title: Clinical features of acute hepatitis E super-infections on chronic hepatitis B.
abstract: OBJECTIVE
  To examine the clinical features and risk factors for adverse outcomes in chronic hepatitis B (CHB) superimposed with hepatitis E virus (HEV).
  
  
  METHODS
  This retrospective cohort study included 228 patients with acute HEV infection (showing clinical acute hepatitis symptomology and positivity for anti-HEV immunoglobulin M) with underlying CHB (confirmed by positivity for hepatitis B surface antigen and/or hepatitis B virus (HBV) DNA over 6 mo) who had been admitted to the Shanghai Public Health Clinical Center, which represents the regional tertiary hospital for infectious diseases in Shanghai city, China. Data for adverse outcomes were collected, and included severe liver diseases (defined as liver failure and/or acute liver decompensation) and liver-related mortality. Logistic regression modeling was performed to determine the risk factors for adverse outcomes.
  
  
  RESULTS
  The symptoms caused by superimposed acute hepatitis E (AHE) were much more severe in cirrhotic patients (n= 94) than in non-cirrhotic patients (n= 134), as evidenced by significantly higher liver complications (77.7%vs28.4%,P< 0.001) and mortality rate (21.3%vs7.5%,P= 0.002). Most of the cirrhotic patients (n= 85, 90.4%) had no prior decompensation. Among the non-cirrhotic patients, superimposed AHE caused progressively more severe diseases that corresponded with the CHB disease stages, from immune tolerant to immune reactivation phases. Few risk factors were identified in the cirrhotic patients, but risk factors for non-cirrhotic patients were found to be intermediate HBV DNA levels (OR: 5.1,P= 0.012), alcohol consumption (OR: 6.4,P= 0.020), and underlying diabetes (OR: 7.5,P= 0.003) and kidney diseases (OR: 12.7,P= 0.005). Only 28.7% of the cirrhotic patients and 9.0% of the non-cirrhotic patients had received anti-HBV therapy previously and, in all cases, the efficacy had been suboptimal.
  
  
  CONCLUSIONS
  CHB-related cirrhosis and intermediate HBV DNA level were associated with severe disease in superinfected patients, and successful antiviral treatment might counter this outcome.
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Chong
authors.initials: C
authors.lastname: Chen
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Shu-Ye
authors.initials: SY
authors.lastname: Zhang
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Dan-Dan
authors.initials: DD
authors.lastname: Zhang
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Xin-Yan
authors.initials: XY
authors.lastname: Li
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Yu-Ling
authors.initials: YL
authors.lastname: Zhang
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Wei-Xia
authors.initials: WX
authors.lastname: Li
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Jing-Jing
authors.initials: JJ
authors.lastname: Yan
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Min
authors.initials: M
authors.lastname: Wang
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Jing-Na
authors.initials: JN
authors.lastname: Xun
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Chuan
authors.initials: C
authors.lastname: Lu
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Yun
authors.initials: Y
authors.lastname: Ling
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Yu-Xian
authors.initials: YX
authors.lastname: Huang
authors.affiliation: Chong Chen, Liang Chen, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China.
authors.forename: Liang
authors.initials: L
authors.lastname: Chen
mesh_terms: D000208:Acute Disease; D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use; D016009:Chi-Square Distribution; D002681:China; D060085:Coinfection; D004279:DNA, Viral / Q000097:blood; D005260:Female; D006514:Hepatitis B Surface Antigens / Q000097:blood; D006513:Hepatitis B e Antigens / Q000097:blood; D006515:Hepatitis B virus / Q000235:genetics / Q000276:immunology / Q000472:pathogenicity*; D019694:Hepatitis B, Chronic / Q000097:blood / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D016751:Hepatitis E / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D016752:Hepatitis E virus / Q000472:pathogenicity*; D006801:Humans; D008103:Liver Cirrhosis / Q000175:diagnosis / Q000821:virology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D012307:Risk Factors; D015163:Superinfection / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D062606:Tertiary Care Centers; D016896:Treatment Outcome
chemical_list: D000998:Antiviral Agents; D004279:DNA, Viral; D006514:Hepatitis B Surface Antigens; D006513:Hepatitis B e Antigens
keywords: Cirrhosis; Co-infections; Liver decompensation; Liver failure; Stages of hepatitis B virus infection