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Brüggemann Y, Klöhn M, Wedemeyer H, Steinmann E. Hepatitis E virus: from innate sensing to adaptive immune responses. Nat Rev Gastroenterol Hepatol 2024; 21:710-725. [PMID: 39039260 DOI: 10.1038/s41575-024-00950-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/24/2024]
Abstract
Hepatitis E virus (HEV) infections are a major cause of acute viral hepatitis in humans worldwide. In immunocompetent individuals, the majority of HEV infections remain asymptomatic and lead to spontaneous clearance of the virus, and only a minority of individuals with infection (5-16%) experience symptoms of acute viral hepatitis. However, HEV infections can cause up to 30% mortality in pregnant women, become chronic in immunocompromised patients and cause extrahepatic manifestations. A growing body of evidence suggests that the host immune response to infection with different HEV genotypes is a critical determinant of distinct HEV infection outcomes. In this Review, we summarize key components of the innate and adaptive immune responses to HEV, including the underlying immunological mechanisms of HEV associated with acute and chronic liver failure and interactions between T cell and B cell responses. In addition, we discuss the current status of vaccines against HEV and raise outstanding questions regarding the immune responses induced by HEV and treatment of the disease, highlighting areas for future investigation.
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Affiliation(s)
- Yannick Brüggemann
- Department of Molecular and Medical Virology, Ruhr University Bochum, Bochum, Germany
| | - Mara Klöhn
- Department of Molecular and Medical Virology, Ruhr University Bochum, Bochum, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Partner Sites Hannover-Braunschweig, Hannover, Germany
- Cluster of Excellence RESIST (EXC 2155), Hannover Medical School, Hannover, Germany
| | - Eike Steinmann
- Department of Molecular and Medical Virology, Ruhr University Bochum, Bochum, Germany.
- German Center for Infection Research (DZIF), External Partner Site, Bochum, Germany.
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2
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Biswas S, Shalimar. Liver Transplantation for Acute Liver Failure- Indication, Prioritization, Timing, and Referral. J Clin Exp Hepatol 2023; 13:820-834. [PMID: 37693253 PMCID: PMC10483009 DOI: 10.1016/j.jceh.2023.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/17/2023] [Indexed: 09/12/2023] Open
Abstract
Acute liver failure (ALF) is a major success story in gastroenterology, with improvements in critical care and liver transplant resulting in significant improvements in patient outcomes in the current era compared to the dismal survival rates in the pretransplant era. However, the ever-increasing list of transplant candidates and limited organ pool makes judicious patient selection and organ use mandatory to achieve good patient outcomes and prevent organ wastage. Several scoring systems exist to facilitate the identification of patients who need a liver transplant and would therefore need an early referral to a specialized liver unit. The timing of the liver transplant is also crucial as transplanting a patient too early would lead to those who would recover spontaneously receiving an organ (wastage), and a late decision might result in the patient becoming unfit for transplant (delisted) or have an advanced disease which would result in poor post-transplant outcomes. The current article reviews the indications and contraindications of liver transplant in ALF patients, the various prognostic scoring systems, etiology-specific outcomes, prioritization and timing of referral.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences New Delhi, India
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3
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Shingina A, Mukhtar N, Wakim-Fleming J, Alqahtani S, Wong RJ, Limketkai BN, Larson AM, Grant L. Acute Liver Failure Guidelines. Am J Gastroenterol 2023; 118:1128-1153. [PMID: 37377263 DOI: 10.14309/ajg.0000000000002340] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/04/2023] [Indexed: 06/29/2023]
Abstract
Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios.
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Affiliation(s)
- Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nizar Mukhtar
- Department of Gastroenterology, Kaiser Permanente, San Francisco, California, USA
| | - Jamilé Wakim-Fleming
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland Ohio, USA
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
- Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | | | - Anne M Larson
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
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4
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Songtanin B, Molehin AJ, Brittan K, Manatsathit W, Nugent K. Hepatitis E Virus Infections: Epidemiology, Genetic Diversity, and Clinical Considerations. Viruses 2023; 15:1389. [PMID: 37376687 DOI: 10.3390/v15061389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
According to the World Health Organization, approximately 20 million people worldwide are infected annually with the hepatitis E virus (HEV). There are four main genotypes of HEV. Genotype 1 and genotype 2 are common in developing countries and are transmitted by contaminated water from a fecal-oral route. Genotype 3 and genotype 4 are common in developed countries and can lead to occasional transmission to humans via undercooked meat. Hepatitis E virus 1 and HEV3 can lead to fulminant hepatitis, and HEV3 can lead to chronic hepatitis and cirrhosis in immunocompromised patients. The majority of patients with HEV infection are asymptomatic and usually have spontaneous viral clearance without treatment. However, infection in immunocompromised individuals can lead to chronic HEV infection. Both acute and chronic HEV infections can have extrahepatic manifestations. No specific treatment is required for acute HEV infection, no treatment has been approved in chronic infection, and no HEV vaccine has been approved by the (United States) Food and Drug Administration. This review focuses on the molecular virology (HEV life cycle, genotypes, model systems, zoonosis), pathogenesis, clinical manifestation, and treatment of chronic HEV infection, especially in immunocompromised patients, to provide clinicians a better understanding of the global distribution of these infections and the significant effect they can have on immunocompromised patients.
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Affiliation(s)
- Busara Songtanin
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Adebayo J Molehin
- Department of Microbiology & Immunology, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
| | - Kevin Brittan
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Wuttiporn Manatsathit
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
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Takakusagi S, Kakizaki S, Takagi H. The Diagnosis, Pathophysiology, and Treatment of Chronic Hepatitis E Virus Infection-A Condition Affecting Immunocompromised Patients. Microorganisms 2023; 11:1303. [PMID: 37317277 DOI: 10.3390/microorganisms11051303] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/01/2023] [Accepted: 05/13/2023] [Indexed: 06/16/2023] Open
Abstract
Hepatitis E is a zoonosis caused by hepatitis E virus (HEV), which was first discovered 40 years ago. Twenty million HEV infections worldwide are estimated each year. Most hepatitis E cases are self-limiting acute hepatitis, but the virus has been recognized to cause chronic hepatitis. Following the first case report of chronic hepatitis E (CHE) in a transplant recipient, CHE has recently been identified as associated with chronic liver damage induced by HEV genotypes 3, 4, and 7-usually in immunocompromised patients such as transplant recipients. In addition, patients infected with HIV and those receiving chemotherapy for malignancy, along with patients with rheumatic disease and COVID-19, have recently been reported as having CHE. CHE can be easily misdiagnosed by usual diagnostic methods of antibody response, such as anti-HEV IgM or IgA, because of the low antibody response in the immunosuppressive condition. HEV RNA should be evaluated in these patients, and appropriate treatments-such as ribavirin-should be given to prevent progression to liver cirrhosis or liver failure. While still rare, cases of CHE in immunocompetent patients have been reported, and care must be taken not to overlook these instances. Herein, we conduct an overview of hepatitis E, including recent research developments and management of CHE, in order to improve our understanding of such cases. The early diagnosis and treatment of CHE should be performed to decrease instances of hepatitis-virus-related deaths around the world.
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Affiliation(s)
- Satoshi Takakusagi
- Department of Gastroenterology and Hepatology, Kusunoki Hospital, 607-22 Fujioka, Fujioka 375-0024, Gunma, Japan
| | - Satoru Kakizaki
- Department of Clinical Research, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki 370-0829, Gunma, Japan
| | - Hitoshi Takagi
- Department of Gastroenterology and Hepatology, Kusunoki Hospital, 607-22 Fujioka, Fujioka 375-0024, Gunma, Japan
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Azevedo Silva M, Ruge Gonçalves A, Leal C, Eliseu L. Severe hepatitis E in an immunocompetent young female treated with ribavirin. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:269-270. [PMID: 36043559 DOI: 10.17235/reed.2022.9105/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
A healthy 24-year-old woman was admitted to the emergency department with acute hepatitis. She denied traveling, consumption of drugs, herbs, alcohol or medication other than the same oral contraceptive for years. The etiological work-up revealed positive Herpes Simplex Virus (HSV) 1+2 serology (IgG and IgM). Other viral serologies were negative, while Hepatitis E Virus (HEV) serology and viraemia were pending. Liver biopsy showed portal and lobular necroinflammatory activity without specific etiological findings. The remaining work-up was unremarkable. The patient developed jaundice. Acyclovir was started, considering a possible herpetic hepatitis, while waiting for HSV viraemia and immunohistochemistry in the liver biopsy, which later revealed to be negative. Despite therapy, hyperbilirubinemia and liver cytolysis worsened. At this point, HEV serology and viraemia came back positive. Ribavirin was started with rapid clinical and biochemical improvement. Liver enzymes were normal and HEV viraemia was negative after 12 weeks of ribavirin, remaining undetectable 3 months later.
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Affiliation(s)
| | | | - Carina Leal
- Gastroenterology, Centro Hospitalar de Leiria, Portugal
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Hrynkiewicz R, Niedźwiedzka-Rystwej P. Etiology of viral induced acute liver failure and defensins as potential therapeutic agents in ALF treatment. Front Immunol 2023; 14:1153528. [PMID: 37153560 PMCID: PMC10160486 DOI: 10.3389/fimmu.2023.1153528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023] Open
Abstract
Acute liver failure (ALF) is a rare and severe disease, which, despite continuous advances in medicine, is still characterized by high mortality (65-85%). Very often, a liver transplant is the only effective treatment for ALF. Despite the implementation of prophylactic vaccinations in the world, the viral background of ALF is still a problem and leads to many deaths. Depending on the cause of ALF, it is sometimes possible to reverse this condition with appropriate therapies, which is why the search for effective antiviral agents seems to be a very desirable direction of research. Defensins, which are our natural antimicrobial peptides, have a very high potential to be used as therapeutic agents for infectious liver diseases. Previous studies on the expression of human defensins have shown that increased expression of human α and β-defensins in HCV and HBV infections is associated with a better response to treatment. Unfortunately, conducting clinical trials for ALF is very difficult due to the severity of the disease and the low incidence, therefore animal models are important for the development of new therapeutic strategies. One of the best animal models that has real reference to research on acute liver failure (ALF) is rabbit hemorrhagic disease in rabbits caused by the Lagovirus europaeus virus. So far, there have been no studies on the potential of defensins in rabbits infected with Lagovirus europaeus virus.
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You S, Zhu B, Xin S. Clinical Manifestations of Hepatitis E. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1417:185-197. [PMID: 37223867 DOI: 10.1007/978-981-99-1304-6_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The clinical manifestations of hepatitis E are similar to those of other types of viral hepatitis. While acute hepatitis E is usually self-limited, pregnant women and chronic liver disease patients suffering from acute hepatitis E usually present with severe clinical manifestations that may develop into fulminant hepatic failure. Chronic HEV infection is typically seen in organ transplant patients; most HEV cases are asymptomatic and rarely display jaundice, fatigue, abdominal pain, fever, fatigue, or ascites. The clinical manifestations of HEV infection in neonates are diverse and have varied clinical signs, biochemistry, and virus-biomarkers. Lastly, the extrahepatic manifestations and complications of hepatitis E are in need of further study.
