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Gu T, Zheng CY, Deng YQ, Yang XF, Bao WM, Tang YM. Systematic Evaluation of Guidelines for the Diagnosis and Treatment of Hepatitis E Virus Infection. J Clin Transl Hepatol 2024; 12:739-749. [PMID: 39130619 PMCID: PMC11310757 DOI: 10.14218/jcth.2023.00508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 08/13/2024] Open
Abstract
Background and Aims The hepatitis E virus (HEV) is a zoonotic disease, and infection with HEV in humans primarily causes acute infections and can progress to chronic manifestation in immunocompromised individuals. Over the past decade, guidelines for diagnosing and treating HEV infection have been developed. This study aimed to systematically assess the quality of current guidelines for diagnosing and treating HEV infection, and we analyzed the differences in guideline quality and primary recommendations and explored possible reasons for these differences. Methods Guidelines published between 2013 and 2022 were searched, and studies were identified using selection criteria. The study assessed the quality of the included guidelines using the Appraisal of Guidelines for Research and Evaluation tool, extracted the primary recommendations in the guidelines, determined the highest level of evidence supporting the recommendations, and reclassified the evidence using the Oxford Centre for Evidence-Based Medicine grading system. Results Seven guidelines were included in the final analysis. The quality of the guidelines varied widely. The discrepancies may have been caused by the lack of external experts, the failure to consider influencing factors in guideline application, and the lack of consideration of the public's opinion. Analysis of the heterogeneity in primary recommendations revealed differences in algorithms for managing chronic HEV infection, the dosage of ribavirin, and a low level of evidence supporting the primary recommendations. Conclusions Guideline quality and primary recommendations vary considerably. Refinement by guideline developers and researchers would facilitate updating and applying guidelines for diagnosing and treating HEV infection.
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Affiliation(s)
- Ting Gu
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, Yunnan, China
| | - Cai-Ying Zheng
- Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yan-Qin Deng
- Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiao-Feng Yang
- Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Wei-Min Bao
- Department of Colorectal Surgery, The First People’s Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Ying-Mei Tang
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, Yunnan, China
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Sintusek P, Khunsri S, Chansaenroj J, Thongmee T, Poovorawan Y. Prevalence and the impact of hepatitis E infection in pediatric liver transplanted recipients with hepatitis in Thailand. Pediatr Transplant 2024; 28:e14642. [PMID: 37947005 DOI: 10.1111/petr.14642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/13/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The hepatitis E virus (HEV) infection typically causes acute and self-limiting hepatitis. However, chronic infection can occur in immunocompromised hosts. This study determined the prevalence and impact of HEV infection in liver transplanted (LT) children who had transaminitis. METHODS The demographic data, anti-HEV IgM/IgG, serum/stool HEV RNA, and management for LT children with acute or persistent transaminitis from 2003 to 2020 were retrospectively reviewed. HEV serology was tested by ELISA, and HEV RNA was detected by semi-nested PCR. RESULTS Seventy-two children with LT with persistent transaminitis with a median age of 4.41 (1.32, 9.14) years (55.6% female) and one with acute hepatitis were investigated for HEV infection. Anti-HEV IgM, anti-HEV IgG, serum, or stool HEV RNA was investigated in 95.8% (N = 69), 93.1% (N = 67), 43.1% (N = 31), and 37.5% (N = 27) of patients, respectively. The prevalence of HEV infection was 37.5% (N = 27). There was no significant difference in characteristics between the HEV-infected and HEV-non-infected patients. Moreover, 22.2% (N = 16) and 15.3% (N = 11) of patients had past HEV infection and HEV-related acute or chronic infection, respectively. Most of the patients had primary treatment as the presumed graft rejection without improvement. In two patients, detectable HEV RNA in serum turned undetectable in approximately 2 weeks and 2 months, and liver enzyme levels normalized after reducing immunosuppressive therapy. CONCLUSIONS The prevalence of HEV infection among pediatric LT recipients with hepatitis was high. Chronic HEV infection was evidenced in two patients. Investigations of HEV infection in pediatric LT recipients with persistent transaminitis should guide proper management.
