOT) recipients.
  
  
  METHODS
  We have undertaken an in-depth study of 6 chronic HEV-infected heart transplant recipients to gain further insight into the clinical, biochemical and virologic presentation of this disorder.
  
  
  RESULTS
  In 6 patients (2.3%) chronic HEV infection, genotype 3, was identified. Immunosuppression in these patients was tacrolimus-based, combined with either everolimus or prednisolone and/or mycophenolate mofetil. Median follow-up after case detection was 26 months (range 21 to 40 months). All chronic HEV cases had elevated liver enzyme values. IgM antibodies at presentation were positive in 2 of 6 (33%) patients. Liver histology in 4 of 6 (67%) patients showed advanced fibrosis within 2 years after infection. One patient spontaneously cleared the HEV infection: 1 after dose reduction of immunosuppressive therapy and 3 during ribavirin therapy. One patient has yet to clear the virus and remains on ribavirin therapy.
  
  
  CONCLUSIONS
  Chronic HEV infection in heart transplant (HTx) recipients may lead to rapid fibrosis of the liver. We advise additional HEV RNA screening in solid-organ transplant recipients with elevated liver enzymes, because antibody production is often delayed, as demonstrated in these patients. Dose reduction of immunosuppressive therapy should be the first intervention strategy to achieve viral clearance in chronic HEV-infected immunocompromised patients. Ribavirin treatment should be considered in cases of chronic HEV.
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Ludi
authors.initials: L
authors.lastname: Koning
authors.forename: Suzan D
authors.initials: SD
authors.lastname: Pas
authors.forename: Robert A
authors.initials: RA
authors.lastname: de Man
authors.forename: Aggie H M M
authors.initials: AH
authors.lastname: Balk
authors.forename: Robert J
authors.initials: RJ
authors.lastname: de Knegt
authors.forename: Fiebo J
authors.initials: FJ
authors.lastname: ten Kate
authors.forename: Albert D M E
authors.initials: AD
authors.lastname: Osterhaus
authors.forename: Annemiek A
authors.initials: AA
authors.lastname: van der Eijk
mesh_terms: D000328:Adult; D002908:Chronic Disease; D005260:Female; D016027:Heart Transplantation; D016751:Hepatitis E / Q000175:diagnosis* / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis* / Q000628:therapy