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Affiliation(s)
- Shaoli You
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Bing Zhu
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shaojie Xin
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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9
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Hepatitis A and E in the Mediterranean: A systematic review. Travel Med Infect Dis 2022; 47:102283. [DOI: 10.1016/j.tmaid.2022.102283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/05/2022] [Accepted: 02/23/2022] [Indexed: 11/23/2022]
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Wu J, Shi C, Sheng X, Xu Y, Zhang J, Zhao X, Yu J, Shi X, Li G, Cao H, Li L. Prognostic Nomogram for Patients with Hepatitis E Virus-related Acute Liver Failure: A Multicenter Study in China. J Clin Transl Hepatol 2021; 9:828-837. [PMID: 34966646 PMCID: PMC8666371 DOI: 10.14218/jcth.2020.00117] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/14/2021] [Accepted: 04/16/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIMS Timely and effective assessment scoring systems for predicting the mortality of patients with hepatitis E virus-related acute liver failure (HEV-ALF) are urgently needed. The present study aimed to establish an effective nomogram for predicting the mortality of HEV-ALF patients. METHODS The nomogram was based on a cross-sectional set of 404 HEV-ALF patients who were identified and enrolled from a cohort of 650 patients with liver failure. To compare the performance with that of the model for end-stage liver disease (MELD) scoring and CLIF-Consortium-acute-on-chronic liver failure score (CLIF-C-ACLFs) models, we assessed the predictive accuracy of the nomogram using the concordance index (C-index), and its discriminative ability using time-dependent receiver operating characteristics (td-ROC) analysis, respectively. RESULTS Multivariate logistic regression analysis of the development set carried out to predict mortality revealed that γ-glutamyl transpeptidase, albumin, total bilirubin, urea nitrogen, creatinine, international normalized ratio, and neutrophil-to-lymphocyte ratio were independent factors, all of which were incorporated into the new nomogram to predict the mortality of HEV-ALF patients. The area under the curve of this nomogram for mortality prediction was 0.671 (95% confidence interval: 0.602-0.740), which was higher than that of the MELD and CLIF-C-ACLFs models. Moreover, the td-ROC and decision curves analysis showed that both discriminative ability and threshold probabilities of the nomogram were superior to those of the MELD and CLIF-C-ACLFs models. A similar trend was observed in the validation set. CONCLUSIONS The novel nomogram is an accurate and efficient mortality prediction method for HEV-ALF patients.
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Affiliation(s)
- Jian Wu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Laboratory Medicine, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Cuifen Shi
- Department of Infectious Disease, The Second People’s Hospital of Yancheng City, Yancheng, Jiangsu, China
| | - Xinyu Sheng
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yanping Xu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jinrong Zhang
- Department of Laboratory Medicine, The People’s Hospital of Dafeng City, Yancheng, Jiangsu, China
| | - Xinguo Zhao
- Department of Respiration, The Fifth People’s Hospital of Wuxi, Wuxi, Jiangsu, China
| | - Jiong Yu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xinhui Shi
- Department of Laboratory Medicine, The First People’s Hospital of Yancheng City, Yancheng, Jiangsu, China
| | - Gongqi Li
- Department of Clinical Laboratory, Linyi Traditional Hospital, Linyi, Shandong, China
| | - Hongcui Cao
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory for Diagnosis and Treatment of Aging and Physic-chemical Injury Diseases, Hangzhou, Zhejiang, China
- Correspondence to: Hongcui Cao, State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou, Zhejiang 310003, China. ORCID: https://orcid.org/0000-0002-6604-6867. Tel: +86-571-87236451, Fax: +86-571-87236459, E-mail:
| | - Lanjuan Li
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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El-Mokhtar MA, Ramadan HKA, Thabet MM, Abd-Elkader AS, Fouad M, Sallam MM, Elgohary EA, Abd El-Hafeez AA, Mohamed ME, Sayed IM. The Unmet Needs of Hepatitis E Virus Diagnosis in Suspected Drug-Induced Liver Injury in Limited Resource Setting. Front Microbiol 2021; 12:737486. [PMID: 34690979 PMCID: PMC8533821 DOI: 10.3389/fmicb.2021.737486] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Currently, there are no specific biomarkers for drug-induced liver injury (DILI), and the diagnosis of DILI is based mainly on the exclusion of other causes of liver dysfunction and the recognition of potential causative drugs. Hepatitis E virus (HEV) diagnosis is not routinely enrolled in many countries, and HEV infection could be misdiagnosed as DILI. Methodology: We retrospectively analyzed plasma samples (n = 80) collected from suspected DILI for HEV markers such as anti-HEV IgM, anti-HEV IgG, and HEV RNA. Anti-HEV antibodies were assessed using commercial ELISA kits. HEV RNA was tested by RT-qPCR targeting HEV ORF2/3, the receiver operating characteristic (ROC) curve was plotted, and a putative threshold for liver function parameters was determined. Results: Out of 80 samples, 12 samples were positive for anti-HEV IgM and anti-HEV IgG, and HEV RNA was detected in seven samples. The median viral load was 3.46 × 103 IU/ml, and the isolated viruses belonged to HEV genotype 1. The level of liver enzymes such as alanine transaminase (ALT) and aspartate transaminase (AST), but not alkaline phosphatase (ALP), was significantly higher in HEV confirmed cases than in non-HEV confirmed cases. We identified a plasma ALT level of at least 415.5 U/L and AST level of at least 332 U/L; ALT/ALP ratio of at least 5.08 could be used as a guide for the patients diagnosed as DILI to be tested for HEV infection. The previous liver function parameters showed high sensitivity and good specificity. Conclusion: Hepatitis E virus was detected in suspected DILI cases. The diagnosis of DILI is not secure until HEV testing is done. Liver function parameters can be used as a guide for HEV testing in suspected DILI cases in countries with limited resources.
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Affiliation(s)
- Mohamed A El-Mokhtar
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Asyut, Egypt.,Microbiology and Immunology Department, Faculty of Pharmacy, Sphinx University, Asyut, Egypt
| | - Haidi Karam-Allah Ramadan
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Marwa M Thabet
- Department of Clinical pathology, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Alaa S Abd-Elkader
- Department of Clinical pathology, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Magdy Fouad
- Hepato-Gastroenterology Unit, Tropical Medicine Department, Faculty of Medicine, El-Minia University, Minya, Egypt
| | - Mohammad M Sallam
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Elsayed A Elgohary
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Amer Ali Abd El-Hafeez
- Pharmacology and Experimental Oncology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt.,Department of Cellular and Molecular Medicine, University of California, San Diego, San Diego, CA, United States
| | - Mona Embarek Mohamed
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Asyut, Egypt
| | - Ibrahim M Sayed
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Asyut, Egypt
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El-Mokhtar MA, Karam-Allah Ramadan H, Abdel Hameed MR, M Kamel A, A Mandour S, Ali M, Abdel-Malek MAY, M Abd El-Kareem D, Adel S, H Salama E, Khalaf KAB, Sayed IM. Evaluation of hepatitis E antigen kinetics and its diagnostic utility for prediction of the outcomes of hepatitis E virus genotype 1 infection. Virulence 2021; 12:1334-1344. [PMID: 34002677 PMCID: PMC8143225 DOI: 10.1080/21505594.2021.1922027] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
HEV-Ag ELISA assay is a reliable diagnostic test in resource-limited areas. HEV genotype 1 (HEV-1) infections are either self-limited or progress to fulminant hepatic failure (FHF) and death if anti-HEV therapy is delayed. Limited data is available about the diagnostic utility of HEV Ag on HEV-1 infections. Herein wWe aimed to study the kinetics of HEV Ag during HEV-1 infections at different stages, i.e., acute HEV infection, recovery, and progression to FHF. Also, we evaluated the diagnostic utility of this marker to predict the outcomes of HEV-1 infections. Plasma of acute hepatitis E (AHE) patients were assessed for HEV RNA by RT-qPCR, HEV Ag, and anti-HEV IgM by ELISA. The kinetics of HEV Ag was monitored at different time points; acute phase of infection, recovery, FHF stage, and post-recovery. Our results showed that the level of HEV Ag was elevated in AHE patients with a significantly higher level in FHF patients than recovered patients. We identified a plasma HEV Ag threshold that can differentiate between self-limiting infection and FHF progression with 100% sensitivity and 88.89% specificity. HEV Ag and HEV RNA have similar kinetics during the acute phase and self-limiting infection. In the FHF stage, HEV Ag and anti-HEV IgM have similar patterns of kinetics which could be the cause of liver damage. In conclusion, the HEV Ag assay can be used as a biomarker for predicting the consequences of HEV-1 infections which could be diagnostically useful for taking the appropriate measures to reduce the complications, especially for high-risk groups.
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Affiliation(s)
- Mohamed A El-Mokhtar
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt.,Microbiology and Immunology Department, Faculty of Pharmacy, Sphinx University, Assiut, Egypt
| | - Haidi Karam-Allah Ramadan
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Muhamad R Abdel Hameed
- Department of Internal Medicine and Hematology Unit, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Ayat M Kamel
- Microbiology and Immunology Department, Faculty of Pharmacy, Assiut University, Assiut Egypt
| | - Sahar A Mandour
- Department of Microbiology and Immunology, Faculty of Pharmacy, Deraya University, Minia, Egypt
| | - Maha Ali
- Department of Medical Biochemistry, Faculty of Medicine, Assiut University, Egypt
| | | | | | - Sara Adel
- Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Eman H Salama
- Department of Clinical Pathology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Khaled Abo Bakr Khalaf
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ibrahim M Sayed
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt.,Department of Pathology, School of Medicine, University of California, San Diego, La Jolla, California, USA
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13
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Fagan O, Armstrong P, Merwe KVD, Crosnoi D, Steele C, Sopena-Falco J, Parihar V. Viral hepatitis: A brief introduction, review of management, advances and challenges. World J Meta-Anal 2021; 9:139-152. [DOI: 10.13105/wjma.v9.i2.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/26/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
Viral hepatitis represents a major public health hazard and is associated with significant global mortality. Over the last decade, there have been significant developments in the prevention and treatment of viral hepatitis. These changes have led to a situation whereby global elimination has become a realistic goal, fully endorsed by the World Health Organization (WHO). By 2030, the WHO aims to reduce viral hepatitis mortality by 65% and reduce new infections by 90% by 2030. These are ambitious targets and will only be met through a sustained programme. This will require expertise from hepatologists and virologists and the fields of public health and primary care. In this article, we review the causes of viral hepatitis, its management through prevention and treatments, and the most pressing challenges and recent advances.
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Affiliation(s)
- Olga Fagan
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Paul Armstrong
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Kevin Van Der Merwe
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Daniela Crosnoi
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Chris Steele
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
| | - Julia Sopena-Falco
- Department of Gastroenterology, Saint Vincent’s University Hospital, Dublin 04, Ireland
| | - Vikrant Parihar
- Department of Gastroenterology, Letterkenny University Hospital, Letterkenny F92 AE81, Ireland
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14
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Lee BT, Odin JA, Grewal P. An Approach to Drug-Induced Liver Injury from the Geriatric Perspective. Curr Gastroenterol Rep 2021; 23:6. [PMID: 33846832 DOI: 10.1007/s11894-021-00804-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW With its high variability in both presentation and severity, drug-induced liver injury (DILI) is a complex condition increasingly confronting all providers. DILI has an even more muddled presentation among the geriatric population due to age-related changes in liver physiology and biochemistry as well as polypharmacy common in the geriatric population. RECENT FINDINGS Most cases of DILI are idiosyncratic and unpredictable. DILI, especially related to herbal and dietary supplement (HDS) use, is increasingly recognized as a leading cause of acute liver failure and need for liver transplantation. Unfortunately, liver transplantation is a limited option for the elderly, a population that exhibits significant HDS use. One recent study suggests that early use of N-acetylcysteine may be useful in preventing progression to acute liver failure in non-acetaminophen DILI. In the future, a personalized medicine approach using genomic signatures may be feasible to prevent DILI. This review serves to raise recognition of the unique aspects of DILI in the geriatric population to promote rapid diagnosis and early intervention to prevent progression to liver failure and death. For now, DILI remains a diagnosis of exclusion, and care providers for the elderly must focus on obtaining a thorough history that includes HDS use and intervening early in suspected DILI cases.