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Affiliation(s)
- Palittiya Sintusek
- Thai Pediatric Gastroenterology, Hepatology and Immunology (TPGHAI) Research Unit, Department of Pediatrics, Division of Gastroenterology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Chulalongkorn University, Bangkok, Thailand
| | - Siriporn Khunsri
- Thai Pediatric Gastroenterology, Hepatology and Immunology (TPGHAI) Research Unit, Department of Pediatrics, Division of Gastroenterology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Chulalongkorn University, Bangkok, Thailand
| | - Jira Chansaenroj
- Center of Excellence in Clinical Virology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Thanunrat Thongmee
- Center of Excellence in Clinical Virology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Yong Poovorawan
- Center of Excellence in Clinical Virology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
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Hui W, Wei L. Treatment of Hepatitis E. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1417:215-226. [PMID: 37223869 DOI: 10.1007/978-981-99-1304-6_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Hepatitis E virus (HEV) infections are the most common cause of acute hepatitis, but they can also take a chronic course. There is no specific therapy for acute hepatitis, and current treatment is supportive. Choosing ribavirin as the first-line therapy for chronic HEV is advisable, especially immunosuppressed individuals. Moreover, ribavirin therapy in the acute phase of infection provides major benefits for those at high risk of acute liver failure (ALF)/acute-on-chronic liver failure (ACLF). Pegylated interferon α has been used successfully for treatment of hepatitis E but is associated with major side effects. Cholestasis is one of the most common, but devastating, manifestations in hepatitis E. Current therapy for HEV aims to treat symptoms. Therapy generally involves several measures, such as vitamins, albumin, and plasma for supporting treatment, symptomatic treatment for cutaneous pruritus, ursodeoxycholic acid, Obeticholic acid, S-adenosylmethionine, etc. for removing jaundice. HEV infection during pregnancy and patients with underlying liver disease may develop liver failure. For these patients, active monitoring, standard care, and supportive treatment are the foundations. Ribavirin has successfully been used to prevent liver transplantation (LT). Prevention and treatment of complications are important for treatment of liver failure. Liver support devices are intended to support liver function until such time as native liver function recovers, or until LT. LT is widely considered as irreplaceable and definitive treatment for liver failure, particularly for patients who do not improve with supportive measures to sustain life.
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Affiliation(s)
- Wei Hui
- Chronic Disease Management Center, Youan Hospital, Capital Medical University, Beijing, China
| | - Linlin Wei
- The Second Department of Liver Disease Center, Youan Hospital, Capital Medical University, Beijing, China.
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Ma Z, de Man RA, Kamar N, Pan Q. Chronic hepatitis E: Advancing research and patient care. J Hepatol 2022; 77:1109-1123. [PMID: 35605741 DOI: 10.1016/j.jhep.2022.05.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 12/15/2022]
Abstract
The hepatitis E virus (HEV) was initially thought to exclusively cause acute hepatitis. However, the first diagnosis of chronic hepatitis E in transplant recipients in 2008 profoundly changed our understanding of this pathogen. We have now begun to understand that specific HEV genotypes can cause chronic infection in certain immunocompromised populations. Over the past decade, dedicated clinical and experimental research has substantiated knowledge on the epidemiology, transmission routes, pathophysiological mechanisms, diagnosis, clinical features and treatment of chronic HEV infection. Nevertheless, many gaps and major challenges remain, particularly regarding the translation of knowledge into disease prevention and improvement of clinical outcomes. This article aims to highlight the latest developments in the understanding and management of chronic hepatitis E. More importantly, we attempt to identify major knowledge gaps and discuss strategies for further advancing both research and patient care.
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Affiliation(s)
- Zhongren Ma
- Biomedical Research Center, Northwest Minzu University, Lanzhou, China
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Nassim Kamar
- Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Disease (Infinity), University Paul Sabatier, Toulouse, France
| | - Qiuwei Pan
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands.
