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World J Hepatol. Jan 18, 2016; 8(2): 117-122
Published online Jan 18, 2016. doi: 10.4254/wjh.v8.i2.117
Hepatitis E virus infection in the liver transplant recipients: Clinical presentation and management
Avin Aggarwal, Ryan B Perumpail, Swetha Tummala, Aijaz Ahmed
Avin Aggarwal, Ryan B Perumpail, Swetha Tummala, Aijaz Ahmed, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, United States
Author contributions: All authors contributed to the manuscript.
Conflict-of-interest statement: We declare that we have no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Aijaz Ahmed, MD, Associate Professor, Medical Director Liver Transplant Program, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 750 Welch Road, Suite 210, Palo Alto, Stanford, CA 94304, United States. aijazahmed@stanford.edu
Telephone: +1-650-4986091 Fax: +1-650-4985692
Received: October 7, 2015
Peer-review started: October 7, 2015
First decision: November 6, 2015
Revised: December 19, 2015
Accepted: January 5, 2016
Article in press: January 7, 2016
Published online: January 18, 2016
Processing time: 100 Days and 6.5 Hours
Abstract

Hepatitis E virus (HEV) is an emerging pathogen and an increasingly recognized cause of graft hepatitis, especially in the post-orthotopic liver transplantation immunocompromised population. The exact incidence and prevalence of HEV infection in this population remains unclear but is certainly greater than historical estimates. Identifying acute HEV infection in this population is imperative for choosing the right course of management as it is very difficult to distinguish histologically from acute rejection on liver biopsy. Current suggested approach to manage acute HEV involves modifying immunosuppression, especially discontinuing calcineurin inhibitors which are the preferred immunosuppressive agents post-orthotopic liver transplantation. The addition of ribavirin monotherapy has shown promising success rates in clearing HEV infection and is used commonly in reported cases.

Keywords: Chronic hepatitis E infection; Solid organ transplant; Immunosuppression; Ribavirin; Hepatitis E virus; Orthotopic liver transplantation

Core tip: Hepatitis E virus (HEV) is an emerging pathogen in developed countries and an important cause of graft hepatitis in the post-orthotopic liver transplantation population that is often misdiagnosed either due to low index of suspicion or due to poor diagnostic assays. We recommend mandatory HEV testing in such cases, and careful treatment with modification of immunosuppression, especially switching from calcineurin inhibitors to a different class. Ribavirin has shown to be increasingly successful in treating HEV infection and preventing graft failure from acute HEV infection, if diagnosed early.