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Affiliation(s)
- Brian T Lee
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Joseph A Odin
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA. .,Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, NY, USA.
| | - Priya Grewal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.,Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, NY, USA
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El Costa H, Gouilly J, Abravanel F, Bahraoui E, Peron JM, Kamar N, Jabrane-Ferrat N, Izopet J. Effector memory CD8 T cell response elicits Hepatitis E Virus genotype 3 pathogenesis in the elderly. PLoS Pathog 2021; 17:e1009367. [PMID: 33617602 PMCID: PMC7932504 DOI: 10.1371/journal.ppat.1009367] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 03/04/2021] [Accepted: 02/09/2021] [Indexed: 12/17/2022] Open
Abstract
Genotype 3 Hepatitis E virus (HEV-3) is an emerging threat for aging population. More than one third of older infected patients develops clinical symptoms with severe liver damage, while others remain asymptomatic. The origin of this discrepancy is still elusive although HEV-3 pathogenesis appears to be immune-mediated. Therefore, we investigated the role of CD8 T cells in the outcome of the infection in immunocompetent elderly subjects. We enrolled twenty two HEV-3-infected patients displaying similar viral determinants and fifteen healthy donors. Among the infected group, sixteen patients experienced clinical symptoms related to liver disease while six remained asymptomatic. Here we report that symptomatic infection is characterized by an expansion of highly activated effector memory CD8 T (EM) cells, regardless of antigen specificity. This robust activation is associated with key features of early T cell exhaustion including a loss in polyfunctional type-1 cytokine production and partial commitment to type-2 cells. In addition, we show that bystander activation of EM cells seems to be dependent on the inflammatory cytokines IL-15 and IL-18, and is supported by an upregulation of the activating receptor NKG2D and an exuberant expression of T-Bet and T-Bet-regulated genes including granzyme B and CXCR3. We also show that the inflammatory chemokines CXCL9-10 are increased in symptomatic patients thereby fostering the recruitment of highly cytotoxic EM cells into the liver in a CXCR3-dependent manner. Finally, we find that the EM-biased immune response returns to homeostasis following viral clearance and disease resolution, further linking the EM cells response to viral burden. Conversely, asymptomatic patients are endowed with low-to-moderate EM cell response. In summary, our findings define immune correlates that contribute to HEV-3 pathogenesis and emphasize the central role of EM cells in governing the outcome of the infection. The outcome of Genotype 3 Hepatitis E virus (HEV-3) infection differs among the elderly. Some patients develop severe forms of Hepatitis E while others remain asymptomatic. Nonetheless, parameters which can lead to severe versus silent infection are largely unknown. Therefore, we investigated immunological features of CD8 T cells in infected patients (aged ≥55) with similar viral determinants but distinct clinical outcomes. We show that drastic phenotypic changes were specifically observed within the effector memory (EM) compartment. Compared to asymptomatic patients, symptomatic ones display a strong activation of both HEV-3-specific and -nonspecific EM CD8 T cells associated with qualitative and quantitative alterations in cytokine production. In addition, EM cells are endowed with high cytotoxic capacity and have the ability to rapidly migrate to the liver. Finally, we report that the inflammatory response to HEV-3 infection shape EM cell activation and function in symptomatic elderly patients. In summary, our results present the first report demonstrating that the nature and the magnitude of EM CD8 T cell response play an important role in the outcome of HEV-3 infection in the elderly.
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Affiliation(s)
- Hicham El Costa
- Infinity—Université Toulouse, CNRS, Inserm, Toulouse, France
- Laboratoire de Virologie, Centre National de référence HEV, Institut Fédératif de Biologie, CHU Toulouse, Toulouse, France
- * E-mail:
| | - Jordi Gouilly
- Infinity—Université Toulouse, CNRS, Inserm, Toulouse, France
| | - Florence Abravanel
- Infinity—Université Toulouse, CNRS, Inserm, Toulouse, France
- Laboratoire de Virologie, Centre National de référence HEV, Institut Fédératif de Biologie, CHU Toulouse, Toulouse, France
| | | | - Jean-Marie Peron
- Département de Gastroentérologie, CHU Toulouse, Toulouse, France
| | - Nassim Kamar
- Infinity—Université Toulouse, CNRS, Inserm, Toulouse, France
| | | | - Jacques Izopet
- Infinity—Université Toulouse, CNRS, Inserm, Toulouse, France
- Laboratoire de Virologie, Centre National de référence HEV, Institut Fédératif de Biologie, CHU Toulouse, Toulouse, France
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16
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El-Mokhtar MA, Sayed IM. Model systems for studying extrahepatic pathogenesis of hepatitis E virus. Current knowledge and future directions. Rev Med Virol 2021; 31:e2218. [PMID: 33475223 DOI: 10.1002/rmv.2218] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 01/05/2021] [Indexed: 02/06/2023]
Abstract
Hepatitis E Virus is the most common cause of acute viral hepatitis globally. HEV infection is endemic in developing countries. Also, autochthonous and sporadic cases are reported in developed countries. HEV causes acute and chronic infections. Besides, extrahepatic manifestations including neurological, renal, haematological, acute pancreatitis and complications during pregnancy are associated with HEV infections. The pathogenesis of HEV in the extrahepatic tissues is either due to direct cytopathic effect mediated by the virus replication, or immunological mechanisms caused by an uncontrollable host response. Researchers have used different in vivo and in vitro models to study the pathogenesis of HEV in the extrahepatic tissues and analyse the host immune response against HEV infection. This review highlights the extrahepatic disorders associated with HEV infection. We focused on the in vivo and in vitro models as a tool for elucidating the HEV infection beyond the liver and studying the mechanisms of HEV induced tissue damages.
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Affiliation(s)
- Mohamed A El-Mokhtar
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt.,Microbiology and Immunology Department, Faculty of Pharmacy, Sphinx University, Assiut, Egypt
| | - Ibrahim M Sayed
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt.,Department of Pathology, School of Medicine, University of California, San Diego La Jolla, California, USA
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17
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Sayed IM, El-Mokhtar MA, Mahmoud MAR, Elkhawaga AA, Gaber S, Seddek NH, Abdel-Wahid L, Ashmawy AM, Alkareemy EAR. Clinical Outcomes and Prevalence of Hepatitis E Virus (HEV) Among Non-A-C Hepatitis Patients in Egypt. Infect Drug Resist 2021; 14:59-69. [PMID: 33469320 PMCID: PMC7811453 DOI: 10.2147/idr.s289766] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/11/2020] [Indexed: 12/14/2022] Open
Abstract
Background Hepatitis E virus (HEV) is an emerging infectious agent that causes acute hepatitis in developing and developed countries. Diagnosis of HEV infection has not been routinely done in Egyptian hospitals, and clinicians do not prescribe ribavirin (RBV) for acute hepatitis cases of unknown etiology (AHUE). We aimed to screen patients with AHUE for the presence of HEV markers and to determine the complications associated with HEV infection. Patients and Methods HEV markers (anti-HEV IgM, anti-HEV IgG, and HEV RNA) were assessed in patients with AHUE (n=300) admitted to Assiut University Hospitals. RT-qPCR was used to detect the viral load and sequencing analysis was carried out to determine the genotype of the detected viruses. Phylogenetic tree was constructed to evaluate the genetic relatedness between the isolates. Laboratory parameters and the outcomes of infection were determined. Results Acute HEV infection (AHE) was detected in 30 out of 300 (10%) of AHUE patients. Anti-HEV IgM, HEV RNA, and anti-HEV IgG were reported in 83%, 50%, and 43% of the samples, respectively. HEV RNA load ranged from 5×102 IU/mL to 1.1×104 IU/mL. Sequencing of the isolated viruses revealed that five viruses belong to HEV-1 and one isolate belongs to HEV-3 with high homology to the virus recently isolated from the cow and goat milk in the Egyptian villages. Although previous reports showed that attenuated HEV isolates were circulating in Egypt, four out of 30 patients (13%) developed coagulopathy and hepatic encephalopathy and died due to fulminant hepatic failure (FHF) within 3–6 weeks of hospitalization. Age, malignancy, and a history of pre-existing liver diseases were a risky factor for FHF development. Conclusion AHE is common in Upper Egypt. Older patients with malignancy and/or a history of liver diseases are risky. HEV diagnosis and treatment become pivotal in Egyptian hospitals to reduce the fatality rate and they should start urgently and promptly.
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Affiliation(s)
- Ibrahim M Sayed
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed A El-Mokhtar
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mahmoud Abdel Rahman Mahmoud
- Department of Internal Medicine, Gastroenterology and Hepatology unit, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
| | - Amal A Elkhawaga
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Shereen Gaber
- Department of Biochemistry, Faculty of Medicine, Minia University, Minia, Egypt
| | - Nermien H Seddek
- Department of Respiratory Care, College of Applied Medical Sciences-Jubail 4030 (CAMSJ), Imam Abdulrahman Bin Faisal University, Al Jubail 35816, Saudi Arabia
| | - Lobna Abdel-Wahid
- Department of Internal Medicine, Gastroenterology and Hepatology unit, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
| | - Ahmed M Ashmawy
- Department of Internal Medicine, Gastroenterology and Hepatology unit, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
| | - Enas Ahmed Reda Alkareemy
- Department of Internal Medicine, Gastroenterology and Hepatology unit, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt
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18
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Belei O, Ancusa O, Mara A, Olariu L, Amaricai E, Folescu R, Zamfir CL, Gurgus D, Motoc AG, Stânga LC, Strat L, Marginean O. Current Paradigm of Hepatitis E Virus Among Pediatric and Adult Patients. Front Pediatr 2021; 9:721918. [PMID: 34660485 PMCID: PMC8515027 DOI: 10.3389/fped.2021.721918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/31/2021] [Indexed: 12/26/2022] Open
Abstract
Hepatitis E virus (HEV) infection is a polymorphic condition, present throughout the world and involving children and adults. Multiple studies over the last decade have contributed to a better understanding of the natural evolution of this infection in various population groups, several reservoirs and transmission routes being identified. To date, acute or chronic HEV-induced hepatitis has in some cases remained underdiagnosed due to the lower accuracy of serological tests and due to the evolutionary possibility with extrahepatic manifestations. Implementation of diagnostic tests based on nucleic acid analysis has increased the detection rate of this disease. The epidemiological and clinical features of HEV hepatitis differ depending on the geographical areas studied. HEV infection is usually a self-limiting condition in immunocompetent patients, but in certain categories of vulnerable patients it can induce a sudden evolution toward acute liver failure (pregnant women) or chronicity (immunosuppressed patients, post-transplant, hematological, or malignant diseases). In acute HEV infections in most cases supportive treatment is sufficient. In patients who develop chronic hepatitis with HEV, dose reduction of immunosuppressive medication should be the first therapeutic step, especially in patients with transplant. In case of unfavorable response, the initiation of antiviral therapy is recommended. In this review, the authors summarized the essential published data related to the epidemiological, clinical, paraclinical, and therapeutic aspects of HEV infection in adult and pediatric patients.