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Gorris M, van der Lecq BM, van Erpecum KJ, de Bruijne J. Treatment for chronic hepatitis E virus infection: A systematic review and meta-analysis. J Viral Hepat 2021; 28:454-463. [PMID: 33301609 PMCID: PMC7898834 DOI: 10.1111/jvh.13456] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/09/2020] [Accepted: 11/23/2020] [Indexed: 12/19/2022]
Abstract
Hepatitis E virus infection can cause chronic hepatitis in immunocompromised patients with significant chance of progressive fibrosis and possibly cirrhosis. The aim of this systematic review was to summarize the efficacy and safety of the various treatment options for chronic hepatitis E. We performed a systematic literature search. The primary outcome measure was a sustained virological response (SVR). Secondary end points were rapid virological response (RVR), relapse rates, side effects and adverse events. Forty-four articles were included with a total of 582 patients. Reduction of immunosuppressive medication induced viral clearance in 55/174 (32%) of the patients. Meta-analysis of 395 patients showed a pooled SVR rate of 78% (95-CI 72%-84%) after ribavirin treatment. Twenty-five per cent of the patients obtained a RVR, whereas a relapse occurred in 18% of the patients. Anaemia during treatment led to dose reduction, use of erythropoietin and/or blood transfusion in 37% of the patients. A second treatment attempt with ribavirin led to a SVR in 39/51 (76%) of the patients. Pegylated interferon-alpha was administered to 13 patients and SVR was obtained in 85%. Two patients (15%) suffered from acute transplant rejection during treatment with interferon. In conclusion, reduction of immunosuppressive medication and treatment with ribavirin is safe, generally well tolerated and induced viral clearance in 32% and 78% of patients, respectively. Therefore, ribavirin should be considered as first treatment step for chronic hepatitis E. Treatment with pegylated interferon-alpha increases the risk of transplant rejection and should therefore be administered with great caution.
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Affiliation(s)
- Myrte Gorris
- Department of Gastroenterology & HepatologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Bernice M. van der Lecq
- Department of Gastroenterology & HepatologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Karel J. van Erpecum
- Department of Gastroenterology & HepatologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Joep de Bruijne
- Department of Gastroenterology & HepatologyUniversity Medical Center UtrechtUtrechtThe Netherlands
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Hoffmann P, Behnisch R, Gsenger J, Schnitzler P, Gauss A. Hepatitis E seroprevalence in a German cohort of patients with inflammatory bowel diseases. PLoS One 2020; 15:e0239825. [PMID: 33027305 PMCID: PMC7540852 DOI: 10.1371/journal.pone.0239825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIMS The incidence of hepatitis E virus (HEV)-infections in industrialized nations has been increasing over the past years. Patients suffering from inflammatory bowel diseases (IBD) may be more prone to transmission. Data on HEV seroprevalence in IBD patients is scarce and has not been reported in German IBD patients. The German Health Examination Survey for Adults 2008-2011, which included 4.422 samples, found a HEV seroprevalence of 16.8%, increasing with age. The aim of the present study was to determine the seroprevalence of anti-HEV IgG in a German cohort of IBD patients, and to explore which parameters have an impact on HEV seroprevalence. MATERIAL AND METHODS This is an uncontrolled, cross-sectional, retrospective monocentric study. Among the patients visiting the IBD outpatient clinic between 25 January, 2019 and 24 September, 2019, 328 patients with Crohn's disease (CD) and 150 patients with ulcerative colitis (UC) were included in the study. IgG antibodies against HEV were determined by enzyme-linked immunosorbent assay. Positive antibody titers were verified using immunoblot analysis. Medical records were reviewed for demographic and clinical parameters to identify potential risk factors for HEV infection. RESULTS The prevalence of anti-HEV IgG antibodies was 17.4% in CD patients and 24.7% in UC patients. No patient with positive HEV PCR was detected. Greater age of CD und UC patients and longer duration of anti-interleukin 12/23 treatment in CD patients were associated with higher anti-HEV IgG antibody rates. CONCLUSIONS In summary, we conclude that patients with UC have a higher anti-HEV IgG antibody prevalence than the general population in Germany, and that immunosuppressive therapy may carry no higher risk for HEV infection.
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Affiliation(s)
- Peter Hoffmann
- Department of Gastroenterology and Hepatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Rouven Behnisch
- Department of Medical Biometry, Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Julia Gsenger
- Center for Infectious Diseases, Virology, Heidelberg University Hospital, Heidelberg, Germany
| | - Paul Schnitzler
- Center for Infectious Diseases, Virology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annika Gauss
- Department of Gastroenterology and Hepatology, Heidelberg University Hospital, Heidelberg, Germany
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Thakur V, Ratho RK, Kumar S, Saxena SK, Bora I, Thakur P. Viral Hepatitis E and Chronicity: A Growing Public Health Concern. Front Microbiol 2020; 11:577339. [PMID: 33133046 PMCID: PMC7550462 DOI: 10.3389/fmicb.2020.577339] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/03/2020] [Indexed: 12/15/2022] Open
Abstract
Hepatitis E viral infection recently emerges as a global health concern. Over the last decade, the understanding of hepatitis E virus (HEV) had changed with the discovery of new genotypes like genotype-7 and genotype-8 with associated host and mode of infection. Diversification in the mode of hepatitis E infection transmission through blood transfusion, and organ transplants in contrast to classical feco-oral and zoonotic mode is the recent medical concern. The wide spectrum of infection ranging from self-limiting to acute liver failure is now overpowered by HEV genotype-specific chronic infection especially in transplant patients. This concern is further escalated by the extra-hepatic manifestations of HEV targeting the central nervous system (CNS), kidney, heart, and pancreas. However, with the development of advanced efficient cell culture systems and animal models simulating the infection, much clarity toward understanding the pathogenetic mechanism of HEV has been developed. Also this facilitates the development of vaccines research or therapeutics. In this review, we highlight all the novel findings in every aspect of HEV with special emphasis on recently emerging chronic mode of infection with specific diagnosis and treatment regime with an optimistic hope to help virologists and/or liver specialists working in the field of viral hepatitis.
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Affiliation(s)
- Vikram Thakur
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha Kanta Ratho
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Swatantra Kumar
- Centre for Advanced Research, Faculty of Medicine, King George's Medical University, Lucknow, India
| | - Shailendra K Saxena
- Centre for Advanced Research, Faculty of Medicine, King George's Medical University, Lucknow, India
| | - Ishani Bora
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pryanka Thakur
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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8
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Höcker B, Schneble L, Murer L, Carraro A, Pape L, Kranz B, Oh J, Zirngibl M, Dello Strologo L, Büscher A, Weber LT, Awan A, Pohl M, Bald M, Printza N, Rusai K, Peruzzi L, Topaloglu R, Fichtner A, Krupka K, Köster L, Bruckner T, Schnitzler P, Hirsch HH, Tönshoff B. Epidemiology of and Risk Factors for BK Polyomavirus Replication and Nephropathy in Pediatric Renal Transplant Recipients: An International CERTAIN Registry Study. Transplantation 2020; 103:1224-1233. [PMID: 30130322 DOI: 10.1097/tp.0000000000002414] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND BK polyomavirus-associated nephropathy (BKPyVAN) constitutes a serious cause of kidney allograft failure, but large-scale data in pediatric renal transplant recipients and a comprehensive analysis of specific risk factors are lacking. METHODS We analyzed the data of 313 patients in the Cooperative European Pediatric Renal Transplant Initiative Registry, with an observation period of 3.3 years (range, 1-5). The net state of immunosuppressive therapy was assessed by the modified Vasudev score. RESULTS Presumptive BKPyVAN (defined as sustained [>3 wk] high-level BK viremia >10 copies/mL) within 5 years posttransplant occurred in 49 (15.8%) of 311 patients, and biopsy-proven BKPyVAN in 14 (4.5%) of 313. BKPyV viremia was observed in 115 (36.7%) of 311 patients, of whom 11 (9.6%) of 115 developed viremia late, that is, after the second year posttransplant. In 6 (12.5%) of 48 patients with high-level viremia and in 3 (21.4%) of 14 with BKPyVAN, this respective event occurred late. According to multivariable analysis, BKPyV viremia and/or BKPyVAN were associated not only with a higher net state of immunosuppression (odds ratio [OR], 1.3; P < 0.01) and with tacrolimus-based versus ciclosporin-based immunosuppression (OR, 3.6; P < 0.01) but also with younger recipient age (OR, 1.1 per y younger; P < 0.001) and obstructive uropathy (OR, 12.4; P < 0.01) as primary renal disease. CONCLUSIONS Uncontrolled BKPyV replication affects a significant proportion of pediatric renal transplant recipients and is associated with unique features of epidemiology and risk factors, such as young recipient age, obstructive uropathy, and overall intensity of immunosuppressive therapy. BKPyV surveillance should be considered beyond 2 years posttransplant in pediatric patients at higher risk.