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Affiliation(s)
- Oana Belei
- First Pediatric Clinic, Disturbance of Growth and Development on Children Research Center, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Oana Ancusa
- Fifth Department of Internal Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Adelina Mara
- Department of Internal Medicine, Emergency City Hospital, Timisoara, Romania
| | - Laura Olariu
- First Pediatric Clinic, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Elena Amaricai
- Department of Rehabilitation Physical Medicine and Rheumatology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Roxana Folescu
- Department of Balneology, Medical Recovery and Rheumatology, Family Discipline, Center for Preventive Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Lacramioara Zamfir
- Department of Morpho-Functional Sciences I, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Daniela Gurgus
- Department of Balneology, Medical Recovery and Rheumatology, Family Discipline, Center for Preventive Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Andrei G Motoc
- Department of Anatomy and Embriology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Livia Claudia Stânga
- Department of Microbiology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Liliana Strat
- Department of Mother and Child Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Otilia Marginean
- First Pediatric Clinic, Disturbance of Growth and Development on Children Research Center, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
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19
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Busch M, Wedemeyer HH. [Acute liver failure-The importance of rapid diagnostics and early initiation of treatment]. Internist (Berl) 2020; 61:1151-1162. [PMID: 33006624 DOI: 10.1007/s00108-020-00876-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Acute liver failure (ALF) is a rare disease with high mortality. It is defined as coagulopathy and encephalopathy in a person with a previously healthy liver. The etiology of ALF is a decisive prognostic factor and varies depending on the country of origin of the patient. Although in many countries the main triggers are hepatotropic viruses, in western industrial countries toxic medicinal causes and autoimmune phenomena predominate. The course of ALF runs through various phases. The complete picture of ALF can mostly no longer be casually treated but necessitates in particular timely contact with a transplantation center. If a causal treatment exists, the effectiveness is greatly dependent on the timing of initiation. In the best case scenario this can completely avoid liver damage. In the complete picture of ALF the main focus is on the intensive medical care of a threatening multiorgan failure. In this context new standards of treatment were established by studies on plasmapheresis.
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Affiliation(s)
- M Busch
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - H H Wedemeyer
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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20
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Fontana RJ, Engle RE, Gottfried M, Hammed B, Hanje J, Durkalski V, Kleiner DE, Nguyen H, Nishimura N, Lee WM, Farci P. Role of Hepatitis E Virus Infection in North American Patients With Severe Acute Liver Injury. Clin Transl Gastroenterol 2020; 11:e00273. [PMID: 33259165 PMCID: PMC7665257 DOI: 10.14309/ctg.0000000000000273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/07/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The aim of this study was to determine the role of hepatitis E virus (HEV) infection in a large cohort of prospectively enrolled patients with severe acute liver injury (ALI). METHODS Serum samples from 594 consecutive adults enrolled between 2008 and 2018 in the US Acute Liver Failure Study Group ALI registry were tested for anti-HEV IgM and anti-HEV IgG levels. Those with detectable anti-HEV IgM underwent further testing for HEV RNA using real-time polymerase chain reaction. RESULTS The median age of patients was 38 years; 41% were men and 72% Caucasian. Etiologies of ALI included acetaminophen hepatotoxicity (50%), autoimmune hepatitis (8.9%), hepatitis B virus (8.9%), and idiosyncratic drug-induced liver injury (7.9%). Overall, 62 patients (10.4%) were negative for anti-HEV IgM but positive for IgG, whereas only 3 men (0.5%) were positive for both anti-HEV IgM and IgG. These 3 cases were initially diagnosed as having indeterminate, HEV, and hepatitis B virus-related ALI. One of these patients had detectable HEV RNA genotype 3, and another anti-HEV IgM+ patient had detectable HEV antigens by immunohistochemistry on liver biopsy. On multivariate modeling, older (odds ratio: 1.99) and non-Caucasian subjects (odds ratio: 2.92) were significantly more likely to have detectable anti-HEV IgG (P < 0.0001). DISCUSSION Acute HEV infection is an infrequent cause of ALI in hospitalized North American adults. The anti-HEV IgG+ patients were significantly older and more likely to be non-Caucasian. These data are consistent with other population-based studies that indicate exposure to HEV in the general US population is declining over time and might reflect a cohort effect.
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Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ronald E. Engle
- Hepatic Pathogenesis Section, Laboratory of Infectious Diseases, NIAID, Bethesda, Maryland, USA
| | - Michelle Gottfried
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bilal Hammed
- Department of Medicine, UCSF, San Francisco, California, USA
| | - James Hanje
- Department of Medicine, Ohio State University, Columbus, Ohio, USA
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Hanh Nguyen
- Hepatic Pathogenesis Section, Laboratory of Infectious Diseases, NIAID, Bethesda, Maryland, USA
| | - Norihisa Nishimura
- Hepatic Pathogenesis Section, Laboratory of Infectious Diseases, NIAID, Bethesda, Maryland, USA
| | - William M. Lee
- Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Patrizia Farci
- Hepatic Pathogenesis Section, Laboratory of Infectious Diseases, NIAID, Bethesda, Maryland, USA
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21
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Wu J, Huang F, Ling Z, Liu S, Liu J, Fan J, Yu J, Wang W, Jin X, Meng Y, Cao H, Li L. Altered faecal microbiota on the expression of Th cells responses in the exacerbation of patients with hepatitis E infection. J Viral Hepat 2020; 27:1243-1252. [PMID: 32500937 DOI: 10.1111/jvh.13344] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 02/06/2023]
Abstract
Fulminant hepatitis E may lead to acute liver failure (ALF). Perturbations of intestinal microbiota are related to severe liver disease. To study the correlations between faecal microbiota and the occurrence and exacerbation of hepatitis E virus (HEV) infection, we characterized 24 faecal samples from 12 patients with acute hepatitis E (AHE) and 12 patients with HEV-ALF using high-throughput sequencing. We found both the alpha and beta diversity indices showed no significant differences between the AHE and HEV-ALF groups. Several predominant taxa were significantly different between the AHE and HEV-ALF groups. Most notably, the HEV-ALF group had increased levels of Gammaproteobacteria, Proteobacteria, Xanthomonadceae and Stenotrophomonas, but reduced levels of Firmicutes, Streptococcus, Subdoligranulum and Lactobacillus, compared with the AHE group. The levels of Lactobacillaceae and Gammaproteobacteria could be used to distinguish patients with HEV-ALF from those with AHE. In addition, the level of Th lymphocytes was significantly lower in the HEV-ALF group than in the AHE group. The relative abundances of Lactobacillaceae and Gammaproteobacteria were positively correlated with Th lymphocytes, serum international normalized ratio (INR) and hepatic encephalopathy severity. Moreover, surviving patients had higher levels of Lactobacillus mucosae than deceased patients. Our study demonstrated that the presence of altered faecal microbiota is associated with exacerbation of HEV infection; this finding may be useful for exploring the interactions among faecal microbiota, immune responses, mechanisms of infection and progression in patients with HEV, as well as for the development of novel diagnostic and therapeutic strategies.
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Affiliation(s)
- Jian Wu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Department of Laboratory Medicine, The First People's Hospital of Yancheng City, Yancheng, China
| | - Fen Huang
- Medical School, Kunming University of Science and Technology, Kunming, China
| | - Zongxin Ling
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shuangchun Liu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Liu
- Department of Laboratory Medicine, The Fifth People's Hospital of Wuxi, Affiliated to Jiangnan University, Wuxi, China
| | - Jun Fan
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jiong Yu
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Wang
- Department of Laboratory Medicine, The First People's Hospital of Yancheng City, Yancheng, China
| | - Xiuyuan Jin
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yiling Meng
- Department of Laboratory Medicine, Suzhou Vocational Health College, Suzhou, China
| | - Hongcui Cao
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory for Diagnosis and Treatment of Aging and Physic-Chemical Injury Diseases, Hangzhou, China
| | - Lanjuan Li
- State Key Laboratory for the Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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22
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Aslan AT, Balaban HY. Hepatitis E virus: Epidemiology, diagnosis, clinical manifestations, and treatment. World J Gastroenterol 2020; 26:5543-5560. [PMID: 33071523 PMCID: PMC7545399 DOI: 10.3748/wjg.v26.i37.5543] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/11/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023] Open
Abstract
The hepatitis E virus (HEV) is the fifth known form of viral hepatitis and was first recognized as the cause of an epidemic of unexplained acute hepatitis in the early 1980s. Globally, it is one of the most frequent causes of acute viral hepatitis. The majority of HEV infections are asymptomatic and lead to the spontaneous clearance of the virus. Among the eight different genotypes identified to date, HEV genotype 1 (HEV1), HEV2, HEV3, and HEV4 are the most frequent genotypes causing infections in humans. HEV1 and HEV2 are prevalent in developing regions and able to result in large-scale outbreaks originating from contaminated water supplies. They are also responsible for severe hepatitis in pregnant patients and infants. In contrast, HEV3 and HEV4 are zoonotic, and the transmission of these genotypes to humans occurs mainly through the fecal contamination of water and consumption of contaminated meat from infected animals. Their main reservoir is the pig, and they are mostly encountered in developed countries. The major risk groups for HEV infection and its ensuing adverse consequences are pregnant women, infants, older people, immunocompromised individuals, patients with underlying chronic liver diseases, and workers that come into close contact with HEV-infected animals. In the clinical perspective, HEV infections have diverse clinical manifestations including acute and self-limiting hepatitis, acute-on-chronic liver disease, chronic hepatitis, cirrhosis, and liver failure. Although HEV mainly results in acute self-limiting infection, chronic HEV infection may occur among immunocompromised patients (e.g., solid-organ transplant recipients). Additionally, HEV-associated extrahepatic manifestations involving various organs have been reported in the last decade, although the causal link for many of them still needs to be proven. Ribavirin and interferon-alpha are the most widely used agents for the treatment of HEV infections with a certain level of success. However, ribavirin is contraindicated in pregnant patients, and interferon-alpha cannot be used in most transplant recipients. Therefore, there is an urgent need for novel antiviral compounds that are safe and effective particularly for patients having contraindications for ribavirin or interferon-alpha and infected by the ribavirin-resistant HEV. In this review article, a literature search using PubMed and MEDLINE databases was performed, up to March 2020. Only the articles published in English were reviewed.
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Affiliation(s)
| | - Hatice Yasemin Balaban
- Department of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara 06100, Turkey
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Pan K, Wang Y, Pan P, Xu G, Mo L, Cao L, Wu C, Shen X. The regulatory role of microRNA-mRNA co-expression in hepatitis B virus-associated acute liver failure. Ann Hepatol 2020; 18:883-892. [PMID: 31521462 DOI: 10.1016/j.aohep.2019.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 07/16/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Acute liver failure (ALF) is a dramatic disorder requiring intensive care. MicroRNAs (miRNAs) have been identified to play important roles in ALF. This study was performed to identify miRNA-mRNA co-expression network after ALF to investigate the molecule mechanism underlying the pathogenesis of ALF. MATERIALS AND METHODS The microarray dataset GSE62030 and GSE62029 were downloaded from Gene Expression Omnibus database. Overlapping differentially expressed miRNAs (DEmiRNAs) and genes (DEGs) were identified in liver tissues from patients with hepatitis B virus (HBV)-associated ALF in comparison with normal tissues from donors. Gene enrichment analysis was performed. Key pathways associated with the DEGs were identified. The miRNA-mRNA regulatory network was constructed. RESULTS Total 42 DEmiRNAs and 523 DEGs were identified in liver tissues from patients with HBV-associated ALF. Gene ontology and pathways enrichment analysis showed upregulated DEGs were related to immune responses, inflammation, and infection, and downregulated DEGs were associated with amino acids, secondary metabolites and xenobiotics metabolism. In miRNA-mRNA co-expression network, DEGs were regulated by at least one DEmiRNA and transcription factor. Further analysis showed DEmiRNAs, including has-miR-55-5p, has-miR-193b-5p, has-miR-200b-3p, and has-miR-3175 were associated with amino acid metabolism, drug metabolism and detoxication, and signaling pathways including mitogen-activated protein kinase (MAPK), phosphatidylinositol 3-kinase (PI3K)/AKT, Ras, and Rap1. CONCLUSIONS These miRNA-mRNA pairs and changed profiles were associated with and might be responsible for the impairment of detoxification and metabolism induced by HBV-associated ALF.
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Affiliation(s)
- Kanda Pan
- Department of Intensive Care Unit (ICU), The First People's Hospital of Xiaoshan District, Hangzhou, Xiaoshan District, Hangzhou, China
| | - Yunchao Wang
- Department of Intensive Care Unit (ICU), The First People's Hospital of Xiaoshan District, Hangzhou, Xiaoshan District, Hangzhou, China
| | - Ping Pan
- Department of General Medicine, The First People's Hospital of Xiaoshan District, Hangzhou, Xiaoshan District, Hangzhou, China
| | - Guanhua Xu
- Department of Intensive Care Unit (ICU), The First People's Hospital of Xiaoshan District, Hangzhou, Xiaoshan District, Hangzhou, China
| | - Lujiao Mo
- Department of Intensive Care Unit (ICU), The First People's Hospital of Xiaoshan District, Hangzhou, Xiaoshan District, Hangzhou, China
| | - Lijia Cao
- Department of Intensive Care Unit (ICU), The First People's Hospital of Xiaoshan District, Hangzhou, Xiaoshan District, Hangzhou, China
| | - Channi Wu
- Department of Gastroenterology, Zhejiang Xiaoshan Hospital, Xiaoshan District, Hangzhou, China.
| | - Xiaoyuan Shen
- Department of Intensive Care Unit (ICU), The First People's Hospital of Xiaoshan District, Hangzhou, Xiaoshan District, Hangzhou, China
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Di Bartolomeo S, Carubbi F, Cipriani P. Hepatitis E Virus and rheumatic diseases: what do rheumatologists need to know? BMC Rheumatol 2020; 4:51. [PMID: 32974609 PMCID: PMC7504648 DOI: 10.1186/s41927-020-00149-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/26/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hepatitis E virus (HEV) represents the most common cause of acute hepatitis and jaundice in the world. About 2 million of infection cases occur each year in Europe, mainly as autochthonous anthropozoonosis, and HEV can be transmitted through undercooked pork meat. This infection has been linked to various extra-hepatic manifestations, while chronic infections with a rapid development of liver failure have been described in heavily immunosuppressed patients undergoing solid organ transplantations (SOTs), in patients with hematological diseases or with immunodeficiency virus infection. MAIN BODY OF ABSTRACT The purpose of this review article is to describe rheumatic manifestations related to HEV infection and their implications for rheumatologists in the daily clinical practice. Despite recent accumulating literature in this field, little is known about the course of the infection in patients with rheumatic diseases (RDs) and about the impact of immunosuppressive drugs. Moreover, HEV infection can mimic RDs' manifestations or drugs toxicity. Specific guidelines on management are lacking and the majority of data are referred to SOTs receivers. CONCLUSIONS More studies are needed to better understand the real impact of HEV infection in patients with RDs, regarding both clinical outcomes and their management.
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Affiliation(s)
- Salvatore Di Bartolomeo
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L’Aquila, L’Aquila, Italy
- Department of Medicine, ASL1 Avezzano-Sulmona-L’Aquila, L’Aquila and Sulmona, Italy
| | - Francesco Carubbi
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L’Aquila, L’Aquila, Italy
- Department of Medicine, ASL1 Avezzano-Sulmona-L’Aquila, L’Aquila and Sulmona, Italy
| | - Paola Cipriani
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L’Aquila, L’Aquila, Italy
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Patterson J, Hussey HS, Silal S, Goddard L, Setshedi M, Spearman W, Hussey GD, Kagina BM, Muloiwa R. Systematic review of the global epidemiology of viral-induced acute liver failure. BMJ Open 2020; 10:e037473. [PMID: 32690747 PMCID: PMC7375632 DOI: 10.1136/bmjopen-2020-037473] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The aetiology and burden of viral-induced acute liver failure remains unclear globally. It is important to understand the epidemiology of viral-induced ALF to plan for clinical case management and case prevention. PARTICIPANTS This systematic review was conducted to synthesize data on the relative contribution of different viruses to the aetiology of viral-induced acute liver failure in an attempt to compile evidence that is currently missing in the field. EBSCOhost, PubMed, ScienceDirect, Scopus and Web of Science were searched for relevant literature published from 2009 to 2019. The initial search was run on 9 April 2019 and updated via PubMed on 30 September 2019 with no new eligible studies to include. Twenty-five eligible studies were included in the results of this review. RESULTS This systematic review estimated the burden of acute liver failure after infection with hepatitis B virus, hepatitis A virus, hepatitis C virus, hepatitis E virus, herpes simplex virus/human herpesvirus, cytomegalovirus, Epstein-Barr virus and parvovirus B19. Data were largely missing for acute liver failure after infection with varicella-zostervirus, human parainfluenza viruses, yellow fever virus, coxsackievirus and/or adenovirus. The prevalence of hepatitis A-induced acute liver failur was markedly lower in countries with routine hepatitis A immunisation versus no routine hepatitis A immunisation. Hepatitis E virus was the most common aetiological cause of viral-induced acute liver failure reported in this review. In addition, viral-induced acute liver failure had poor outcomes as indicated by high fatality rates, which appear to increase with poor economic status of the studied countries. CONCLUSIONS Immunisation against hepatitis A and hepatitis B should be prioritised in low-income and middle-income countries to prevent high viral-induced acute liver failure mortality rates, especially in settings where resources for managing acute liver failure are lacking. The expanded use of hepatitis E immunisation should be explored as hepatitis E virus was the most common cause of acute liver failure. REGISTRATION PROSPERO registration number: CRD42017079730.
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Affiliation(s)
- Jenna Patterson
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Hannah Sophia Hussey
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Sheetal Silal
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Liz Goddard
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mashiko Setshedi
- Department of Medicine, Division of Gastroenterology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Wendy Spearman
- Department of Medicine, Division of Hepatology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Gregory D Hussey
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Benjamin M Kagina
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Rudzani Muloiwa
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Department of Pediatrics & Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Kar P, Karna R. A Review of the Diagnosis and Management of Hepatitis E. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020; 12:310-320. [PMID: 32837339 PMCID: PMC7366488 DOI: 10.1007/s40506-020-00235-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose of review We aim to provide the readers an up-to-date knowledge of the structure, epidemiology, and transmission followed by a detailed discussion on testing, diagnostics and management of hepatitis E virus infection. We have also included a comprehensive review of hepatitis E in pregnancy. Recent findings European Association for the Study of the Liver established clinical practice guidelines for testing and treatment of suspected hepatitis E virus infections in 2018. Evidence suggests chronic hepatitis E may follow a course similar to hepatitis B/C with progression to cirrhosis and possibly hepatocellular carcinoma in immunocompromised patients. Summary Hepatitis E virus is the most common cause of acute viral hepatitis worldwide. A combination of serology and nucleic acid amplification testing is the recommended strategy for suspected patients. Ribavirin therapy for a period of 3 months is the drug of choice for severe acute hepatitis, acute-on chronic liver failure, and chronic infections from hepatitis E virus in immunocompromised patients who are unresponsive to decreased immunosuppression. PEGylated interferon α can be used for ribavirin-resistant liver transplant patients with chronic hepatitis E. Further research in therapeutic options is essential considering the stormy course of hepatitis E infection during pregnancy and teratogenicity of all available options.
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Affiliation(s)
- P. Kar
- Department of Gastroenterology and Hepatology, Max Super Specialty Hospital,Ghaziabad, Delhi, New Delhi 110017 India
| | - R. Karna
- Maulana Azad Medical College & Lok Nayak Hospital, Bahadurshah Zafar Road, New Delhi, India
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Locally acquired hepatitis E virus in Marche Italy: Clinical/laboratory features and outcome. Dig Liver Dis 2020; 52:434-439. [PMID: 31874836 DOI: 10.1016/j.dld.2019.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/23/2019] [Accepted: 11/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Hepatitis E Virus is endemic in Europe with increasing numbers of cases in recent years, also in Italy where this phenomenon has hitherto been modest. The aim of this study was to document the clinical features/natural history of locally acquired hepatitis E in our territory and explore factors which determine adverse outcome. METHODS Retrospective study of patients with locally-acquired HEV (hepatitis E virus) in Marche, Italy (2011-2019). RESULTS 1189 patients were tested for HEV with 89 confirmed cases. 81 (6.8%) had locally acquired infection; 54 (66%) were male (mean age 55.5 years) and 32 (39.5%) had active co-morbidities. 41 cases were viraemic (all HEV-3 (HEV genotype 1,2,3,4)); acute infection was found in 79 and chronic infection in 2. Forty-five cases (55%) required admission to hospital, for a total of 785 days. 4 patients developed acute on-chronic liver failure, 6 developed acute kidney injury and 8 died: all had active comorbidities. Univariate analysis showed that bilirubin, INR, immunosuppression, cirrhosis and diabetes were associated with death. On multivariant analysis the only predictor of death was the presence of diabetes (p = 0.04). CONCLUSIONS Hepatitis E in Marche Italy is mostly locally acquired and caused by HEV-3 that impacts on the morbidity and mortality particularly for fragile patients.
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Abstract
A 21-year-old man from India presented with acute hepatitis associated with a 1-week history of abdominal pain, pruritus, and dark urine. Over a 7-day admission, the patient's acute hepatitis evolved into acute liver failure with low-grade encephalopathy, markedly elevated transaminases, bilirubin, and impaired hepatic synthetic function. He was eventually diagnosed with acute hepatitis E virus (HEV) and was transitioned to supportive management. Acute HEV is a rare cause of acute liver failure. Hence, this case highlights the importance of early consideration of HEV in all patients with acute hepatitis who have originated from endemic regions.
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Affiliation(s)
- Timothy Phan
- Department of Gastroenterology, Monash Health, Clayton, Melbourne, Victoria, Australia
| | - Christopher Desmond
- Department of Gastroenterology, Monash Health, Clayton, Melbourne, Victoria, Australia
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Yang CH, Sahoo MK, Fitzpatrick M, Lau AH, Pinsky BA, Martinez OM. Evaluating for Human Herpesvirus 6 in the Liver Explants of Children With Liver Failure of Unknown Etiology. J Infect Dis 2020; 220:361-369. [PMID: 30418598 DOI: 10.1093/infdis/jiy644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/05/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Liver failure of unknown etiology (LFUE) has a transplant-free survival rate <25%. Human herpesvirus 6 (HHV-6) may be associated with LFUE, but studies are limited by small sample size. METHODS We identified all children who underwent liver transplant for LFUE at a single quaternary children's hospital; 51/65 cases could be age matched with controls (children who underwent liver transplant for metabolic liver disease). Quantitative polymerase chain reaction for HHV-6 was performed on DNA from formalin-fixed paraffin-embedded liver explant tissue. RESULTS HHV-6 was detected in 34/51 cases (66.7%) and 19/51 controls (37.3%) (P = .005). Average HHV-6 viral load was 213207 copies/106 cells in positive cases (range: 7293-1102030) and 38115 copies/106 cells in positive controls (range: 1382-122375) (P = .0008). HHV-6 was present significantly more often in cases compared to controls in patients younger than 6 years. In particular, in patients younger than 3 years, HHV-6 was present in 13/27 cases (48.1%) and 2/27 controls (7.4%) (P = .0009). CONCLUSIONS HHV-6 was detected in liver explants significantly more often and in higher quantities in children transplanted for LFUE compared to controls, suggesting HHV-6 should be evaluated in young children who present with LFUE.