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Affiliation(s)
- Britta Höcker
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Lukas Schneble
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
| | - Andrea Carraro
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
| | - Lars Pape
- Hanover Medical School, Hanover, Germany
| | - Birgitta Kranz
- Department of General Pediatrics, University Children's Hospital Münster, Münster, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, University Children's Hospital, Hamburg, Germany
| | | | - Luca Dello Strologo
- Pediatric Nephrology and Renal Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Anja Büscher
- Pediatric Nephrology, Pediatrics II, University Children's Hospital Essen, Essen, Germany
| | - Lutz T Weber
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Atif Awan
- Temple Street Children's University Hospital, Dublin, Ireland
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Bald
- Olga Children's Hospital, Clinic of Stuttgart, Stuttgart, Germany
| | - Nikoleta Printza
- 1st Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Krisztina Rusai
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Rezan Topaloglu
- Hacettepe University Faculty of Medicine, Department of Pediatric Nephrology, Ankara, Turkey
| | - Alexander Fichtner
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Kai Krupka
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Lennart Köster
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany.,Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
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Ankcorn MJ, Tedder RS, Cairns J, Sandmann FG. Cost-Effectiveness Analysis of Screening for Persistent Hepatitis E Virus Infection in Solid Organ Transplant Patients in the United Kingdom: A Model-Based Economic Evaluation. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:309-318. [PMID: 32197726 DOI: 10.1016/j.jval.2019.09.2751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 08/08/2019] [Accepted: 09/27/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Despite potentially severe and fatal outcomes, recent studies of solid organ transplant (SOT) recipients in Europe suggest that hepatitis E virus (HEV) infection is underdiagnosed, with a prevalence of active infection of up to 4.4%. OBJECTIVES To determine the cost-effectiveness of introducing routine screening for HEV infection in SOT recipients in the UK. METHODS A Markov cohort model was developed to evaluate the cost-utility of 4 HEV screening options over the lifetime of 1000 SOT recipients. The current baseline of nonsystematic testing was compared with annual screening of all patients by polymerase chain reaction (PCR; strategy A) or HEV-antigen (HEV-Ag) detection (strategy B) and selective screening of patients who have a raised alanine aminotransferase (ALT) value by PCR (strategy C) or HEV-Ag (strategy D). The primary outcome was the incremental cost per quality-adjusted life-year (QALY). We adopted the National Health Service (NHS) perspective and discounted future costs and benefits at 3.5%. RESULTS At a willingness-to-pay of £20 000/QALY gained, systematic screening of SOT patients by any method (strategy A-D) had a high probability (77.9%) of being cost-effective. Among screening strategies, strategy D is optimal and expected to be cost-saving to the NHS; if only PCR testing strategies are considered, then strategy C becomes cost-effective (£660/QALY). These findings were robust against a wide range of sensitivity and scenario analyses. CONCLUSIONS Our model showed that routine screening for HEV in SOT patients is very likely to be cost-effective in the UK, particularly in patients presenting with an abnormal alanine aminotransferase.
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Affiliation(s)
- Michael J Ankcorn
- Blood Borne Virus Unit, Virus Reference Department, National Infection Service, Public Health England, Colindale, London, England, UK; Transfusion Microbiology, National Health Service Blood and Transplant, London, England, UK.
| | - Richard S Tedder
- Blood Borne Virus Unit, Virus Reference Department, National Infection Service, Public Health England, Colindale, London, England, UK; Transfusion Microbiology, National Health Service Blood and Transplant, London, England, UK; Department of Medicine, Imperial College London, London, England, UK
| | - John Cairns
- London School of Hygiene and Tropical Medicine, London, England, UK
| | - Frank G Sandmann
- London School of Hygiene and Tropical Medicine, London, England, UK; Statistics, Modelling and Economics Department, National Infection Service, Public Health England, Colindale, London, England, UK
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10
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Rivero-Juarez A, Vallejo N, Lopez-Lopez P, Díaz-Mareque AI, Frias M, Vallejo A, Caballero-Gómez J, Rodríguez-Velasco M, Molina E, Aguilera A. Ribavirin as a First Treatment Approach for Hepatitis E Virus Infection in Transplant Recipient Patients. Microorganisms 2019; 8:E51. [PMID: 31888090 PMCID: PMC7022260 DOI: 10.3390/microorganisms8010051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/23/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
The hepatitis E virus (HEV) is the major cause of acute hepatitis of viral origin worldwide. Despite its usual course as an asymptomatic self-limited hepatitis, there are highly susceptible populations, such as those with underlying immunosuppression, which could develop chronic hepatitis. In this situation, implementation of therapy is mandatory in the sense to facilitate viral clearance. Currently, there are no specific drugs approved for HEV infection, but ribavirin (RBV), the drug of choice, is used for off-label treatment. Here, we present two cases of chronic HEV infection in transplant patients, reviewing and discussing the therapeutic approach available in the literature. The use of RBV for the treatment of an HEV infection in organ transplant patients seems to be effective. The recommendation of 12 weeks of therapy is adequate in terms of efficacy. Nevertheless, there are important issues that urgently need to be assessed, such as optimal duration of therapy and drug dosage.
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Affiliation(s)
- Antonio Rivero-Juarez
- Infectious Diseases Unit, Clinical Virology and Zoonoses research group, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, 14006 Cordoba, Spain; (P.L.-L.); (M.F.); (J.C.-G.)
| | - Nicolau Vallejo
- Digestive Unit, Complexo Hospitalario Universitario de Santiago, 15705 Santiago de Compostela, Spain; (N.V.); (E.M.)
| | - Pedro Lopez-Lopez
- Infectious Diseases Unit, Clinical Virology and Zoonoses research group, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, 14006 Cordoba, Spain; (P.L.-L.); (M.F.); (J.C.-G.)
| | - Ana Isabel Díaz-Mareque
- Nephrology Unit, Complexo Hospitalario Universitario de Santiago, 15705 Santiago de Compostela, Spain;
| | - Mario Frias
- Infectious Diseases Unit, Clinical Virology and Zoonoses research group, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, 14006 Cordoba, Spain; (P.L.-L.); (M.F.); (J.C.-G.)
| | - Aldara Vallejo
- Microbiology Unit, Complexo Hospitalario Universitario de Santiago, University of Santiago de Compostela, 15705 Santiago de Compostela, Spain; (A.V.); (M.R.-V.); (A.A.)
| | - Javier Caballero-Gómez
- Infectious Diseases Unit, Clinical Virology and Zoonoses research group, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, 14006 Cordoba, Spain; (P.L.-L.); (M.F.); (J.C.-G.)
- Animal Health Department, University of Cordoba-Agrifood Excellence International Campus (ceiA3), 15705 Cordoba, Spain
| | - María Rodríguez-Velasco
- Microbiology Unit, Complexo Hospitalario Universitario de Santiago, University of Santiago de Compostela, 15705 Santiago de Compostela, Spain; (A.V.); (M.R.-V.); (A.A.)
| | - Esther Molina
- Digestive Unit, Complexo Hospitalario Universitario de Santiago, 15705 Santiago de Compostela, Spain; (N.V.); (E.M.)
| | - Antonio Aguilera
- Microbiology Unit, Complexo Hospitalario Universitario de Santiago, University of Santiago de Compostela, 15705 Santiago de Compostela, Spain; (A.V.); (M.R.-V.); (A.A.)