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Affiliation(s)
- Christine H Yang
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | | | | | | | - Benjamin A Pinsky
- Department of Pathology.,Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, California
| | - Olivia M Martinez
- Department of Surgery, Division of Abdominal Transplantation and Stanford Immunology, Stanford University Medical Center, California
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Comprehensive Evaluation of Hepatitis E Serology and Molecular Testing in a Large Cohort. Pathogens 2020; 9:pathogens9020137. [PMID: 32093070 PMCID: PMC7168254 DOI: 10.3390/pathogens9020137] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction: Reliable and cost-effective diagnostics for hepatitis E virus (HEV) infection are necessary. The aim of our study was to investigate which diagnostic test is most accurate to detect HEV infection in immunocompetent and immunosuppressed patients in a real world setting. Patients and Methods: We performed a retrospective analysis of 1165 patients tested for HEV antibodies and HEV PCR at the same time point. Clinical, laboratory and virological data were taken from patient charts. HEV IgA was measured in a subgroup of 185 patients. Results: HEV RNA was detectable in 61 patients (5.2%); most of them (n = 49, 80.3%/n = 43, 70.5%) were HEV IgM+ and IgG+; however, 12 patients (19.6%) were HEV RNA positive/HEV IgM negative and 17 patients (27.8%) were HEV RNA positive/HEV IgG negative. Ten HEV RNA positive patients (16.4%) had neither HEV IgG nor IgM antibodies. Importantly, all of them were immunosuppressed. HEV IgA testing was less sensitive than HEV IgM for HEV diagnosis. Conclusions: HEV infection can be overlooked in patients without HEV specific antibodies. Performing PCR is necessary to diagnose or exclude HEV infection in immunocompromised hosts. In immunocompetent patients, a screening based on HEV antibodies (IgG/IgM) is sufficient.
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Amoroso P, Buonocore S, Lettieri G, Pesce G, Pierri P, De Sena R, Morelli G, Matteis B, Dell'isola C, De Marino V, Ciccaglione AR, Punzi R, Esposito C, Spada E. Changing epidemiology of acute liver failure in Italy: a single-center experience over 25 years. Minerva Med 2020; 111:330-336. [PMID: 31958920 DOI: 10.23736/s0026-4806.19.06331-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Acute liver failure (ALF) is a rare but often lethal syndrome. In Italy, recent data on its incidence and causes are lacking. We report here the epidemiological analysis of ALF cases observed in Campania, a Southern Italian region, over the last 25 years. METHODS Medical records of ALF cases hospitalized from 1992 to 2018 were retrospectively analyzed. RESULTS Two hundred ten ALF cases occurred during 1992-2018: 103 (49%) hepatitis B virus (HBV)-related (including 5 cases also infected with Delta virus), 39 (19%) from undetermined cause, 36 (17%) drug-induced, 11 (5%) Wilson's disease-associated, 8 (4%) hepatitis A virus (HAV)-related and 12 (6%) from other causes. Separate time-periods analysis of data showed a significant progressive decrease in ALF incidence mainly attributable to a decline of HBV and other viruses etiology. Already before 2010, HAV or Delta virus-related cases have no longer been observed. No hepatitis C or E virus-related ALF was detected through the study period. A progressive decrease in frequency of ALF due to undetermined causes or drug was also evident. CONCLUSIONS A decrease in ALF incidence and a changing in its etiology were observed in Campania during 1992-2018. Both results were likely mainly due to 1991 introduction of HBV universal vaccination and may be considered generalizable nationwide.
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Affiliation(s)
- Pietro Amoroso
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy -
| | | | - Gennaro Lettieri
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Gaetano Pesce
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Paola Pierri
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Raffaele De Sena
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Giuseppe Morelli
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Bianca Matteis
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Chiara Dell'isola
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Valeria De Marino
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Anna R Ciccaglione
- Department of Infectious Diseases, National Institute of Health, Rome, Italy
| | - Rodolfo Punzi
- Department of Infectious Diseases, D. Cotugno Hospital, Naples, Italy
| | - Ciro Esposito
- Department of Transplants, A. Cardarelli Hospital, Naples, Italy
| | - Enea Spada
- Department of Infectious Diseases, National Institute of Health, Rome, Italy
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Wang Y, Liu H, Liu S, Yang C, Jiang Y, Wang S, Liu A, Peppelenbosch MP, Kamar N, Pan Q, Zhao J. Incidence, predictors and prognosis of genotype 4 hepatitis E related liver failure: A tertiary nested case-control study. Liver Int 2019; 39:2291-2300. [PMID: 31436371 DOI: 10.1111/liv.14221] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/25/2019] [Accepted: 08/12/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND/AIMS Hepatitis E virus (HEV) infection has been recognized an important insult of acute or acute-on-chronic liver failure (A(C)LF). This study aimed to identify the incidence, predictors and outcomes of A(C)LF in patients with hepatitis E. METHODS All patients diagnosed of hepatitis E between 2012 and 2018 in the tertiary hospital were retrospectively and consecutively analysed. Patients with hepatitis E who developed A(C)LF were enrolled as cases (HEV-LF) and controls were randomly selected from those who did not develop liver failure with 1:3 ratio in the same cohort. RESULTS Eight hundred and nine patients were diagnosed with hepatitis E, among which 80 were identified with HEV-related liver failure (HEV-LF) with HEV as the solely acute aetiology of A(C)LF. Sequencing of HEV genome showed genotype (GT) 4 strains in all available serum samples. Hepatitis E patients with cirrhosis underwent higher risk to develop liver failure, compared to non-cirrhotic patients. Hydrothorax, respiratory infections, lower γ-glutamyl transferase, higher lactate dehydrogenase and alpha-foetoprotein were found to be independent predictors of A(C)LF in patients with hepatitis E. The 28-day and 90-day mortality for HEV-LF was 12.86% and 30.36% respectively. Renal injury and lower triglyceride were independent factors associated with 28-day mortality. Lower alanine aminotransferase and higher International normalized ratio were independent predictors of 90-day mortality. CONCLUSIONS Patients with GT4 hepatitis E are at high risk to develop A(C)LF. Different CLD status impacted the incidence of HEV-LF distinctively. The identified variables shall help to identify HEV patients with high risk for developing liver failure and the risk for death.
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Affiliation(s)
- Yijin Wang
- Department of Pathology and Hepatology, the 5thMedical Centre, Chinese people's Liberation Army General Hospital, Beijing, China
| | - Hongyang Liu
- Department of Pathology and Hepatology, the 5thMedical Centre, Chinese people's Liberation Army General Hospital, Beijing, China.,Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Shuhong Liu
- Department of Pathology and Hepatology, the 5thMedical Centre, Chinese people's Liberation Army General Hospital, Beijing, China
| | - Changshuang Yang
- Department of Pathology and Hepatology, the 5thMedical Centre, Chinese people's Liberation Army General Hospital, Beijing, China
| | - Yiyun Jiang
- Department of Pathology and Hepatology, the 5thMedical Centre, Chinese people's Liberation Army General Hospital, Beijing, China.,Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Shan Wang
- Department of Pathology and Hepatology, the 5thMedical Centre, Chinese people's Liberation Army General Hospital, Beijing, China
| | - Aixia Liu
- Department of Laboratory Medicine, the 5th Medical Centre, Chinese people's Liberation Army General Hospital, Beijing, China
| | - Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Nassim Kamar
- Chef du Pôle Urologie-Néphrologie-UTO-Dialyse, Coordonateur du Département de Néphrologie et Transplantation d'Organes, CHU Rangueil, Toulouse, France
| | - Qiuwei Pan
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Jingmin Zhao
- Department of Pathology and Hepatology, the 5thMedical Centre, Chinese people's Liberation Army General Hospital, Beijing, China
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Meher D, Khatua CR, Singh SP. Letter to the Editor: Concerns Regarding the ACLF Research Consortium (AARC) Study on Corticosteroid Therapy for Autoimmune Hepatitis Flare Causing Acute on Chronic Liver Failure. Hepatology 2019; 70:1873. [PMID: 31121056 DOI: 10.1002/hep.30787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Dinesh Meher
- Department of Gastroenterology, S.C.B. Medical College, Cuttack, India
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Wenter C, Borena W, Oberhuber G, Graziadei I. Acute liver failure in immunocompetent patients infected with hepatitis E. Wien Klin Wochenschr 2019; 131:442-445. [PMID: 31493102 PMCID: PMC6748887 DOI: 10.1007/s00508-019-01547-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/17/2019] [Indexed: 01/10/2023]
Abstract
In almost all immunocompetent patients an acute hepatitis E virus (HEV) infection is clinically silent with spontaneous viral clearance. So far, only a very small number of severe acute HEV infections have been described. This article reports the case of a 78-year-old immunocompetent, diabetic patient, who presented with a symptomatic acute HEV genotype (GT) 3 infection and that progressed to acute liver failure. After starting with an antiviral therapy with ribavirin, the HEV viral load rapidly decreased with a significant improvement of the laboratory parameters as well as a clinical amelioration of the patient. The treatment was continued for 3 months and led to a complete resolution of this acute fulminant hepatitis E. Although the risk is almost negligible this article clearly demonstrates that an acute liver failure due to HEV should also be considered in immunocompetent patients, especially in older male individuals with diabetes mellitus.
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Affiliation(s)
- Christian Wenter
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Milserstraße 10, 6060, Hall in Tirol, Austria
| | - Wegene Borena
- Division of Virology, Medical University Innsbruck, Innsbruck, Austria
| | - Georg Oberhuber
- INNPATH, Institute of Pathology, Tirol Kliniken Innsbruck, Innsbruck, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Milserstraße 10, 6060, Hall in Tirol, Austria. .,Medical University Innsbruck, Innsbruck, Austria.
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Rashid HO, Khan MR, Rashid T, Rashid H, Mahtab MA. Variable Outcome of Acute Viral Hepatitis in Diabetic and Nondiabetic Patients in Bangladesh. Euroasian J Hepatogastroenterol 2019; 9:20-22. [PMID: 31988862 PMCID: PMC6969331 DOI: 10.5005/jp-journals-10018-1290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Diabetes mellitus (DM) are common in Bangladesh, and this country is also well-known for frequent outbreaks of acute viral hepatitis (AVH). The study presented here was designed for the clinical courses of acute hepatitis with and without DM. A total of 300 patients with AVH were enrolled into two groups; group A; patients of AVH with DM (N = 140) and group B; patients with AVH without DM (N = 160). There was no significant difference regarding age, sex, and levels of alanine aminotransferase (ALT) between the two groups. The main cause of AVH was hepatitis E virus (HEV) in 100 and 112 patients of groups A and B, respectively. Jaundice persisted for more than 6 months in 68 of 140 (49%) patients of group A, whereas, this was found in only 11 of 160 patients of group B. Forty-two patients of group A showed evidence of esophageal varices; however, the endoscopic assessment did not reveal any abnormality in patients with group B. Moderate to several hepatic fibrosis was seen in 19 of 140 patients with group A, however, these were not detected in any patient of group B (patient with AVH without DM). Even more important is the fact that four patients of group A died of liver failure, whereas there was no mortality in any patient of group B. The study presented here indicates that all patients with DM with superimposed AVH should be carefully followed up with the possibility of development of severe liver diseases and even mortality. How to cite this article: Harun-or-Rashid, Khan MR, et al. Variable Outcome of Acute Viral Hepatitis in Diabetic and Nondiabetic Patients in Bangladesh. Euroasian J Hepatogastroenterol 2019;9(1): 20-22.
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Affiliation(s)
- Harun Or Rashid
- Department of Hepatology, Rajshahi Medical College Hospital, Rajshahi, Bangladesh
- Harun or Rashid, Department of Hepatology, Rajshahi Medical College Hospital, Rajshahi, Bangladesh, Phone: 880-171-119 04778, e-mail:
| | - Mahbubur R Khan
- Department of Hepatology, Rajshahi Medical College Hospital, Rajshahi, Bangladesh
| | - Tasnova Rashid
- Department of Medicine, Medical College for Women and Hospital, Dhaka, Bangladesh
| | - Humaira Rashid
- Department of Pharmacy, Brac University, Dhaka, Bangladesh
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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Webb GW, Dalton HR. Hepatitis E: an underestimated emerging threat. Ther Adv Infect Dis 2019; 6:2049936119837162. [PMID: 30984394 PMCID: PMC6448100 DOI: 10.1177/2049936119837162] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/08/2019] [Indexed: 12/22/2022] Open
Abstract
Hepatitis E virus (HEV) is the most common cause of viral hepatitis in the world. It is estimated that millions of people are infected every year, resulting in tens of thousands of deaths. However, these estimates do not include industrialized regions and are based on studies which employ assays now known to have inferior sensitivity. As such, this is likely to represent a massive underestimate of the true global burden of disease. In the developing world, HEV causes large outbreaks and presents a significant public-health problem. Until recently HEV was thought to be uncommon in industrialized countries, and of little relevance to clinicians in these settings. We now know that this is incorrect, and that HEV is actually very common in developed regions. HEV has proved difficult to study in vitro, with reliable models only recently becoming available. Our understanding of the lifecycle of HEV is therefore incomplete. Routes of transmission vary by genotype and location: endemic regions experience large waterborne epidemics, while sporadic cases in industrialized regions are zoonotic infections likely spread via the food chain. Both acute and chronic infection has been observed, and a wide range of extrahepatic manifestations have been reported. This includes neurological, haematological and renal conditions. As the complete clinical phenotype of HEV infection is yet to be characterized, a large proportion of cases go unrecognized or misdiagnosed. In many cases HEV infection does not feature in the differential diagnosis due to a lack of knowledge and awareness of the disease amongst clinicians. In combination, these factors have contributed to an underestimation of the threat posed by HEV. Improvements are required in terms of recognition and diagnosis of HEV infection if we are to understand the natural history of the disease, improve management and reduce the burden of disease around the world.
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Affiliation(s)
- Glynn W. Webb
- University of Manchester NHS Foundation Trust, 7 Radnor Rd London NW6 6TT Manchester, UK
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Haffar S, Shalimar, Kaur RJ, Wang Z, Prokop LJ, Murad MH, Bazerbachi F. Acute liver failure caused by hepatitis E virus genotype 3 and 4: A systematic review and pooled analysis. Liver Int 2018; 38:1965-1973. [PMID: 29675889 DOI: 10.1111/liv.13861] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 04/03/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Acute liver failure caused by hepatitis E virus genotype 3 and 4 has been rarely described. Because of the presence of a short golden therapeutic window in patients with viral acute liver failure from other causes, it is possible that early recognition and treatment might reduce the morbidity and mortality. We performed a systematic review and pooled analysis of acute liver failure caused by hepatitis E virus genotype 3 and 4. METHODS Two reviewers appraised studies after searching multiple databases on June 12th, 2017. Appropriate tests were used to compare hepatitis E virus genotype 3 vs 4, suspected vs confirmed genotypes, hepatitis E virus-RNA positive vs negative, and to discern important mortality risk factors. RESULTS We identified 65 patients, with median age 58 years (range: 3-79), and a male to female ratio of 1.2:1. The median bilirubin, ALT, AST and alkaline phosphatase (expressed by multiplication of the upper limit of normal) levels were 14.8, 45.3, 34.8 and 1.63 respectively. Antihepatitis E virus IgG, antihepatitis E virus IgM and hepatitis E virus-RNA were positive in 84%, 91% and 86% of patients respectively. The median interval from symptoms onset to acute liver failure was 23 days, and 16 patients underwent liver transplantation. Final outcome was reported in 58 patients and mortality was 46%. Age was a predictor of poor prognosis in multivariate analysis. No important differences were found between patients infected with genotype 3 vs 4, patients with confirmed vs suspected genotypes, or patients with positive vs negative RNA. CONCLUSION Acute liver failure caused by hepatitis E virus genotype 3 and 4 is rare, similar between genotypes, occurs commonly in middle-aged/elderly patients and has a very high mortality. Age is predictive of poor prognosis in multivariate analysis.
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Affiliation(s)
- Samir Haffar
- Digestive center for diagnosis and treatment, Damascus, Syrian Arab Republic
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ravinder J Kaur
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - Mohammad H Murad
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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[Acute liver failure]. ACTA ACUST UNITED AC 2018; 22:38-47. [PMID: 32288865 PMCID: PMC7138136 DOI: 10.1007/s00740-018-0243-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Acute liver failure (ALF) is a rare condition with fatal outcome. Characteristic is rapid onset of liver damage without preexisting liver diseases, including hepatic encephalopathy and coagulopathy. Early and correct diagnosis is essential for further management of patients, since diagnosis impacts therapy choice. Survival of patients with ALF has improved dramatically due to advances in critical care medicine and the use of liver transplantation.
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Baylis SA, Moradpour D, Wedemeyer H, Negro F. EASL Clinical Practice Guidelines on hepatitis E virus infection. J Hepatol 2018; 68:1256-1271. [PMID: 29609832 DOI: 10.1016/j.jhep.2018.03.005] [Citation(s) in RCA: 377] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/09/2018] [Indexed: 02/08/2023]
Abstract
Infection with hepatitis E virus (HEV) is a significant cause of morbidity and mortality, representing an important global health problem. Our understanding of HEV has changed completely over the past decade. Previously, HEV was thought to be limited to certain developing countries. We now know that HEV is endemic in most high-income countries and is largely a zoonotic infection. Given the paradigm shift in our understanding of zoonotic HEV and that locally acquired HEV is now the commonest cause of acute viral hepatitis in many European countries, the focus of these Clinical Practice Guidelines will be on HEV genotype 3 (and 4).
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Abstract
Although the overall prevalence is on the decline, viral hepatitis still plays a major role in the development of acute liver failure (ALF) worldwide. Hepatitis A, B, D, and E contribute to most fulminant viral courses. These viruses have not gained much attention in recent years yet remain relevant from a clinical perspective as the incidence in certain populations is on the increase. Other viral therapies and immunotherapies are currently being examined as treatments for hepatitis D and hepatitis E. Clinicians should still maintain a high index of suspicion for viral causes in approaching patients with ALF.
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Abstract
Acute liver failure of all causes is diagnosed in between 2000 and 2500 patients annually in the United States. Drug-induced acute liver failure is the leading cause of acute liver failure, accounting for more than 50% of cases. Nonacetaminophen drug injury represents 11% of all cases in the latest registry from the US Acute Liver Failure Study Group. Although rare, acute liver failure is clinically dramatic when it occurs, and requires a multidisciplinary approach to management. In contrast with acetaminophen-induced acute liver failure, non-acetaminophen-induced acute liver failure has a more ominous prognosis with a lower liver transplant-free survival.
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Affiliation(s)
- Arul M Thomas
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - James H Lewis
- Division of Gastroenterology, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Room M2408, Washington, DC 20007, USA.
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Rivero-Juarez A, Frias M, Lopez-Lopez P, Martinez-Peinado A, Risalde MÁ, Brieva T, Machuca I, Camacho Á, García-Bocanegra I, Gomez-Villamandos JC, Rivero A. Detection of hepatitis E virus RNA in saliva for diagnosis of acute infection. Zoonoses Public Health 2018; 65:584-588. [PMID: 29659194 DOI: 10.1111/zph.12472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Indexed: 12/31/2022]
Abstract
Diagnosis of acute hepatitis E virus (HEV) infection is established by detection of anti-HEV IgM antibodies by ELISA or by amplification of serum viral RNA. Here, we evaluate the diagnostic value of testing HEV RNA in saliva to identify patients with acute HEV infection. Prospective proof-of-concept study including patients with acute hepatitis. Whole blood and neat saliva samples were obtained from all patients. Saliva samples were processed and analysed for HEV RNA by RT-PCR within 2 hr after collection. A total of 34 patients with acute hepatitis and 12 healthy donors were included in the study. HEV RNA in serum was confirmed by RT-PCR in eight of these patients (23.5%; 95% CI: 12.2%-40.2%). HEV was isolated in the saliva of eight of 34 patients (23.5%; 95% CI: 12.2%-40.2%). All patients with HEV RNA amplified in saliva had detectable HEV RNA in serum. HEV was isolated neither in the saliva of any of the 26 patients without detectable HEV RNA in serum nor in healthy donors. Our study suggests that acute HEV infection could be diagnosed by assessing viral load in saliva.
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Affiliation(s)
- A Rivero-Juarez
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
| | - M Frias
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
| | - P Lopez-Lopez
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
| | - A Martinez-Peinado
- Servicio de Análisis Clínico, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
| | - M Á Risalde
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
| | - T Brieva
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
| | - I Machuca
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
| | - Á Camacho
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
| | - I García-Bocanegra
- Animal Health Department, Veterinary Science College, Universidad de Córdoba, Cordoba, Spain
| | - J C Gomez-Villamandos
- Animal Pathology Department, Veterinary Science College, Universidad de Córdoba, Cordoba, Spain
| | - A Rivero
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Cordoba, Spain
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E-xchange: Hepatitis E and the Risk of Plasma Products for Organ Transplant Recipients. Transplantation 2018; 102:1209-1210. [PMID: 29561323 DOI: 10.1097/tp.0000000000002186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liu L, Xiao D, Yu JH, Shen R, Wang M, Li Q. Clinical course of sporadic acute hepatitis E in a hepatitis B virus endemic region. Int J Infect Dis 2018; 70:107-114. [PMID: 29551632 DOI: 10.1016/j.ijid.2018.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/03/2018] [Accepted: 03/09/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES In China, the epidemic pattern of acute hepatitis E virus (HEV) infection has changed from waterborne outbreaks to foodborne sporadic cases. However, the clinical course of sporadic acute hepatitis E (AHE) has not been well defined. METHODS Consecutive patients with AHE who were admitted to the Jinan Infectious Disease Hospital, Jinan, Shandong Province between January 2003 and December 2014 were evaluated and followed. Demographic data, clinical manifestations, results of laboratory tests, and outcomes were recorded. Risk factors for liver failure and death were analyzed. RESULTS A total of 680 patients with AHE were identified during the study period. The incidence was highest in February, March, and April, accounting for about 41% of the cases. The male to female ratio was 5.1:1 (574/106). The average age was 50.9±12.8years. The prevalence rates of prodromal fever, fatigue, loss of appetite, and jaundice were 25.6%, 85.6%, 83.8%, and 92.8%, respectively. The median (range) serum alanine aminotransferase, aspartate aminotransferase, bilirubin, albumin, and platelet levels were 727 (8-6270) U/l, 300 (17-6226) U/l, 196.8 (8.0-1083) μmol/l, 33.0 (15.2-45.8) g/l, and 162 (10-589)×109/l, respectively. The prevalence of hepatitis B surface antigen (HBsAg) was 18.5% (126/680) and of liver cirrhosis was 9.4% (64/680). Thirteen percent (89/680) of the cases progressed to liver failure, including 4.1% (28/680) with acute liver failure (ALF) and 9.0% (61/680) with acute-on-chronic liver failure (ACLF). Among patients with HBsAg positivity or cirrhosis, 28.6% (36/126) and 36.0% (23/64), respectively, progressed to ACLF. Multiple logistic regression analysis indicated that age >53years, prodromal fever, HBsAg positivity, cirrhosis, and thrombocytopenia (platelet count <150×109/l) were independently associated with the development of liver failure, with an odds ratio (95% confidence interval) of 2.5 (1.5-4.3), 1.9 (1.1-3.2), 3.7 (2.0-6.7), 2.1 (1.1-4.2), and 5.9 (3.3-10.4), respectively. The overall mortality was 5.6% (38/680), and the mortality rates in patients with and without underlying liver disease were 9.3% (22/237) and 3.6% (16/443), respectively. Multiple logistic regression analysis indicated that hepatic encephalopathy, bilirubin >500μmol/l, international normalized ratio (INR)>2, and severe thrombocytopenia (platelet count <100×109/l) were independently associated with death, with an odds ratio (95% confidence interval) of 7.2 (2.4-21.8), 5.8 (1.9-17.2), 24.1 (7.9-73.3), and 10.8 (3.6-32.9), respectively. CONCLUSIONS In areas that are dual endemic for hepatitis B virus and HEV, the HEV vaccine for patients with obvious liver diseases is of significance. Thrombocytopenia is an important predictor of liver failure and mortality in sporadic AHE.