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Abstract
PURPOSE OF REVIEW Infections represent a significant source of morbidity and mortality after kidney transplantation in children. We review recent advances in epidemiology, assessment, prevention and treatment for several different infections. RECENT FINDINGS Infections, such as bacterial urinary tract infection or opportunistic viral infection remain common, may be increasing and represent a large proportion of hospitalization. Extended antiviral agent use reduces the incidence of cytomegalovirus disease but its efficacy to reduce Epstein-Barr virus disease remains controversial. Human herpesvirus-6 and hepatitis E virus represent new infections to keep in mind. Ureteral stenting increases the rate of early UTI. Several new vaccines are now available, but rates of complete vaccination pretransplant are low. SUMMARY Infections remain a critical posttransplant issue associated with significant medical burdens. Emerging data on associated risk factors, assessment of and treatment for infections provide clinicians with new knowledge.
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12
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Höcker B, Tabatabai J, Schneble L, Oh J, Thiel F, Pape L, Rusai K, Topaloglu R, Kranz B, Klaus G, Printza N, Yavascan O, Fichtner A, Krupka K, Bruckner T, Waldherr R, Pawlita M, Schnitzler P, Hirsch HH, Tönshoff B. JC polyomavirus replication and associated disease in pediatric renal transplantation: an international CERTAIN Registry study. Pediatr Nephrol 2018; 33:2343-2352. [PMID: 30058047 DOI: 10.1007/s00467-018-4029-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/16/2018] [Accepted: 07/19/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND JC polyomavirus (JCPyV)-associated nephropathy (JCPyVAN) is a severe, but rare complication in adult renal transplant (RTx) recipients. Related data in pediatric patients are scarce. METHODS Based on the CERTAIN Registry, we therefore performed a multi-center, retrospective study on the JCPyV antibody status, prevalence of JCPyV replication, and its associated disease in 139 pediatric RTx recipients (mean age, 8.5 ± 5.3 years). JCPyV DNA in plasma and/or urine was measured by quantitative PCR at a median time of 3.2 (IQR, 0.3-8.1) years post-transplant. RESULTS 53.2% of patients were JCPyV-seronegative prior to transplantation; younger age was associated with JCPyV seronegativity. 34/139 (24.5%) patients post-transplant showed active JCPyV replication in either urine (22.0%), plasma (13.4%), or both (7.6%). JCPyV viremia occurred significantly (p < 0.001) more often in patients with viruria (34.6%) than in those without (7.6%), but 7/118 (5.9%) had isolated viremia. High-level viruria (> 107 copies/mL) was found in 29.6% of viruric patients. A higher net state of immunosuppression constituted an independent risk factor for JCPyV replication both in urine and plasma (OR 1.2, p < 0.02). Male patients tended to have a higher risk of JCPyV viremia than females (OR 4.3, p = 0.057). There was one male patient (0.7%) with JCPyVAN 7 years post-transplant, which resolved after reduction of immunosuppressive therapy. No patient exhibited progressive multifocal leukoencephalopathy. CONCLUSIONS This first multi-center study on JCPyV in pediatric renal transplant recipients shows that JCPyV replication is common (24.5%), with strong immunosuppression being a significant risk factor, but associated nephropathy is rare.
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Affiliation(s)
- Britta Höcker
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Julia Tabatabai
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
- German Center for Infection Research, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Lukas Schneble
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, University Children's Hospital, Martinistr. 52, 20246, Hamburg, Germany
| | - Florian Thiel
- Department of Pediatric Nephrology, University Children's Hospital, Martinistr. 52, 20246, Hamburg, Germany
| | - Lars Pape
- Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany
| | - Krisztina Rusai
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Rezan Topaloglu
- Faculty of Medicine, Department of Pediatric Nephrology, Hacettepe University, Ankara, Turkey
| | - Birgitta Kranz
- Department of General Pediatrics, University Children's Hospital Münster, Waldeyerstraße 22, 48149, Münster, Germany
| | - Günter Klaus
- Department of Pediatric Nephrology, University Children's Hospital Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Nikoleta Printza
- 1st Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Onder Yavascan
- Department of Pediatric Nephrology, Tepecik Teaching and Research Hospital, 1140/1 Sk No: 1, 35180 Yenisehir, İzmir, Turkey
| | - Alexander Fichtner
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Kai Krupka
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Rüdiger Waldherr
- Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Michael Pawlita
- Division of Molecular Diagnostics of Oncogenic Infections, German Cancer Research Center, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine, University of Basel, Petersplatz 10, 4009, Basel, Switzerland
- Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
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