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Affiliation(s)
- Li Liu
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Di Xiao
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Jin-Hong Yu
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Rui Shen
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Meng Wang
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China; Division of Infectious Diseases, Jinan Central Hospital, Shandong University, Jinan, China
| | - Qiang Li
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China.
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De Winter BCM, Hesselink DA, Kamar N. Dosing ribavirin in hepatitis E-infected solid organ transplant recipients. Pharmacol Res 2018; 130:308-315. [PMID: 29499270 DOI: 10.1016/j.phrs.2018.02.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/06/2018] [Accepted: 02/26/2018] [Indexed: 12/22/2022]
Abstract
Hepatitis E virus (HEV) is the most common cause of viral hepatitis worldwide. Genotypes 1 and 2 (GT1 and GT2) are mainly present in developing countries, while GT3 and GT4 are prevalent in developed and high-income countries. In the majority of cases, HEV causes a self-limiting hepatitis. GT3 and GT4 can be responsible for a chronic hepatitis that can lead to cirrhosis in immunocompromized patients, i.e. solid-organ- and stem-cell-transplant-patients, human immunodeficiency virus-infected patients, and patients receiving chemotherapy or immunotherapy. HEV has also been associated with extra-hepatic manifestations such as neurologic disorders (Guillain-Barré Syndrome and neuralgic amyotrophy) and kidney disease. In patients with chronic hepatitis, reduction of immunosuppression, when possible, is the first therapeutic option. In the remaining patients, ribavirin therapy has been shown to very efficient for treating HEV infection leading to a sustained virological response in nearly 80-85% of patients. However, the mechanism of action of ribavirin in this setting is still unknown, as is the impact of HEV RNA polymerase mutations. There are unmet needs with regard to the treatment of chronic HEV with ribavirin. These include the optimal dosing and duration of treatment, and the potential beneficial effects of therapeutic drug monitoring on the virological response and the incidence of side effects. In the present review, we will provide an overview of HEV epidemiology, its mode of transmission and clinical manifestations, as well as its treatment by ribavirin with a focus on the drug's pharmacokinetics and dosing.
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Affiliation(s)
- Brenda C M De Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Rotterdam Transplant Group, Division of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France
| | - Nassim Kamar
- Department of Internal Medicine, Division of Nephrology and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, Université Paul Sabatier, Toulouse, France.
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Yuan S, Qian Y, Tan D, Mo D, Li X. Therapeutic plasma exchange: A prospective randomized trial to evaluate 2 strategies in patients with liver failure. Transfus Apher Sci 2018; 57:253-258. [PMID: 29571962 DOI: 10.1016/j.transci.2018.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 02/01/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare two means of performing therapeutic plasma exchange (TPE) in patients with liver failure. METHOD This open-label monocentric randomized trial, conducted in a single prestigious general healthcare facility, recruited liver failure patients with an indication to receive artificial liver support therapy for TPE. All patients underwent TPE procedures and were administered in a random sequence: heparin-free or systemic heparinization with unfractionated heparin. The primary endpoint was completion of TPE sessions, and the secondary endpoints included the safety and efficacy. RESULTS In the period of the studying, there were 164 patients being recruited in and underwent total of 398 randomized TPEs: 168 with unfractionated heparin and 230 with heparin-free. In unfractionated heparin group, there were 3 cases (1.79%) being interrupted due to uncontrollable intraoperative pulmonary hemorrhages and gastrointestinal bleeding. In heparin-free group, 228 (99.13%) were completed successfully and 2 of them (0.87%) were switched from heparin-free to unfractionated heparin eventually. No significant differences were found between the two groups for either RRs or IRs (P > 0.05). CONCLUSION Heparin-free regimen is feasible and safer than systemic heparinization with unfractionated heparin in the process of TPEs in patients with liver failure.
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Affiliation(s)
- Su'e Yuan
- Xiangya Hospital Central South University, Changsha, Hunan Province, China; Xiangya Nursing School Central South University, Changsha, Hunan Province, China.
| | - Yun Qian
- Xiangya Hospital Central South University, Changsha, Hunan Province, China
| | - De'ming Tan
- Xiangya Hospital Central South University, Changsha, Hunan Province, China
| | - Dan Mo
- Xiangya Hospital Central South University, Changsha, Hunan Province, China
| | - Xue'bing Li
- Xiangya Hospital Central South University, Changsha, Hunan Province, China
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Guerra JADAA, Kampa KC, Morsoletto DGB, Junior AP, Ivantes CAP. Hepatitis E: A Literature Review. J Clin Transl Hepatol 2017; 5:376-383. [PMID: 29226104 PMCID: PMC5719195 DOI: 10.14218/jcth.2017.00012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/27/2017] [Accepted: 07/20/2017] [Indexed: 12/13/2022] Open
Abstract
Hepatitis E is the fifth known form of human viral hepatitis. Although not very common in our clinical practice, the incidence in Western countries is increasing. Infection with the hepatitis E virus (HEV) may be related to acute illness, liver failure, chronic hepatitis and cirrhosis. HEV itself is an RNA virus, with eight described genotypes (HEV 1-8), four of which more commonly affect humans and have, thus, been better studied. Besides liver manifestations, genotype 3 is also related to extra-hepatic manifestations, such as neurological, renal and rheumatological. Evolution to chronic disease occurs especially in patients who underwent transplantation, have hematological malignancies requiring chemotherapy, or have infection with the human immunodeficiency virus. The diagnosis may be difficult because of the low availability of tests and due to low sensibility and specificity. The acute form of illness does not have to be treated, but the chronic one does. We present here a literature review of hepatitis E and the relation between chronic hepatitis E and transplantation.
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Affiliation(s)
- Juliana Ayres de Alencar Arrais Guerra
- Nossa Senhora das Graças Hospital, Alcides Munhoz Street, 433 – Mercês, Curitiba – PR, Brazil
- *Correspondence to: Juliana Ayres de Alencar Arrais Guerra, Nossa Senhora das Graças Hospital, Alcides Munhoz Street, 433 – Mercês, Curitiba – PR 80810-040, Brazil. Tel: +55-41-3240-6060, E-mail:
| | - Katia Cristina Kampa
- Nossa Senhora das Graças Hospital, Alcides Munhoz Street, 433 – Mercês, Curitiba – PR, Brazil
| | | | - Alcindo Pissaia Junior
- Nossa Senhora das Graças Hospital, Alcides Munhoz Street, 433 – Mercês, Curitiba – PR, Brazil
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Abstract
Hepatitis E virus (HEV) infection can lead to acute and chronic hepatitis as well as to extrahepatic manifestations such as neurological and renal disease; it is the most common cause of acute viral hepatitis worldwide. Four genotypes are responsible for most infection in humans, of which HEV genotypes 1 and 2 are obligate human pathogens and HEV genotypes 3 and 4 are mostly zoonotic. Until quite recently, HEV was considered to be mainly responsible for epidemics of acute hepatitis in developing regions owing to contamination of drinking water supplies with human faeces. However, HEV is increasingly being recognized as endemic in some developed regions. In this setting, infections occur through zoonotic transmission or contaminated blood products and can cause chronic hepatitis in immunocompromised individuals. HEV infections can be diagnosed by measuring anti-HEV antibodies, HEV RNA or viral capsid antigen in blood or stool. Although an effective HEV vaccine exists, it is only licensed for use in China. Acute hepatitis E is usually self-limiting and does not require specific treatment. Management of immunocompromised individuals involves lowering the dose of immunosuppressive drugs and/or treatment with the antiviral agent ribavirin.
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Fredricks DN. Viruses Associated With Unexplained Acute Liver Failure: Next Generation Reveals the Last Generation. Clin Infect Dis 2017; 65:1486-1488. [PMID: 29020151 DOI: 10.1093/cid/cix597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Donnelly MC, Scobie L, Crossan CL, Dalton H, Hayes PC, Simpson KJ. Review article: hepatitis E-a concise review of virology, epidemiology, clinical presentation and therapy. Aliment Pharmacol Ther 2017; 46:126-141. [PMID: 28449246 DOI: 10.1111/apt.14109] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 12/21/2016] [Accepted: 03/30/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatitis E virus (HEV) is a leading cause of acute icteric hepatitis and acute liver failure in the developing world. During the last decade, there has been increasing recognition of autochthonous (locally acquired) HEV infection in developed countries. Chronic HEV infection is now recognised, and in transplant recipients this may lead to cirrhosis and organ failure. AIM To detail current understanding of the molecular biology of HEV, diagnostic and therapeutic strategies and propose future directions for basic science and clinical research. METHODS PubMed was searched for English language articles using the key words "hepatitis E", "viral hepatitis", "autochthonous infection", "antiviral therapy", "liver transplantation", "acute", "chronic", "HEV", "genotype", "transmission" "food-borne", "transfusion". Additional relevant publications were identified from article reference lists. RESULTS There has been increasing recognition of autochthonous HEV infection in Western countries, mainly associated with genotype 3. Chronic HEV infection has been recognised since 2008, and in transplant recipients this may lead to cirrhosis and organ failure. Modes of transmission include food-borne transmission, transfusion of blood products and solid organ transplantation. Ribavirin therapy is used to treat patients with chronic HEV infection, but new therapies are required as there have been reports of treatment failure with ribavirin. CONCLUSIONS Autochthonous HEV infection is a clinical issue with increasing burden. Future work should focus on increasing awareness of HEV infection in the developed world, emphasising the need for clinicians to have a low threshold for HEV testing, particularly in immunosuppressed patients. Patients at potential risk of chronic HEV infection must also be educated and given advice regarding prevention of infection.
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Affiliation(s)
- M C Donnelly
- Department of Hepatology and Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - L Scobie
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
| | - C L Crossan
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
| | - H Dalton
- Royal Cornwall Hospital Trust and European Centre for Environment and Human Health, University of Exeter, Truro, UK
| | - P C Hayes
- Department of Hepatology and Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - K J Simpson
- Department of Hepatology and Scottish Liver Transplant Unit, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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